Recognition & Management of Sepsis Objectives • What is Sepsis? • Why worry about Sepsis? • Pitfalls • The ACI/CEC Sepsis Project • How to recognise Sepsis • How to treat Sepsis • How to get help WHAT IS SEPSIS? Definitions Pathophysiology Definitions • Sepsis is the presence of infection that induces a systemic response • Expect the patient to have signs and symptoms of a systemic response • May not always have symptoms and signs at the site of infection Definitions • SIRS criteria: 2 of the following + suspected or confirmed infection = Sepsis Temp < 36°C or > 38°C WCC < 4 or > 12 RR > 24 HR > 90 • Severe Sepsis: Sepsis plus organ dysfunction • Septic Shock: Sepsis with BP <90mmHg for 1 hour despite adequate fluid resuscitation or the need for inotropes to maintain BP >90mmHg Excuse me SIRS! The problems with SIRS criteria • Derived from retrospective data • Aim was to standardise definitions NOT aid early recognition • Only HR, RR, temperature will be available initially • A large study found temperature is normal in 17% of patients with sepsis1 • HR often affected by β-blockers • Not diagnostic or prognostic 1.Brun-Buisson C, Doyon F, Carlet J et al Incidence, Risk Factors and Outcome of Severe Sepsis and Septic Shock in Adults: A Multicentre Prospective Study in Intensive Care Units JAMA: 274(12), 27 Sept, 1995; 968-974 Pathophysiology • Pathogenic features of the microorganism • Patient’s immune response to these features • Failure of the immune system to control an initially localised infection • Exaggerated immune and inflammatory response • Cellular dysfunction • Vasodilation and leaky capillaries Pathophysiology • Distributive shock • Myocardial depression • Bone marrow suppression • Activation of clotting cascade  DIC • Organ dysfunction • MODS • Death Common sources of sepsis • Respiratory 35% • Urinary tract 35% • Intra Abdominal 10% • Unknown 10% • Meningitis/septic arthritis/ skin/vascular access devices 10% COST WHY WORRY ABOUT SEPSIS? MORTALITY TIME CRITICAL Why worry about sepsis? • Increasing incidence 1997 to 2005 severe sepsis/septic shock increased from 7.7% of ICU admissions to 14.0 % in Australia (4 fold increase in total patients)1 More common in the elderly  incidence increases as the population ages • Cost The cost of care is huge (US$16.7 billion in 2001)2 1. Peake S, for the ARISE Investigators: The outcome of sepsis and septic shock presenting to the Emergency Department in Australia and New Zealand. Critical Care 2007, 11(Suppl 2):P73 2. Angus DC et al: Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 29:1303, 2001 US National Centre Health Statistics – June 2011 Which patient has the highest mortality? 1. 59yr old male - large inferior STEMI 2. 27yr old male - multi trauma ISS 3. 65yr old female - bleeding gastric ulcer and BP 90/60 4. 74yr female P 65 BP 105/60 RR 24 Temp 35 C mildly confused** 5. 32yr female DKA pH 6.90 BSL 45 HCO3 9 Mortality 1. Inferior AMI 5% 2. Trauma ISS 16-24 7% 3. GIH + low BP 11% 4. Septic Shock 25% 5. Severe DKA <1% 1) Armstrong PW et al., JAMA, 2007;297:43–51. 2) Clemet N, SJTREM 28:18 2010 3) Rockall TA BMJ. 311(6999):2226, 1995 July 22 4) Mitchell M et al Crit Care Med 2010 Vol. 38, No. 2 5) Hamdy O, Sep 2009 Mortality • 25% mortality for severe sepsis and septic shock in Australia and NZ1 • Studies suggest that mortality may be decreasing with time but is still unacceptably high • 215 000 deaths annually in the USA • Delayed recognition and delayed appropriate initial treatment increase mortality 1. Peake S, for the ARISE Investigators: The outcome of sepsis and septic shock presenting to the Emergency Department in Australia and New Zealand. Critical Care 2007, 11(Suppl 2):P73 US National Centre Health Statistics – June 2011 Mortality vs. Time to Antibiotics Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Kumar A; Roberts D; Wood KE; Light B; Parrillo JE; Sharma S; Suppes R; Feinstein D; Zanotti S; Taiberg L; Gurka D; Kumar A; Cheang M Critical Care Medicine. 34(6):1589-96, 2006 Jun. Hypotension, Lactate & Mortality Howell et al: Occult hypoperfusion and mortality in patients with suspected infection. Intensive Care Med 2007 Pit falls • Fail to recognise sepsis • Under-appreciate the mortality • Do not see sepsis as a time critical illness Later tonight….. • After a few drinks…… • Fall down 10 stairs at a hotel • Friends find you semi-conscious at the bottom of the stairs • What next? Trauma Call • Two Intensive Care paramedics for transfer • Trauma Call – Team response at major facility • Staff Specialist, 2-3 registrars, 3 senior nursing staff and various others • Seen immediately in a resuscitation bay • Within one hour your emergency care will be complete – cast for your broken wrist! At the same time…. • 72 year old lady • Epigastric pain and nausea • Pulse 60 • Blood pressure 115/65 • Temp 37.2 C • Respiratory rate 25/minute, SpO2 99% on RA • Alert and Orientated .....a very different experience • Seen 2 hours post arrival by an intern • Seen 5 hours post arrival by a junior surgical registrar • Cared for by an RN-Year 2 in a non acute bed • Provisional diagnosis of bilary colic • Stay NBM for an ultrasound in the morning The next morning… • • • • • • • An experienced nurse asks MO to review the patient Steadily increasing RR overnight (now 36) Confused and slightly agitated Pulse 65, BP 105/60, SpO2 98% RA ABG pH 7.20 Lactate 5 IDC – no urine out Hypertension – on numerous medications including a β blocker Fail to see Sepsis as time critical • TRAUMA Golden Hour • AMI Time is muscle • STROKE Time is Brain • SEPSIS KILLS TIME IS LIFE The Sepsis Project • In 2009 the Clinical Excellence Commission published a Clinical Focus Report after a review of IIMS NSW data showed 167 incidents in 18 months • Incident reports detailed delays in diagnosis or inadequate treatment of sepsis • In response the Sepsis project has been established as a joint initiative between the Agency for Clinical Innovation, Clinical Excellence Commission and the Emergency Care Institute Sepsis Project Goals Reduce preventable harm to patients with sepsis: Recognise • Flagging of sepsis risk factors, signs and symptoms at Triage • Early involvement of senior clinicians in diagnosis and management Resuscitate • Appropriate fluid resuscitation • Prompt administration of antibiotics - first intravenous antibiotic administered within one hour of recognition Refer • To the appropriate in-hospital clinical teams or retrieval Sepsis adverse event/RCA in this hospital ACI/CEC Sepsis Project Phase 1 - Emergency Departments Phase 2 - Extend project to improve processes for recognition and management of sepsis on wards Sepsis pathway • Developed with wide clinical consultation • Key message that SEPSIS KILLS • 3 R’s of sepsis linked to project goals Recognise Resuscitate Refer Sepsis Pilot Study time to first intravenous antibiotic administration Project resources • Sepsis Toolkit available on the ACI/CEC website including sepsis pathway, Adult First Dose Empirical IV antibiotic guideline, implementation guide and planning tool, data collection guidelines, education resources • ACI/CEC Sepsis Project team telephone support • Monthly teleconferences • Site visits on request • www.cec.health.nsw.gov.au/programs/sepsis HOW TO RECOGNISE SEPSIS The key to success Recognition - the hardest part • Challenging diagnosis to make • Wide range of presentations - non specific signs • Results from the variation in host responses and the diversity in behaviour of micro-organisms • Signs can be subtle especially in some groups - elderly - immunocompromised - chronically ill • If any doubt - ask for senior medical review - measure serum lactate Which signs and symptoms are most common in patients with severe sepsis? • tachypnea 99% • tachycardia 97% • fever > 38°C 70% • hypothermia < 36°C 13% • metabolic acidosis 38% • acute oliguria 54% • acute encephalopathy 35%. Brun-Buisson C, Doyon F, Carlet J et al Incidence, Risk Factors and Outcome of Severe Sepsis and Septic Shock in Adults: A Multicentre Prospective Study in Intensive Care Units JAMA: 274(12), 27 Sept, 1995 SEPSIS PATHWAY Does your patient have risk factors, signs or symptoms of infection? Immunocompromised Skin: cellulitis, wound Indwelling medical device Urine: dysuria, frequency, odour Recent surgery/invasive procedure Abdomen: pain, peritonism History of fever or rigors Chest: cough, shortness of breath Red Flags in ambulance handover Neuro: decreased mental alertness, neck stiffness, headache AND RECOGNISE Does your patient have 2 or more yellow criteria?  Respirations ≤ 10 or ≥ 25 per minute  Sp02 < 95%  Systolic blood pressure ≤ 100 mmHg  Pulse ≤ 50 OR ≥ 120 per minute  Altered LOC or change in cognitive status  Temp ≤ 35.5 or ≥ 38.5OC Re-assess Treat and re-assess simultaneously: NO Sepsis may still be a concern YES Perform venous blood gas if available Does your patient have any red criteria?  SBP ≤ 90mmHg  Lactate ≥ 4 mmol/L  Age > 65 years  Immunocompromised  Base Excess < - 5.0 Respond and Escalate Does your patient have any red criteria?  SBP ≤ 90mmHg  Lactate ≥ 4 mmol/L  Age > 65 years  Immunocompromised YES NO YES NO Respond and Escalate This patient may have SEPSIS: • Inform the doctor-in-charge • Monitor vital signs & fluid balance • Obtain blood cultures x 2 sets • Investigate source of infection: e.g. urinalysis, urine M/C/S, chest x-ray • Obtain IV access and start IV fluids • Administer empiric antibiotics within one hour unless another diagnosis is more likely Refer to Therapeutic Guidelines: Antibiotic, version 14 http://proxy9.use.hcn.com.au/ • Refer / communicate with admitting team  Base Excess < - 5.0 This patient has SEVERE SEPSIS or SEPTIC SHOCK until proven otherwise: • Inform the doctor-in-charge • Expedite transfer to a resuscitation area or equivalent • Turn over page for Resuscitation Guideline CONSIDER ELIGIBILITY for ARISE Treatment Simple, early treatment saves lives • ANTIBIOTICS WITHIN 1 HOUR • IMMEDIATE and appropriate FLUID RESUSCITATION Do you know the average time it takes to commence antibiotic treatment in your ED? Antibiotics • Make giving antibiotics a clinical priority same as an ECG on someone with chest pain or giving thrombolysis to an AMI • • • • • Give antibiotics within one hour Take 2 sets of blood cultures first Do not delay awaiting other investigations Antibiotic cover for suspected cause If cause unknown, cover with broad spectrum antibiotics • Refer to Therapeutic Guidelines or the ACI/CEC Sepsis Adult 1st Dose Empirical IV Antibiotic Guideline Antibiotic Guideline • ACI/CEC guideline for the prescription and administration of the FIRST DOSE of IV antibiotics • Based on the Therapeutic Guidelines: Antibiotic version 14, 2010 • Easy to use resource that incorporates the best available evidence and the principles of appropriate use of antibiotics Antibiotics – special situations • Febrile Neutopenia piperacillin/Tazobactam or cefipime plus gentamicin • Suspected MRSA Add vancomycin • Line Sepsis vancomycin + gentamicin • Toxic Shock lincomycin or clindamycin Fluid resuscitation • Give 20 mL/kg of 0.9% sodium chloride as a bolus • Repeat if no response • Can continue to give fluid boluses if no signs of pulmonary oedema • However, if the patient remains in shock after the 2nd bolus seriously consider starting a vasopressor • Aim MAP > 65 mmHg Monitoring and Re-assessment • Ongoing frequent clinical review. • ECG, BP, SpO2 monitoring • Aim for MAP > 65mmHg • Measure urine output: aim > 0.5mL/kg/hr • MONITOR LACTATE - Each 10% decrease in lactate correlates with an 11% decrease in mortality1 1. Shapiro NI. Ann Emerg Med 2005;45:524-528 Refer • Referral to a surgeon to drain any pus • Seek advice from Infectious Diseases • Consult admitting team • HDU/ICU – seek advice early • Do you need the patient retrieved? You can never call too early for help Improving sepsis care • Think Sepsis - use the sepsis pathway, be vigilant • Identify local medical and nursing champions to lead the change in the process of care • Provide education for nursing and medical staff • Audit time to IV antibiotics and IV fluids to monitor improvement • Facilitate a culture where staff are encouraged to alert senior staff if they suspect sepsis Objectives achieved • What is Sepsis? • Why worry about Sepsis? • Pitfalls • The ACI/CEC Sepsis Project • How to recognise Sepsis • How to treat Sepsis • How to get help Key messages • SEPSIS KILLS • TIME IS LIFE • Recognise Resuscitate Refer Dr Chris Jenkins Staff Specialist Emergency Physician John Hunter Hospital ACI/CEC Sepsis Management Group member/lead author [email protected] Mary Fullick Sepsis Project Manager Clinical Excellence Commission Tel: (02) 9269 5542 [email protected] Dr Tony Burrell Director Patient Safety Clinical Excellence Commission Tel: (02) 9269 5550 [email protected]