Sepsis. ...striking a balance. Dr Ron Daniels.

Transcription

1 Sepsis...striking a balance Dr Ron Daniels Fellow: NHS Improvement Faculty Chair: United Kingdom Sepsis Group, Sepsis Trust & UK SSC Sepsis as a Global Emergency Committee, Global Sepsis Alliance Midland Hotel Manchester, 15 th November 2011

2 Sepsis is under appreciated. Sepsis is under funded. We (us doctors) over complicate sepsis care. I have less to offer septic patients once they re in my ICU. It is inevitable that we will get our act together.

3 Sepsis is under appreciated. Sepsis is under funded. We (us doctors) over complicate sepsis care. I have less to offer septic patients once they re in my ICU. It is inevitable that we will get our act together. Only question is, how many of our patients will die first?

4 How to achieve the balance?

5 Media pressures Event reduction targets Over control Evangelism Informed patients Lack of availability Withhold antimicrobials Give antimicrobials

6 Lazy or no stewardship Naive patients Lazy clinicians Sepsis evangelism Sepsis/SSI etc targets Resultant public panic Withhold antimicrobials Give antimicrobials

7 Reduce injudicious use Promote rapid response when appropriate Withhold antimicrobials Give antimicrobials

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9 What we need to do 1. Work out why ideal sepsis care continues to elude us 2. Move from recognizing sepsis to suspecting it 3. Make the case for simplifying sepsis care 4. Establish sepsis as a medical emergency And not forgetting

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11 A U.K. Perspective

12 A U.K. Perspective North Stand

13 A U.K. Perspective Breast cancer

14 A U.K. Perspective Breast cancer

15 A U.K. Perspective Breast cancer

16 A U.K. Perspective

17 Lung 1 Colon 2 Breast 3 Sepsis 4 1,2,3 4 Intensive Care National Audit Research Centre (2006)

18 Why do we need to simplify sepsis care?

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22 Standards currently achieved for ~14% of UK patients 39% in my hospital How many in yours??? Source: UK SSC data

23 Comparison with ACS

24 Comparison with ACS 75% in 30 mins 80%

25 Perspective Severe Sepsis Acute coronary syndrome No. cases per 100,000 per annum NNT basic care Sepsis Six (our data) 6 First hour antibiotics 5 Clopidogrel 48 β blockade 42 Aspirin 26 NNT invasive care EGDT (Rivers) 6 Resusc Bundle (SSC) 18 Thrombolysis 15 PCI over thrombolysis 33

26 Stroke 67,000 deaths per year FAST Campaign National Stroke Association Target: Specialist assessment in 60 min 40% mortality reduction Myocardial infarction/ ACS 89,000 deaths per year National Infarct Angioplasty Project Target: Call to needle 60 min Door to needle 20 min Sepsis 37,000 (+) deaths per year...

27 Are antibiotics the equivalent of PCI for sepsis?

28 SSC antibiotics Begin IV antibiotics as early as possible, and always within the first hour of recognising severe sepsis (1D) and septic shock. (1B) Broad spectrum: one or more agents active against likely bacterial/ fungal pathogens and with good penetration into presumed source. (1B) Reassess antimicrobial regimen daily to optimise efficacy, prevent resistance, avoid toxicity & minimise costs. (1C)

29 Cumulative Initiation of Effective Antimicrobial Therapy and Survival in Septic Shock 1.0 survival fraction cumulative antibiotic initiation fraction of total patients time from hypotension onset (hrs) Kumar et al. CCM. 2006:34:

30 Running average survival in septic shock based on antibiotic delay (n=2154) For each hour s delay in administering antibiotics in septic shock, mortality increases by 7.6% Funk and Kumar Critical Care Clinics 2011 (in press)

31 Begin IV antibiotics as early as possible, and always within the first hour of recognising severe sepsis (1D) and septic shock. (1B) Citation: Kumar A et al. Crit Care Med 2006: 34(6) Retrospective, 15 years, 14 sites n = 2,154 median 6 h, 50% administered in 6h Only 5% first 30 minutes survival 87% 12% first hour survival 84%

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33 Early antibiotics are good... Author n Setting Median time (mins) Odds Ratio for death Gaieski Crit Care Med 2010; 38: Daniels Emerg Med J 2010; doi: Kumar Crit Care Med 2006; 34(6): Appelboam Critical Care 2010; 14(Suppl 1): ED, USA (Shock) 567 Whole hospital, UK 2154 ED, Canada (Shock) 375 Whole hospital, UK (first hour vs all times) (first hour vs all times) (first hour vs second hour) (first 3 hours vs delayed) Levy Crit Care Med 2010; 38 (2): Multi centre 0.86 (first 3 hours vs delayed)

34 Running average survival in septic shock Running Average Survival in Septic Shock based Based on on antibiotic Antibiotic delay Delay (n=4195) (n=4195) fraction running average survival cumulative fraction of total survivors 0.2 Funk and Kumar Critical Care Clinics 2011 (in press) AbRx Delay (hrs)

35 Will antibiotics prevent sepsis? Antimicrobials Infective insult SIRS CARS Organ dysfunction Time

36 Septic shock: the golden hour Shock threshold Acknowledgement to Anand Kumar

37 Septic shock: the golden hour Shock threshold Antimicrobials Acknowledgement to Anand Kumar

38 Adequacy of initial spectrum and timing of first delivery and achievement of MIC are collectively the key Reduce microbial and toxic load...so hit hard and hit fast... BUT...

39 How do we know which septic patient is going to organ failure? We often don t know the source, let alone the bug... We don t adhere to guidelines, and the guidelines aren t much good We re not very good with our timing So...

40 SSC Results: Critical Care Medicine 2010; 38(2): 1 8

41 Should we have, for first dose, the Sepsis Antibiotic? Pip/ taz? Meropenem? Linezolid? Forget severe sepsis??

42 How to simplify sepsis care..where to start?

43 Sepsis Resuscitation Bundle (To be started immediately and completed within 6 hours) Serum lactate measured Blood cultures obtained prior to antibiotic administration From the time of presentation, broad spectrum antibiotics to be given within 1 hour Control infective source In the event of hypotension and/or lactate >4mmol/L (36mg/dl): Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent) Give vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate >4 mmol/l (36 mg/dl): Achieve central venous pressure (CVP) of >8 mm Hg Achieve central venous oxygen saturation (ScvO 2 ) >70%

44 Sepsis Resuscitation Bundle (To be started immediately and completed within 6 hours) Serum lactate measured Blood cultures obtained prior to antibiotic administration From the time of presentation, broad spectrum antibiotics to be given within 1 hour Control infective source In the event of hypotension and/or lactate >4mmol/L (36mg/dl): Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent) Give vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate >4 mmol/l (36 mg/dl): Achieve central venous pressure (CVP) of >8 mm Hg Achieve central venous oxygen saturation (ScvO 2 ) >70%

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53 Sepsis as a CQUIN measure

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55 Where to start? Unfortunately, only 30% will have severe sepsis in ED Median time to worst obs over 2.5 hours Range minutes Nelson JL, Smith BL, Jared JD et al. Prospective trial of real time electronic surveillance to expedite early care of severe sepsis. Annals of Emergency Medicine 2011; 57: 500 4

56 Know your reliability Resuscitation bundle item Achieved Failed 2005 Data % % % Blood cultures taken Antibiotics as per guidelines in <1hr Lactate measured Adequate fluid resuscitation

57 Know your processes Seen by first doctor Onset of Severe Sepsis Seen by Senior Doctor Discussed with Senior Doctor Arrive Critical Care Seen by Critical Care Specialist 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 Blood Culture taken Antibiotics given Radiology CVP line placed

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67 Compliance at Good Hope Hospital (%) Sepsis 6 Resusc Both Apr-09 Jun-09 Aug-09 Oct-09

68 Compliance at Good Hope Hospital (%) Sepsis 6 Resusc Both Mortality Apr-09 Jun-09 Aug-09 Oct-09

69 Mortality by Sepsis Six Cohort size Mortality % RRR Total Sepsis Six : Oxygen therapy Blood culture Antibiotic administration Fluid challenges Lactate and haemoglobin measurement Urine output monitoring. within one hour

70 Mortality by Sepsis Six Cohort size Mortality % RRR % (%) (NNT) Total 567 (100) Sepsis Six Sepsis Six 220 (38.8) (61.2) (4.16)

71 Mortality by antibiotics Cohort size Mortality % RRR % (NNT) Total 567 (100%) Delayed Antibiotics Antibiotics within 1 h 217 (38.4%) (61.6%) (5.77)

72 Mortality by fluid challenges Cohort size Mortality % RRR % (NNT) Total 567 (100%) No fluids in 1h 183 (32.3%) 44.8 Fluids in 1h 384 (67.7%) (6.73)

73 For patients receiving the Sepsis Six 2.0 fewer Critical Care bed days 3.4 fewer hospital bed days Compared with other survivors Equates to c. 5,000 cost saving

74 The clincher

75 Achieving 80% reliability For each year, for every 500 beds.. 62 lives saved 883 fewer bed days 520 fewer CC bed days Direct costs for survivors reduced by 0.78M

76 Behind the scenes of UKSG

77 Response to National Outcomes Framework Consultation Response to NHS CE Innovation call Lobbying of NQB Lobbying of NCDs Successful engagement of Health Foundation QIPP NHS Institute Patient Safety Forum Media!

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80 Summary Sepsis is a medical emergency and a big killer Awareness and recognition are the key Early antibiotics and fluids will save more lives than Critical Care Pre hospital recognition may improve the reliability of basic interventions We need to get the balance right, together

81 Sepsis should be afforded the same import as ACS and stroke Increasing public and media expectations and Department of Health attention will drive higher standards We will be the ones ultimately responsible for delivering those standards and for driving change Reliable delivery of early basic care depends on a seamless care process from home to specialist care: just like for ACS and stroke

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85 Declaration of interests Within the last 24 months, I have received travel expenses and honoraria to deliver two U.K lectures from Astra Zeneca, manufacturers of the antibiotic Meropenem. I have also received consultancy fees from CareFusion, manufacturers of the antiseptic preparation ChloraPrep