disclosures code sepsis (not now…maybe later) · •equivocal cvl use ... –within 6 hours from...

5/31/2014

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CODE SEPSIS (not now…maybe later)

David Shimabukuro, MDCM Associate Professor

Medical Director, 13 ICU Physician Lead, UCSF DSRIP Sepsis Project

Disclosures

• I have no disclosures

Agenda

• Epidemiology

• The “Surviving Sepsis Campaign Bundles”

• The UCSF Experience

• Future considerations

Agenda

• Epidemiology




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Epidemiology

• By the numbers…

– Greater than 750,000 adults every year

– Greater then $10 billion a year in associated costs

– US mortality rate between 25-30%

Compared to other major diseases

†National Center for Health Statistics, 2001. §American

Cancer Society, 2001. *American Heart Association. 2000. ‡Angus DC et al. Crit Care Med. 2001 .

0

50

100

150

200

250

300

AIDS* Colon Breast

Cancer§

CHF† Severe Sepsis‡

Ca

se

s/1

00

,000

Incidence of Severe

Sepsis

US Death rate over time

0

50

100

150

200

250

300

2000 2002 2004 2006 2008 2010

Heart Disease

Malignant Neoplasms

Cerebrovascular Disease

Septicemia

National Vital Statistics Reports, vol 6, no 4, May 08, 2013

Agenda

• Epidemiology




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What is Sepsis??

• A variable condition that affects each of us differently and is initiated by an infectious insult.

• Involves the systemic activation of the inflammatory response and an unbalancing of the coagulation cascade

Septic Shock

SEVERE SEPSIS plus hypotension (Systolic

blood pressure < 90 or Mean Arterial Blood Pressure < 65) OR

Lactate > 4

Severe Sepsis

SEPSIS plus evidence

of at least one alteration in organ

perfusion

Sepsis

SIRS plus confirmed

or suspected infection

Sepsis: ACCP/SCCM Definitions

SIRS

T > 38.3 C or < 36 C

HR > 90 beats/min Tachypnea

WBC > 12K or < 4K

Severe Sepsis Definition

Crit Care Med February 2013 Volume 41 Number 2 pp. 580-637

Management of Severe Sepsis and Septic Shock


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1


• Blood cultures should not delay administration of antibiotics.

• It is not uncommon for blood cultures to be negative despite the presence of a severe infection.

Crit Care Med 2006 Vol. 34, No. 6

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• Normalization of lactate as a resuscitation goal is suggested

– Use of rate of lactate clearance is mentioned, but not endorsed as a sole target


• Fluid Therapy

– Crystalloids are first choice for the overwhelming majority of patients

– Albumin can be used to reduce volume from crystalloids, but no difference on mortality

– Hydroxyethyl starches should not be used

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• Corticosteroids

– For refractory hypotension despite fluids and vasopressors/inotropes

– Do not perform ACTH stimulation test

• Glucose

– Target level to less than 180 mg/dL


• Blood Products

– HGB level 7.0 – 9.0 g/dL after hypoperfusion has resolved

– FFP not to be used unless bleeding is present or for planned invasive procedure

– PLT to be given prophylactically when <10K in absence of bleeding


• More recommendations…refer to original paper

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• 1341 patients

• 31 academic emergency departments

• Primary end-point: 60-day in-hospital mortality

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Major criticisms

• Academic centers

• “usual care” not defined

• Equivocal CVL use

• Antibiotic time

Sepsis Screening


Great….but when should we do it and how should it be done!!!!

Sepsis Screening

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Sepsis Screening Sepsis Screening

• Important to have one that works for the hospital

• Should probably do once a shift (no clear data)

• Screening works as a reminder for continued vigilance

Agenda

• Epidemiology




Severe Sepsis Resuscitation Goals* • Lactate

– Within 6 hours from time of presentation (TOP)

• Blood Cultures – Drawn before an antibiotic is given

• Antibiotics – Start of administration within 1 hour of the TOP (non ED), 3

hours (ED)

• Fluid Resuscitation – 20-30 mL/kg or a minimum of 1000 mL of crystalloid (or

albumin equivalent) administered as a bolus within 1 hour of TOP for hypotension or lactate > 4 mmol/L

• Vasopressors – Hypotension unresponsive to initial fluid bolus

• CA 1115 Waiver, DSRIP Category 4, Superset of Interventions, Severe Sepsis • Dellinger et al. (2008). Surviving Sepsis Campaign: International guidelines for management

of severe sepsis and septic shock: 2008. Crit Care Med,1, 296-327.

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APeX Sepsis Screening

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9 ICU severe sepsis BPA analysis

33 patients total Patients with

Severe Sepsis = 15 Patients without

Severe Sepsis = 18

BPA Triggered 18 patients

True Positive (TP) = 13

False Positive (FP) = 5

Positive Predictive Value TP/ (TP+FP) = 72%

No BPA Triggered

15 Patients

False Negative (FN) = 2

True Negative (TN) = 13

Negative Predictive Value

TN / (FN+TN) = 87%

Sensitivity

TP/ (TP+FN) = 87 % Specificity

TN/ (FP+TN) = 72%

41

14 M BPA Analysis

42

73 patients total Patients with

severe sepsis = 13 Patients without

severe sepsis = 60*

BPA triggered 21 patients

True Positive (TP) = 13

False Positive (FP) = 8

Positive Predictive Value TP/ (TP+FP) = 62%

No BPA triggered 52 patients

False Negative (FN) = 0*

True Negative (TN) = 52*

Negative Predictive Value TN / (FN+TN) = 100%

Sensitivity

TP/ (TP+FN) = 100 % Specificity

TN/ (FP+TN) = 87%

Code Sepsis

What is a Code Sepsis?

– A silent alert sent by pager to a designated team that includes a Pharmacist, the RRT and the ICU Fellow

– Purpose is to expedite severe sepsis resuscitation

How is a Code Sepsis Activated?

– Sepsis Navigator via the Severe Sepsis BPA

– Pagerbox

Roles and Responsibilities

• Bedside RN

– Activates Code Sepsis & notifies Primary Team

– Presents patient conditions

– Assists with sepsis resuscitation

• Primary Team

– Responds to patient’s bedside

– Collaborate on treatment decisions

– Write orders as needed

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Roles and Responsibilities • RRT

– Validate positive screen

– Support timely blood culture collection and administration of antibiotics and fluids

– Maintain time to assure resuscitation in 60 minutes

• Pharmacist – Facilitate verification, dispensing & delivery of antibiotics

– Follow-up with primary team for subsequent dosing

• ICU Fellow – Assist with selection/ordering of antibiotics, fluids, vasopressors

– Assist with blood culture collection as needed

– Assist with determining level of care

Our data

UCSF Sepsis Bundle Compliance

Sepsis Bundle Compliance

22%

4%0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Lactate BCx BSA Fluids Full Bundle Compliance

ED

Acute Care

ICU

14% Overall

Date of download: 8/27/2012

Copyright © American College of Chest Physicians. All rights reserved.

From: Nationwide Trends of Severe Sepsis in the 21st Century (2000-2007)National Trends of Severe Sepsis in

21st Century

CHEST. 2011;140(5):1223-1231. doi:10.1378/chest.11-0352

Frequency of admission and mortality rates due to severe sepsis, 2000-2007. Bars represent SEM.

Figure Legend:

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Agenda

• Epidemiology




50

New York Times, July 11, 2012

Future Considerations

• State mandates

– New York

– California: DSRIP

• NQF

• CMS

– TJC

– Leapfrog

Summary

• A very heterogeneous disease that is difficult to diagnose in its early stages and difficult to treat in its later stages.

• Routine screening can allow for earlier identification

• Early intervention can attenuate its course, but the mainstay of treatment is supportive care.

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ORGAN DYSFUNCTION EXAMPLES:

Lactate > 2 mmol/L

Neuro: Encephalopathy,focal neurologic deficits,altered mental status

Pulm: Increased oxygenrequirement to maintainbaseline Sp02

Renal: Acute kidney injury; urine output < 30 cc/hr X2 hours; Cr > 2 mg/dL

GI: Bilirubin > 2 mg/dL

Heme: Platelet count < 100 K, INR > 1.5 or PTT > 60 secs

CV: SBP < 90 or > 40 below baseline, or MAP < 65

Sepsis Screeningand Treatment Tool

≥ 2 SIRS OR

Confirmed/SuspectedInfection

≥ 2 SIRS+

Infection

YES

NEW onsetorgan

dysfunction?

Hypotensionrefractory to

fluid boluses?

Treat for SEPTIC SHOCK

YES

Treat for SEVERE SEPSIS

Treat for SEPSISConsider SEVERE SEPSIS

InfectionOnly

If the patient screens negative, and you suspect

sepsis, then TREAT FOR SEPSIS.

START

See Next Page for Treatment Recommendations

disclosures code sepsis (not now…maybe later) · •equivocal cvl use ... –within 6 hours from...

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