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Sepsis, Sepsis, SepsisMicah Beachy, DO, FACPAssociate Professor of Internal MedicineImmediate Past Chair, ACP Council of Early Career Physicians

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Disclosures / Disclaimers

Disclosures: None

Disclaimer: None

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Describe the differences between the old definition, the sepsis 3 definition, and CMS core measure

Identify how qSOFA should be incorporated into care

Review components of the 3 & 6 hour bundle

Objectives

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Sepsis Definitions

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Definition: Sepsis-1

Definition developed by consensus conference in 1991

Based of the host’s response to infection• Temp >38C or <36C• Heart Rate >90/min• Respiratory rate >20/min• WBC >12,000/mm3 or <4000/mm3

Bone RC, et al., Crit Care Med. 1992:20(6): 864-874

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Definitions of Sepsis Syndromes

SIRS: HR>90, temp >38.2 or <36, RR >20, WBC >12K or <4K, altered mentation

Sepsis: SIRS plus confirmed or suspected infection Severe Sepsis: Sepsis plus evidence of acute organ

failure Septic Shock: Sepsis with hypotension despite

adequate fluid resuscitation

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Definition: Sepsis-2

Expert panel expanded the diagnostic criteria in 2001

Sepsis Syndromes remained similar

Levy MM, et al; Intensive Care Med 2003; 29(4):530-538

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Definition: CMS

• SEP-1 Core Measure for Severe Sepsis and Septic Shock

• Started October 2015• Focuses on adherence to the 3 & 6 hour

bundle• Retrospective review of sepsis patient• 7 component metrics create a composite score• Pass/fail

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(image of Oola from Star Wars, he was Majordomo to Jabba the Hut)

(image of ostrich with its head in sand)

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Definition: Sepsis-3

Released in 2016 Wanted to differentiate between sepsis and

uncomplicated infection Wanted to remove improve the consistency and

specificity of language used

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Infection

SepsisSeptic Shock

Definition: Sepsis-3

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Sepsis-1/2 Core Measure Sepsis-3

SIRS Downplaysutility

Sepsis SIRS + infx SIRS + infx Life threateningorgan dysfunction(qSOFA ≥2)

Severe Sepsis End organ dysfunction OR lactate ≥4

Sepsis + lactate >2

n/a

Septic Shock Persistent hypotension

Persistenthypotension or lactate ≥4

Persistent hypotension

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Definition: Further Consideration

2016 Surviving Sepsis Campaign guidelines adopted Sepsis-3 definition

CMS has no current plans of changing their SEP-1 definition

Billing/coding utilizing ICD-10 codes which includes severe sepsis

Utilizing qSOFA

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qSOFA

Sepsis-3 definition• “life-threatening organ dysfunction due to dysregulated

host response to infection”

Given lack of gold standard for sepsis several clinical criterion were evaluated in ICU & non-ICU settings• SIRS• Sepsis-Related Organ Failure Assessment (SOFA)• Logistic Organ Dysfunction System (LODS)• qSOFA

Assessment of Clinical Criteria for Sepsis For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288

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qSOFA

Blood pressure <100 mm Hg Altered Mental Status Tachypnea ≥ 22/min

0-3 points: 1 point for each criteria (>2 is positive)

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qSOFAAssessment of Clinical Criteria for Sepsis For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288

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qSOFAAssessment of Clinical Criteria for Sepsis For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288

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qSOFAAssessment of Clinical Criteria for Sepsis For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288

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qSOFA

Task force recommendations• ICU setting

• Score of ≥ 2 in infected patients as criteria for sepsis• qSOFA should be used in non-ICU setting to consider

sepsis

• Limitations• “The qSOFA is not an alert that alone will differentiate

patients with infection from those without infection”• Variability of assessing mental status• Serum lactate not included in risk model

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Surviving Sepsis Campaign: Components of

the 3 & 6 hour bundle

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• Panel of 55 international experts• Adopted the Sepsis-3 definition; not qSOFA• 93 statements on early management and

resuscitation of patients with sepsis or septic shock• 32 strong recommendations• 39 weak recommendations• 18 best-practice statements

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SSC: Recommendations

Sepsis and septic shock are medical emergencies; treatment and resuscitation

should begin immediately (BPS)

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SSC: Initial Resuscitation

Sepsis induced hypo-perfusion at least 30 mL/kg of IV crystalloid within first 3 hours (strong recommendation, low quality of evidence)

After initial fluid resuscitation additional fluids should be guided by reassessment (BPS)

Target a MAP of >65 for septic shock patients requiring vasopressor support (strong recommendation, low quality of evidence)

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We recommend the protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion. During the first 6 hours of resuscitation, the goals of initial resuscitation should include all of the following as a part of a treatment protocol:

a) CVP 8–12 mm Hgb) MAP ≥ 65 mm Hgc) Urine output ≥ 0.5 mL/kg/hrd) Scvo2 ≥ 70%.

2012 Recommendation for Initial Resuscitation.

We recommend the protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion. During the first 6 hours of resuscitation, the goals of initial resuscitation should include all of the following as a part of a treatment protocol:

a) CVP 8–12 mm Hgb) MAP ≥ 65 mm Hgc) Urine output ≥ 0.5 mL/kg/hrd) Scvo2 ≥ 70%.

2012 Recommendation for Initial Resuscitation.

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Intravenous Fluids

EGDT 2.8 L

Usual Care 2.3 L

Intravenous Antibiotics

EGDT 97.5%

Usual Care 96.9%

Intravenous Fluids

EGDT 2.8 L

Usual Care 2.3 L

Intravenous Antibiotics

EGDT 97.5%

Usual Care 96.9%

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SCC: Recommendations

The overall management of sepsis has changed…• In all three studies patients had early antibiotics, >

30ml/kg of intravenous fluid prior to randomization.

“We need therefore to be very careful about over interpreting the results in areas where this paradgim is not valid.“

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SCC: Antimicrobial

IV antimicrobials should be started quickly after recognition and within one hour for both sepsis and septic shock (strong recommendation, moderate quality of evidence)

Initiate empiric broad-spectrum therapy with ≥ 1 antimicrobials to cover all likely pathogens in sepsis/septic shock patients (strong recommendation, moderate quality of evidence).

We recommend that empiric antimicrobial therapy be narrowed once pathogen identification and sensitivities are established and/or clinical improvement is noted (BPS)

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SCC: Bundles

Under revision to match SSC 2016

Expected release mid-May 2018

2012: 3-6 Hour Bundle 2018: 3-6 Hour Bundle

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SCC: Recommendations

”We recommend that hospitals and hospital systems have a performance improvement program for

sepsis, including sepsis screening for acutely ill, high-risk patients (BPS)”

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Clinical Effectiveness Sepsis Program

Clinical Effectiveness (CE) program partnership with multi-disciplinary sepsis operational team focused on reducing variability in sepsis care

Implemented tools and processes to improve early identification

Standardized documentation for outside transfers to assist with screening

Developed education and ongoing marketing campaign EHR improvements implemented to assist with core

measure adherence Development of a code sepsis team

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Clinical Effectiveness Sepsis Program

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FY Quarter

# of Sepsis Cases

Sepsis Mortality

Index Deaths (Obs)Expected

DeathsLives Saved

2017-1 319 0.69 30 44 142017-2 341 0.63 29 46 172017-3 372 0.73 39 53 142017-4 351 0.82 37 45 8

FY17 Total Lives Saved = 53

Lives Saved

02468

1012141618

2017-1 2017-2 2017-3 2017-4

# of

Liv

es S

aved

FY Quarter

Lives Saved

Lives Saved

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Sepsis Team Members Past and Present

CE Steering Members Past and Present

Acknowledgments

Lisa Ablan Kelly Cawcutt Jo Jameson Greg Peitz Karen TownsleyMike Altschuld Kellie Clapper Brandi Johansen Kiri Rolek Melanie TuamoheloaNate Anderson Sandy Crites Brandon Jordon Jamie Rudd Jana UryaszOzgur Araz Tracy Diehm Dan Kalin Todd Sauer Trevor VanschooneveldLorena Baccaglini Val Driscoll Katie Kerrigan Dara Schlecht Suzanne WatsonAaron Barksdale Dave Gannon Maria Lander Lisa Schlitzkus Adam WellsMicah Beachy Jodi Garrett Anna May Michelle Schulte Tammy WinterboerNancy Bernard Ashley Gay Amy Mead Megan Skryja Kirstin WoodburyJustin Birge Emilie Goldsberry Jenny Nano Christopher Smith Wes ZegerCharlotte Brewer Meredith Hellman Jennifer Nguyen Sue Stensland Qin Zijian

Michael Ash David W MercerMary Jo Brummel Rosanna MorrisJames Canedy Sue NussJulie Fedderson Matt PospisilHarris Frankel Debra RombergerDeb Istas Cory Shaw

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