webinar - surviving sepsis: state of the art
DESCRIPTION
Intervention: Sepsis Date: Thursday, May 8, 2014 Sponsor: •Canadian Patient Safety Institute •Canadian ICU Collaborative Speakers: •John C. Marshall, MD FACS, St. Michael’s Hospital, University of Toronto Purpose of the Call: Provide update on the Surviving Sepsis CampaignTRANSCRIPT
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SURVIVING SEPSIS: STATE OF THE ART
Thursday, May 8 2014 Jeudi 8 mai 2014
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Your Hosts & Presenters Vos hôtes et présentateurs
Bruce Harries, Moderator
Denny Laporta, MD, FRCPC, CSPQ
Ardis Eliason, Technical Host
John C. Marshall, MD, FRCSC, FACS
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Interacting in WebEx: Today’s Tools Interagir dans Webex : outils à utiliser
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08/05/2014
Type your message & click ‘send’
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Who’s Online? Qui est en ligne?
POINTER
08/05/2014
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What professions are represented? Quelles professions sont représentées?
Nurse MD
Educator / Quality Improvement Professional
Infection Control
Administrator / Senior Leader
Other
POINTER
Respiratory Therapist
Nutritionist
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Dr. John C. Marshall
Surviving Sepsis: State of the Art
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The Surviving Sepsis Campaign:
State of the Art
St. Michael’s Hospital University of Toronto
John C. Marshall MD FACS
Safer Healthcare Now May 8, 2014
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Paris, 1997 …
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• Definitions • Diagnosis of infection • Antibiotics • Hemodynamic support • Source control • ICU care • Adjunctive therapies • Novel therapies
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Phase 1 Barcelona declaration Phase 2 Evidence-based guidelines Phase 3 Implementation and evaluation
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A global program to reduce mortality rates in severe sepsis
ESICM, ISF and SCCM
Partially funded by unrestricted educational grants
from Baxter, Edwards, Philips and Lilly
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Sponsoring Organizations • American Association of Critical Care Nurses • American College of Chest Physicians • American College of Emergency Physicians • American Thoracic Society • Australian and New Zealand Intensive Care Society • European Society of Clinical Microbiology and Infectious
Diseases • European Society of Intensive Care Medicine • European Respiratory Society • International Sepsis Forum • Society of Critical Care Medicine • Surgical Infection Society
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Guidelines Meeting
London, England
June 2003
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- Crit Care Med 32:858, 2004
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The Sepsis Bundles
• Institute for Healthcare Improvement (IHI)
• Measurable activities that indicate compliance with guidelines
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- N Engl J Med 355:1640, 2006
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San Francisco, January 2006
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American Association of Critical-Care Nurses American College of Chest Physicians American College of Emergency Physicians American Thoracic Society Canadian Critical Care Society European Society of Clinical Microbiology and Infectious Diseases European Society of Intensive Care Medicine European Respiratory Society International Sepsis Forum Society of Critical Care Medicine Japanese Association for Acute Medicine Japanese Society of Intensive Care Medicine Surgical Infection Society Participation and endorsement by the German Sepsis Society and the Latin American Sepsis Institute.
Sponsors 2006
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- Crit Care Med 36:296, 2008
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Miami 2010
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- Crit Care Med 41:580, 2013
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Grading of Recommendations
Assessment, Development, and Evaluation
• Strength of the Evidence
• Strength of the Recommendation
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Improving Sepsis Care
• Recognition
• Resuscitation
• Diagnosis and treatment of infection
• Physiologic support
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Improving Sepsis Care
• Recognition
• Resuscitation
• Diagnosis and treatment of infection
• Physiologic support
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Rates of Sepsis, U.S. 1979 - 2001
- Martin, N Engl J Med 348:1546, 2003
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Sepsis in the Emergency Department
• Acute change in health status
• Unexplained organ dysfunction
• Febrile illness
• Underlying co-morbidities
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Sepsis on the
Hospital Ward
• Fever, tachycardia
• Altered mental status
• Fluid retention
• New organ dysfunction
• Often subtle presentation
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Sepsis
Think of it!
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Improving Sepsis Care
• Recognition
• Resuscitation
• Diagnosis and treatment of infection
• Physiologic support
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Optimize Oxygen Delivery to Tissues
• Restore intravascular volume
• Support cardiac function
• Provide oxygen
• Enhance O2 carrying capacity
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Lactate Metabolism
Anerobic
Aerobic
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Resuscitation
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Early Goal-directed Therapy for Septic Shock
Standard Goal-Directed (N=133) (N=130) MVO2 65.3+11.4 70.4+10.7* APACHE II 15.9+6.4 13.0+6.3* Mortality 46.5% 30.5%*
* p<0.02 - Rivers, N Engl J Med 345:1368, 2001
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CVP
Mean Arterial Pressure > 8
<8 Fluids
ScvO2
> 65 <65
Pressors
Goals achieved > 70 Transfusion,
Inotropes
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- Angus, N Engl J Med 370:1683, 2014
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The SAFE Study Investigators, N Engl J Med 2004;350:2247
Saline and Albumin are Equally Efficacious
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Mortality is Increased with Starches
- Zarychanski, JAMA 309:678, 2013
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- N Engl J Med 370:1583, 2014
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- N Engl J Med 370:1583, 2014
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Improving Sepsis Care
• Recognition
• Resuscitation
• Diagnosis and treatment of infection
• Physiologic support
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Diagnosis
Antibiotics
Source Control
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Odd
s R
atio
for D
eath
(9
5% C
I)
1
10
100
Time from Onset of Hypotension (Hours)
-Kumar, Crit Care Med 34:1589, 2006
Impact of Delayed Antibiotic Therapy on Clinical Outcome
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“Early versus late necrosectomy in severe necrotizing pancreatitis”
Number Mortality Early 25 58% Late 11 27%
- Mier et al Am.J.Surg 173:71, 1997
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Improving Sepsis Care
• Recognition
• Resuscitation
• Diagnosis and treatment of infection
• Physiologic support
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Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury
and the acute respiratory distress syndrome
Mortality (%) Controls 39.8
Volume-limited 31.0*
ARDSNet; NEJM 342:1301, 2000
*P=0.007
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Impact of Fluid Strategy in ARDS
Conservative Liberal p. (N=503) (N=497) 60 day mortality 25.5% 28.4% 0.30 Ventilator-free days 14.6±0.5 12.1±0.5 <0.001 ICU-free days 13.4±0.4 11.2±0.4 <0.001 CNS failure FD 18.8±0.5 17.2±0.5 0.03
- ARDSNet, N Engl J Med 354:2564, 2006
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Survival in NICE/SUGAR
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Drotrecogin alfa was ineffective in low risk patients …
Abraham E N Engl J Med 2005;353:1332
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Time to Shock Reversal
Survival Sprung et al, N Engl J
Med 358:111,2008
CORTICUS
N=499
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Has It Made a Difference?
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• Global process change initiative based on “sepsis bundles”
• 15,022 patients enrolled
• 7% absolute, 5.4% relative mortality reduction (p<0.001)
Surviving Sepsis Campaign
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Unadjusted Risk-adjusted
Bundle target Population N OR p-value
OR 95% CI p-value
Measure Lactate All 15,022 0.86 <0.0001
0.97 [0.90, 1.05] 0.48
Obtain blood cultures before antibiotics All 15,022
0.70 <0.0001 0.76 [0.70, 0.83] <0.0001
Commence broad-spectrum antibiotics All 15,022
0.78 <0.0001 0.86 [0.79, 0.93] <0.0001
Achieve tight glucose control All 15,022 0.65 <0.0001
0.67 [0.62, 0.71] <0.0001
Administer drotrecogin alfa Multi-organ failure 8,733 0.90 0.26
0.84 [0.69, 1.02] 0.07
Administer drotrecogin alfa Shock despite fluids 7,854 0.91 0.30
0.81 [0.68, 0.96] 0.02
Administer low-dose steroids Shock despite fluids 7,854 1.06 0.18
1.06 [0.96, 1.17] 0.24
Demonstrate CVP ≥ 8 mm Hg Shock despite fluids 7,854 1.08 0.10
1.00 [0.89, 1.12] 0.98
Demonstrate ScvO2 ≥ 70% Shock despite fluids 7,854 0.94 0.24
0.98 [0.86, 1.10] 0.69
Achieve low plateau pressure control Mechanical ventilation 7,860 0.67 <0.0001
0.70 [0.62, 0.78] <0.0001
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- Kaukonen et al JAMA 2014
Survival in Sepsis is Improving
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Conclusions • The SSC has raised awareness regarding sepsis management and defined optimal approaches to care
• This has been associated with improved survival
• But the elements responsible for that improvement need further study
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Thank You!!
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QUESTIONS?
RAISE YOUR HAND / LEVEZ LA MAIN
OR/OU
CHAT TO “ALL PARTICIPANTS”
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a Canadian Critical Care Knowledge Translation Network
“aC3KTion Net”
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aC3KTion Net • Network of ICUs (Networks) from across
Canada • Academic • Community
• Primary activity will be Knowledge Translation and development of Critical Care Knowledge Synthesis products
• Not KT Research
• Measurement of uptake/outcomes
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Network Activities • Measurement of current practice • Knowledge Synthesis: Development of clinical practice guidelines,
evidence syntheses and scoping reviews.
• Testing of Knowledge Products: Reviewed and tested before implementation, to ensure acceptability, ability to achieve intended purpose and ascertain possible barriers
• Knowledge Implementation: Local teams will use strategies/tools tailored to knowledge product. – Education, protocols, checklists, order sets, organizational changes and
reminder systems – PDSA cycles to track implementation activities
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Even when motivated to change our behavior, we cannot manage what we do not measure.
Measurement can identify gaps in best practice.
Measurement can illuminate the results of our efforts at implementing best practice.
Measurement can inform future research direction.
Measurement- Why?
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Model for Participation • Main benefits of participation
– Access to KT activities/initiatives – Access to KS products – Access to educational events/webinars – Access to a repository of knowledge products, protocols etc. – Opportunity to participate in incubator units – Ability to influence network activities – Benchmarked reports of performance with national peers – A vehicle to drive critical care quality improvement
• ICUs provide periodic data in return
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Current Status
• Baseline Data Collection – Started and ongoing. Site recruitment ongoing.
• Development of barriers/enablers Questionnaires – Completed
• Repository of KT tools/Products – Being populated
• KT activities – Slated for 2014
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Questions/Comments?
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Canadian ICU Collaborative Faculty
Paule Bernier, P.Dt., Msc, Présidente, Ordre professionnel des diététistes du Québec; Sir MB David Jewish General Hospital (McGill University), Montreal
Paul Boiteau MD, Department Head, Critical Care Medicine, Alberta Health Services; Professor of Medicine, University of Calgary Mike Cass, BSc, RN, MScN, Advanced Practice Nurse, Trillium Health Centre Leanne Couves, Improvement Advisor, Improvement Associates Ltd. Maryanne D’Arpino, Patient Safety Improvement Lead, CPSI Bruce Harries, Collaborative Director, Improvement Associates Ltd. Denny Laporta MD, Intensivist, Department of Adult Critical Care, Jewish General Hospital; Faculty of Medicine, McGill University Claudio Martin MD,Intensivist, London Health Sciences Centre, Critical Care Trauma Centre; Professor of Medicine and Physiology,
University of Western Ontario; Chair/Chief of Critical Care Western Cathy Mawdsley, RN, MScN, CNCC; Clinical Nurse Specialist – Critical Care, London Health Sciences Centre; John Muscedere MD, Assistant Professor of Medicine, Queens University; Intensivist, Kingston General Hospital Yoanna Skrobik MD, Intensivist, Hôpital Maisonneuve Rosemont, Montréal; Expert Panel for the new Pain, Sedation and Delirium
Guidelines, Society of Critical Care Medline (SCCM)
69 08/05/2014
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Reminders Rappels
Call is recorded Slides and links to
recordings will be available on Safer Healthcare Now! Communities of Practice
Additional resources are available on the SHN Website and Communities of Practice
L'appel est enregistré Les diapositives et liens
vers les enregistrements seront disponibles sur Des soins de santé plus sécuritaires maintenant! Communautés de pratique
Des ressources supplémentaires sont disponibles sur le site Web SSPSM et Communautés de Pratique
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THANK YOU MERCI
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