the sepsis timebomb - wordpress.com · the sepsis timebomb james wigfull ... shock to effective...
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The Sepsis Timebomb
James Wigfull Critical Care and Anaesthesia Sheffield Teaching Hospitals
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Relationship of SIRS, Sepsis and Infection
The ACCP/SCCM consensus Conference Committee, Chest 1992;101:1644-55.
INFECTION
SEPSIS
SIRS
BURNS
OTHER
TRAUMA
BACTEREMIA
FUNGEMIA
PARASITEMIA
VIREMIA
OTHER
PANCREATITIS
POST-PUMP SYNDROME
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Sepsis and mortality
Vallés et al. Chest 2003;123:1615–1624
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Time
Antiinflammatory
(endogenous)
CARS
SIRS RECOVERY
Organ Injury
van der Poll T, van Deventer SJH. Infect Dis Clin N Am
Infection
Antimicrobials
Sepsis and Septic Shock: An
Intensivist’s Immunologic View
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Microbial load
Inflammatory response
Toxic burden
Cellular dysfunction/tissue injury
TIME
Sepsis and Septic Shock: An ID View
Shock Threshold
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“An Injury Paradigm of Sepsis and Septic Shock” Prof A Kumar, University of Manitoba
Microbial load
Inflammatory response
Toxic burden
Cellular dysfunction/tissue injury
TIME
Antimicrobial
therapy
Shock
Threshold
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“An Injury Paradigm of Sepsis and Septic Shock” Prof A Kumar, University of Manitoba
Microbial load
Inflammatory response
Toxic burden
Cellular dysfunction/tissue injury
TIME
earlier
antimicrobial
therapy
Shock
Threshold
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“An Injury Paradigm of Sepsis and Septic Shock” Prof A Kumar, University of Manitoba
Microbial load
Inflammatory response
Toxic burden
Cellular dysfunction/tissue injury
TIME
Antimicrobial
therapy
+
Source control
Shock
Threshold
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Kumar et al. CCM. 2006:34:1589-96.
Cumulative Initiation of Effective Antimicrobial Therapy and Survival in Septic Shock
time from hypotension onset (hrs)
fraction o
f to
tal patients
0.0
0.2
0.4
0.6
0.8
1.0 survival fraction
cumulative antibiotic initiation
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Kumar et al, CCM. 2006:34:1589-96.
Mortality Risk with Increasing Delays in Initiation of Effective Antimicrobial Therapy
Time (hrs)
Od
ds R
atio
of D
ea
th
(95
% C
on
fid
en
ce
In
terv
al)
1
10
100
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Comparison with other time dependent interventions
Not recognized early Easy diagnosis
Insidious onset Clear onset
Often develops on wards Presents to A&E
NNT
Severe sepsis 6-8 Septic shock
NNT
MI 30 CVA 30-40 Trauma 30
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Door to balloon time and mortality in AMI
Adapted from Cannon et al. JAMA 2000; 283: 2941-7.
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Door to balloon time and mortality in AMI
0-2h >2-3h >3-4h >4-6h >6-12h >12h
"Preventable deaths" 0 282 1350 1555 1384 204
0
200
400
600
800
1000
1200
1400
1600
"P
reven
tab
le" d
eath
s p
er
year
By getting door-to-balloon times of <2h for ALL STEMI patients,
we would save 4775 lives per year.
Adapted from Cannon et al. JAMA 2000; 283: 2941-7.
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Shock to effective antibiotic time and mortality in septic shock
Adapted from Kumar et al. Crit Care Med 2006; 34: 1589-96.
0-2h >2-3h >3-4h >4-6h >6-12h >12h
%Mortality 26.7 36.1 36.6 46.8 62.3 83.1
% of patients 26.8 9.0 7.8 12.8 18.8 24.9
0
10
20
30
40
50
60
70
80
90 P
erc
en
tag
e o
f p
ati
en
ts
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0-2h >2-3h >3-4h >4-6h >6-12h >12h
"Preventable" Deaths 0 1093 1000 3318 8710 18239
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
"P
reven
tab
le" d
ea
ths p
er
year
Shock to effective antibiotic time and mortality in septic shock
Adapted from Kumar et al. Crit Care Med 2006; 34: 1589-96.
By getting shock-to-antibiotic times of <2h for ALL septic shock patients,
we would save 32,360 lives per year.
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83 72
50 35 26
18
Ab’s given
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Effect of Failure to Implement Source Control if Required
0
20
40
60
80
100
Source Control
Implemented
Source Control Not
Implemented
% total patients
% survival
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Cumulative Source Control Implementation and
Survival in Septic Shock
time from hypotension onset (hrs)
fraction o
f to
tal patients
0.0
0.2
0.4
0.6
0.8
1.0 survival fraction cumulative source control implementation
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Source Control/Antimicrobial Interaction and Survival in Septic Shock
Antimicrobial Initiation Post-Shock
< 3 h 3-6 h
Source
Control
Initiation
Post-Shock
< 6 h
> 24 h
92%
(n=75)
70.3%
(n=37)
80.0%
(n=60)
46.0%
(n=50)
44.4%
(n=63)
13.0%
(n=100)
19.0%
(n=94)
36.0%
(n=25)
69.0%
(n=29)
> 6 h
6-24 h
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83
83
78
78
72
72
60
Ab’s given Source control
22 30
46%
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0
1
2
3
4
5
6
7
8
9
A B C D E F
A: SHEWS 2 to SpR review
B: SpR review to Antibiotics
C: CT booking to scan
D: CTscan to report
E: Scan to theatre booking
F: Booking to arrival
Audit of Event timing from SHEWS 2 to theatre for
the deteriorating colorectal patient at NGH from
October 2009 to March 2010
hours
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0
5
10
15
20
25
Survivors Non-
survivors
Total time fromtrigger to theatre
Audit of Event timing from SHEWS 2 to theatre for
the deteriorating colorectal patient at NGH from
October 2009 to March 2010
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Resulting in 25000 deaths
100 000 will develop significant complications
170 000 patients per year in the UK receive higher risk emergency general surgery
The Size Of The Problem
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Number of ITU beds by country
0 5 10 15 20 25 30
Germany
Belgium
Croatia
USA
Canada
France
Netherlands
Spain
Australia
New Zealand
China
UK
Series1 Series2
█ ITU beds per 100000 population
█ ITU beds per 100 acute hospital beds
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Key recommendations
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Key recommendations
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Key recommendations
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Key recommendations
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Key recommendations
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The National Emergency
Laparotomy Audit
Dave Murray
National Clinical Lead
www.nela.org.uk [email protected]
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Audit against standards
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–Patient Pathway:
•Clear diagnostic and monitoring plans
•Adoption of escalation strategy with early involvement of senior staff
•Timing of diagnostic tests / timing of surgery • Adequate emergency theatre access with appropriate prioritisation
• Post-operative location
• Risk of death estimated and documented:
• prior to surgery to ensure adjustments made in urgency of care and seniority of staff involved
• at end of surgery to determine optimal location for post-operative care
•Key Recommendations: Delivery of Care
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Key Recommendations: Individualised care •High risk patients
–≥10% 30d mortality
–Two consultants in theatre (surgeon and anaesthetist)
–Post-op Critical Care Unit
–‘Elderly’ patients
– Specialist input pre- and post-op
– Nutrition
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The role of Outcome Measures in
improving quality of care
• 30-day mortality
• Risk adjusted via P-POSSUM
• Unplanned
‒ return to theatre
‒ escalation of care
‒ 30-day readmission
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The role of Process Measures in
improving quality of care
• Admission to first dose of antibiotics
• Time from decision to theatre
• Pre-op CT scan
• Objective assessment of risk of death
• High risk patients directly admitted to critical care post-op
• Key Standards of Care relate to patient’s predicted risk of death
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Conclusions
With the onset of shock – the mortality clock starts ticking!
Timely delivery of appropriate antibiotics is everybody’s responsibility – deal with it if it hasn’t already happened
Source control – the mortality clock does not wait for a convenient theatre slot