the surviving sepsis campaign: the sepsis epidemic: how to win

The Surviving Sepsis The Surviving Sepsis Campaign:Campaign:

The Sepsis Epidemic: The Sepsis Epidemic:

How to WinHow to Win

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TTime ime SSensitive ensitive IInterventionsnterventions

• AMI – “Door to PCI” Focus on the timely return of blood flow to the affected

areas of the heart. • Stroke – “Time is Brain”

The sooner that treatment begins, the better are one’s chances of survival without disability.

• Trauma – “The Golden Hour” Requires immediate response and medical care “on the

scene.” Patients typically transferred to a qualified trauma center

for care.

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SSevereevere SSepsisepsis vs. vs.

CCurrenturrent CCareare PPrioritiesriorities

Care PrioritiesU.S.

Incidence# of Deaths Mortality Rate

AMI (1) 900,000 225,000 25%

Stroke (2) 700,000 163,500 23%Trauma (3)

(Motor Vehicle)

2.9 million (injuries)

42,643 1.5%

Severe Sepsis (4) 751,000 215,000 29%

Source: (1) Ryan TJ, et al. ACC/AHA Guidelines for management of patients with AMI. JACC. 1996; 28: 1328-1428. (2) American Heart Association. Heart Disease and Stroke Statistics – 2005 Update. Available at: www.americanheart.org. (3) National Highway Traffic Safety Administration. Traffic Safety Facts 2003: A Compilation of Motor Vehicle Crash Data from the Fatality Analysis Reporting System and the General Estimates System. Available at http://www.nhtsa.dot.gov/. (4) Angus DC et al. Crit Care Med 2001;29(7): 1303-1310.

http://www.nhtsa.dot.gov/

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The Surviving Sepsis The Surviving Sepsis CampaignCampaign

• = ~ 50,000 people in the US each year.

• = ~ 1,100,000 individuals worldwide each year.

Angus DC, et al. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Critical Care Medicine. Jul 2001;29(7):1303-1310.

25% Reduction In Sepsis Mortality By 2009

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A Major Study of A Major Study of “Reliability” in American “Reliability” in American

Health Care…Health Care…

• McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003) 439 indicators of clinical quality of care 30 acute and chronic conditions Medical records for 6712 patients Participants had received 54.9% of scientifically indicated care (Acute: 53.5%; Chronic

56.1%; Preventative 54.9%)

• Conclusion: The Defect Rate in technical quality of American health care is approximately

45%

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Interview Interview AuditAudit

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Supportive and Adjunctive TherapiesSupportive and Adjunctive TherapiesResults of the German “Prevalence” StudyResults of the German “Prevalence” Study

Brunkhorst FM, Engel C, Ragaller M, Welte T, Rossaint R, Gerlach H,Mayer K, John S, Stuber F, Weiler N, Oppert M, Moerer O, Bogatsch H,Hartog C, Loeffler M, Reinhart K for the German Competence Network Sepsis (SepNet). (2008) Practice and Perception - A Nationwide Survey of Therapy Habits in Sepsis. Crit Care Med (in press).

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Surviving SepsisSurviving SepsisCampaignCampaign

What steps

can we take?

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Early goal directed therapy reduced mortality from 46.5% to 30.5%.

Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England Journal of

Medicine. 2001;345(19):1368-1377.

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Early Goal-Directed Therapy Early Goal-Directed Therapy for Sepsis Induced for Sepsis Induced

Hypoperfusion Hypoperfusion

Rivers E, et al. N Engl J Med 2001;345:1368-77

In-hospital mortality

(all patients)

0

10

20

30

40

50

60 Standard therapyEGDT

28-day mortality 60-day mortality

Mort

ality

(%

)

NNT to prevent 1 event (death) = 6-8

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Low dose hydrocortisone prolonged survival in septic shock for patients with RAI.

Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on

mortality in patients with septic shock. Journal of the American Medical Association. 2002;288(7):862–871.

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Annane et al. Annane et al. JAMAJAMA 2002; 288:862-871 2002; 288:862-871

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Low tidal volume ventilation reduced mortality from 39.8% to 31%.

Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute

respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. New England Journal of

Medicine. 2000;342(18):1301–1308.

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0

5

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ARDSnet

Mechanical Ventilation Protocol

Results: Mortality

The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000;342:1301-1378

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Recombinant Human Activated Protein C

reduced mortality from 30.8% to 24.7%.

Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. New

England Journal of Medicine. 2001; 344(10):699–709.

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Mortality and Numbers Mortality and Numbers of Organs Failingof Organs Failing

Percent Mortality

0

10

20

30

40

50

60

1 2 3 4 5

Placebo

Number of Organs Failing at Entry

NEJM 2001;344:699

rhAPC

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Tight glycemic control reduced mortality from 8% to 4.6% and reduced mortality from

sepsis overall regardless of cause.

Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. New England

Journal of Medicine. 2001;345(19):1359-1367.

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The Role of Intensive InsulinThe Role of Intensive InsulinTherapy in the Critically IllTherapy in the Critically Ill

• At 12 months, intensive insulin therapy reduced mortality by 3.4% (P<0.04)

van den Berghe G, et al. N Engl J Med 2001;345:1359-67

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Days after admission

80

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50 100 150 200 250

P=0.01

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Timely and appropriate

antibiotics reduce mortality in

critically ill patients.

Iregui M, Ward S, Sherman G, Fraser VJ, Kollef MH. Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia. Chest Journal. Jul

2002;122(1):262-268.

Leibovici L, Shraga I, Drucker M, et al: The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection. Journal of Internal Medicine. 1998;244(5):379–386.

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What if we did them

all together?

Surviving Sepsis Campaign: Surviving Sepsis Campaign: international guidelines for international guidelines for

management of severe sepsis management of severe sepsis and septic shock: 2008and septic shock: 2008

Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender

JS, Zimmerman JL, Vincent JL; International Surviving Sepsis Campaign Guidelines Committee.

Crit Care Med. 2008 Jan;36(1):296-327. Erratum in: Crit Care Med. 2008

Apr;36(4):1394-6.

www.survivingsepsis.org

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Sepsis Resuscitation Bundle Sepsis Resuscitation Bundle ((6 hours6 hours):):

1. Serum lactate measured.2. Blood cultures obtained prior to antibiotic administration.3. From the time of presentation, broad-spectrum antibiotics administered within 3 hours for ED admissions and 1 hour for non-ED ICU admissions.4. In the event of hypotension and/or lactate > 4 mmol/L (36 mg/dl):

a) Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent).

b) Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg.

5. In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L (36 mg/dl): a) Achieve central venous pressure (CVP) of > 8 mm Hg.b) Achieve central venous oxygen saturation (ScvO2) of > 70%.*

* Achieving a mixed venous oxygen saturation (SvO2) of 65% is an acceptable alternative.

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Sepsis Management BundleSepsis Management Bundle((24 hours24 hours):):

1. Low-dose steroids administered for septic shock

in accordance with a standardized ICU policy.

2. Recombinant Activated Protein C administered in accordance with a standardized ICU policy.

3. Glucose control maintained > lower limit of normal, but < 150 mg/dl (8.3 mmol/L).

4. Inspiratory plateau pressures maintained < 30 cm H2O for mechanically ventilated patients.

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Identification: SegmentationIdentification: Segmentation

• Segment is a part of a whole.

• Define a situation that in which you should have (some) control.

• Make that your first segment.

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SegmentsSegments

ICU

Wards ED ICUWards ICU Emergency

the surviving sepsis campaign: the sepsis epidemic: how to win

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