Diagnosis and Sepsis - UCSF CME€¦ · Diagnosis and Management of ... SIRS plus confirmed or...

Post on 09-Oct-2020

1 views 0 download

Transcript of Diagnosis and Sepsis - UCSF CME€¦ · Diagnosis and Management of ... SIRS plus confirmed or...

10/26/2015

1

Diagnosis and Management of Sepsis

David Shimabukuro, MDCMMedical Director, 13 ICU

Physician Lead, UCSF Sepsis Bundle Compliance and Mortality Reduction

Disclosures

• I have no disclosures

10/26/2015

2

The following feature has been edited for content and to run in 

the allotted time

Agenda

• Epidemiology

• Definitions and Diagnosis

• Treatment

– Definitive

– End‐organ support

10/26/2015

3

Agenda

• Epidemiology

• Definitions and Diagnosis

• Treatment

– Definitive

– End‐organ support

Epidemiology

10/26/2015

4

Epidemiology

Epidemiology

10/26/2015

5

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

Epidemiology

38%

20%

8%

8%

14% 12%

Cause

Lung

Blood

Skin/Soft Tissue

Abdominal

Genitourinary

Other

10/26/2015

6

Agenda

• Epidemiology

• Definitions and Diagnosis

• Treatment

– Definitive

– End‐organ support

CASE

Mrs. M is an 82 year‐old woman with a past medical history significant for Alzheimer’s, hypothyroidism, and hypertension, was admitted to the floor from a skilled nursing facility with dysarthria from an acute CVA.  

10/26/2015

7

CASE

On hospital day 2, she is quite somnolent but arouses with tactile stimulation.  Her vitals are BP 120/76, HR 78, RR 30, Temp 38, and oxygen saturation 90% on 6LNC (she was on RA yesterday evening).  Her WBC this morning has increased to 11.1 from 8.9.

CASE

10/26/2015

8

Does she have…

1. Systemic inflammatory response syndrome

2. Sepsis

3. Severe Sepsis

4. Septic shock

5. None of the above

I would order a lactate?

1. No

2. Yes

10/26/2015

9

CASE

Her lactate level returns at 4.4 mmol/L.

Does she have…

1. Systemic inflammatory response syndrome

2. Sepsis

3. Severe Sepsis

4. Septic shock

5. None of the above

10/26/2015

10

I would transfer her to the ICU

1. No

2. Yes

I would place a central venous catheter

1. No

2. Yes

10/26/2015

11

Sepsis Definitions

• SIRS

• Sepsis

• Severe Sepsis

• Septic Shock

Septic Shock

SEVERE SEPSIS plushypotension (Systolicblood pressure < 90 orMean Arterial Blood Pressure < 65) OR Lactate > 4

Severe Sepsis

SEPSIS plus evidenceof 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 CHR > 90 beats/minTachypneaWBC > 12K or < 4K

SIRS

T > 38.3 C or < 36 CHR > 90 beats/minTachypneaWBC > 12K or < 4K

SIRS

T > 38.3 C or < 36 CHR > 90 beats/minTachypneaWBC > 12K or < 4K

10/26/2015

12

Severe Sepsis Definition

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

10/26/2015

13

San Francisco Definition

Sepsis is defined as a life‐threatening organ dysfunction due to a dysregulated host response to infection.

10/26/2015

14

What is Sepsis??

• A variable condition that affects each of us differently and is initiated by a known or suspected infectious insult.

Is catching it earlier better??

10/26/2015

15

Sepsis Screening

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

Sepsis Screening

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

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

10/26/2015

16

Sepsis Screening

Sepsis Screening

10/26/2015

17

Sepsis Screening

• Important to have one that works for your hospital

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

• Screening works as a reminder for continued awareness and vigilance

• (Determine time of presentation)

Agenda

• Epidemiology

• Definitions and Diagnosis

• Treatment

– Definitive

– End‐organ support

10/26/2015

18

Definitive Treatment

• Antibiotics

• Source Control

Management of Severe Sepsis and Septic Shock

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

10/26/2015

19

Management of Severe Sepsis and Septic Shock

1

Crit Care Med 2006 Vol. 34, No. 6

10/26/2015

20

10/26/2015

21

End‐organ support (by improving tissue perfusion)…

Management of Severe Sepsis and Septic Shock

10/26/2015

22

Management of Severe Sepsis and Septic Shock

• Fluid Therapy

– Crystalloids are first choice for the overwhelming majority of patients

– Albumin can be used to reduce volume from crystalloids

– Hydroxyethyl starches should not be used

Management of Severe Sepsis and Septic Shock

• Fluid Therapy

– WATCH OUT!!!!!

– Too much fluid is bad and not enough is bad…

10/26/2015

23

Management of Severe Sepsis and Septic Shock

Management of Severe Sepsis and Septic Shock

10/26/2015

24

Management of Severe Sepsis and Septic Shock

Beyond the 6‐hour resuscitation

10/26/2015

25

Management of Severe Sepsis and Septic Shock

• Lung Injury

– All patients at risk

– Low‐tidal volume ( 6cc/kg IBW)

– Plateau pressure < 30 cm H20

– Permissive hypercapnia

– FIO2:PEEP strategy

Management of Severe Sepsis and Septic Shock

• Corticosteroids

– For refractory hypotension despite fluids and vasopressors/inotropes

– Do not perform ACTH stimulation test

• Glucose

– Target level to less than 180 mg/dL

10/26/2015

26

Management of Severe Sepsis and Septic Shock

• 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

Management of Severe Sepsis and Septic Shock

10/26/2015

27

EGDT

Management of Severe Sepsis and Septic Shock

Does this bundle actually work??

10/26/2015

28

Management of Severe Sepsis and Septic Shock

yes…

no…

Crit Care Med 2010 Vol 38 No 2 pp 367‐374

Management of Severe Sepsis and Septic Shock

10/26/2015

29

Management of Severe Sepsis and Septic Shock

Management of Severe Sepsis and Septic Shock

10/26/2015

30

Management of Severe Sepsis and Septic Shock

Management of Severe Sepsis and Septic Shock

10/26/2015

31

Original Article

A Randomized Trial of Protocol-Based Care for Early Septic Shock

The ProCESS Investigators

N Engl J MedVolume 370(18):1683-1693

May 1, 2014

Cumulative Mortality.

The ProCESS Investigators. N Engl J Med 2014;370:1683-1693

10/26/2015

32

Conclusions

• In a multicenter trial conducted in the tertiary care setting, protocol-based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes.

Original Article

Goal-Directed Resuscitation for Patients with Early Septic Shock

The ARISE Investigators and the ANZICS Clinical Trials Group

N Engl J MedVolume 371(16):1496-1506

October 16, 2014

10/26/2015

33

Probability of Survival and Subgroup Analyses of the Risk of Death at 90 Days.

The ARISE Investigators and the ANZICS Clinical Trials Group. N Engl J Med 2014;371:1496-1506

Conclusions

• In critically ill patients presenting to the emergency department with early septic shock, EGDT did not reduce all-cause mortality at 90 days.

10/26/2015

34

Original Article

Trial of Early, Goal-Directed Resuscitation for Septic Shock

Paul R. Mouncey, M.Sc., Tiffany M. Osborn, M.D., G. Sarah Power, M.Sc., David A. Harrison, Ph.D., M. Zia Sadique, Ph.D., Richard D. Grieve, Ph.D., Rahi Jahan, B.A.,

Sheila E. Harvey, Ph.D., Derek Bell, M.D., Julian F. Bion, M.D., Timothy J. Coats, M.D., Mervyn Singer, M.D., J. Duncan Young, D.M., Kathryn M. Rowan, Ph.D.,

for the ProMISe Trial Investigators

N Engl J MedVolume 372(14):1301-1311

April 2, 2015

Kaplan–Meier Survival Estimates.

Mouncey PR et al. N Engl J Med 2015;372:1301-1311

10/26/2015

35

Conclusions

• In patients with septic shock who were identified early and received intravenous antibiotics and adequate fluid resuscitation, hemodynamic management according to a strict EGDT protocol did not lead to an improvement in outcome.

Changes…

10/26/2015

36

Surviving Sepsis Campaign Bundle Revision 2015

Surviving Sepsis Campaign Bundle Revision 2015

10/26/2015

37

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

Summary

• Definitive treatment involves rapid appropriate antibiotic administration and source control

• Supportive care for end‐organ dysfunction is the mainstay of treatment

• Management bundle continues to evolve

10/26/2015

38

UCSF Experience

Leveraging data in the EMR

• Vital signs/assessments

• Laboratory values

• Problem list

• Medication list

10/26/2015

39

Leveraging data in the EMR

• 6 different algorithms based on patient location

– ED

– Medical/Surgical ward

– Medical/Surgical ICU

– Hematology/Oncology

– CVT ward

– CVT ICU

10/26/2015

40

• Code Sepsis

• UCSF Sepsis Bundle

10/26/2015

Sepsis Updates80

UHC Sepsis Mortality Index

10/26/2015

41