Caring for Sepsis Survivors: From ICU to post-hospital care · Early Hospital Care: Timely...
Transcript of Caring for Sepsis Survivors: From ICU to post-hospital care · Early Hospital Care: Timely...
Caring for Sepsis Survivors: From ICU to post-hospital care
Speaker:Hallie Prescott, MD, MScAssistant Professor in Internal MedicineDivision of Pulmonary & Critical Care MedicineUniversity of Michigan Health System
Webinar seriesSepsis: Across the Continuum of Care
This webinar series is made possible with unrestricted educational support from bioMérieux, Inc.
Mission Statement:
Save lives and reduce suffering by raising awareness of sepsis as a medical emergency.
www.sepsis.org
Sepsis Survivor WeekFebruary 10 - 16
• 1.4 Million Survive Sepsis Each Year
• Up to 60% of sepsis survivors are left not only with physical challenges but mental and emotional challenges too
• Sepsis Survivor Week toolkit & Life After Sepsis resource page
www.sepsis.org
Hallie Prescott, MD, MScUniversity of Michigan
VA Ann Arbor CCMR
@HalliePrescott
Caring for sepsis survivors:From ICU to post-hospital care
February 12, 2019
Disclosures
• Funding:
– NIH/NIGMS K08 GM115859
– US Department of Veterans Affairs IIR 17-219
• Positions– VA employee. This talk does not represent views of US government or
Department of Veterans Affairs
– vice-chair of Surviving Sepsis Campaign Guidelines; this talk does not
necessarily represent views of SSC.
Fleischmann, et al. AJRCCM. 2016.
19.4 million cases 5.3 million deaths
An estimated 14.1 million patients survive
(severe) sepsis each year.
Outline
• The story of one such patient
• Life after sepsis
• What we can do now
• Follow-up on our patient
One patient’s story
49 year old female, mid-level manager at a large
corporation.
PMH: HTN, mild asthma
• Presented to ED with fevers, chills, sore throat, cough
• Admitted with community-acquired pneumonia
• Treated with IV antibiotics
• ARDS
• Septic Shock
• Day #36: extubated
• Day #43: to rehab
3 weeks of inpatient rehab
IQ Testing
Jackson et al. Southern Med J. 2009.
IQ Testing
Jackson et al. Southern Med J. 2009.
Interview with an ICU trialist, 2004
http://www.frontline.in/static/html/fl2120/stories/20041008001708600.html
Is there a residue in sepsis survivors who have had multi-
organ failures or dysfunctions?
Interview with an ICU trialist, 2004
http://www.frontline.in/static/html/fl2120/stories/20041008001708600.html
Is there a residue in sepsis survivors who have had multi-
organ failures or dysfunctions?
“Most people return to normal or near-normal lives even if
they have had severe organ failures…
Most surviving patients come back to being normal.”
Early cohort studies suggest a problem
Jackson et al. Crit Care Med. 2003.
In national sample with baseline
measurement, new and persistent
disability is common after sepsis.
Iwashyna, et al. JAMA. 2010.
Angus, et al. JAMA. 2010.
Moderate-Severe Cognitive Impairment
• 6% → 16%
• 3.5-fold increased odds
Iwashyna, et al. JAMA. 2010.
Functional Disability
• 1-2 new limitations
Iwashyna, et al. JAMA. 2010.
Increased healthcare use, post-acute mortality
Health
Care
Facility
Before Severe Sepsis After Severe Sepsis
Prescott, et al. AJRCCM. 2014.
Frequent hospital readmission
Health
Care
Facility
Prescott, et al. JAMA. 2015.
In matched cohort studies, sepsis
survivors are at increased risk for:
Prescott, et al. JAMA, 2015.
Shen, et al. Crit Care Med. 2016.
Zielske, et al. Eur Arch
Otorhinolaryngol. 2014.
Ou, et al. AJRCCM. 2016.
Yende, at al. AJRCCM. 2014.
Infection AspirationAcute kidney
injury
Cardiovascular
Events
Experimental Animal Data
Post-septic mice are
at increased risk for:
• Infection: succumb to bacterial or fungal challenge
• CV disease: accelerated atherosclerotic disease
• Cancer: accelerated tumor growth
Kaynar, et al. Crit Care. 2014.
Benjamim, et al. Am J Path. 2003.
Benjamim, et al. J Lekoc Biol. 2004.
Deng, et al. J Clin Invest. 2006.
Cavassani, et al. Blood, 2010.
Our current mechanistic framework
Hotchkiss, et al. Lancet Infectious Diseases. 2013.
Shankar-Hari, et al. Crit Care. 2016.
“Epidemiologic criteria for a causal relationship…
not consistently observed.”
Prescott, et al. BMJ. 2016.
Life after sepsis is scary
New Symptoms & Morbidity
Vulnerable to further health set-backs
https://jamanetwork.com/journals/jama/fullarticle/2667724
In summary, sepsis survivors experience
poor long-term outcomes
1 in 5 with
post-acute mortality
3-fold increase in
cognitive impairment
1-2 new functional limitations
(activities of daily living)
40% re-hospitalized
within 90 days
Iwashyna, et al. JAMA. 2010. Prescott, et al. JAMA. 2015.
Prescott, et al. BMJ. 2016.
Outline
• The story of one such patient
• Life after sepsis
• What we can do now
• Follow-up on our patient
But guidelines do not address
long-term outcomes
Rhodes, et al. Crit Care Med. 2017.
• 67 Pages
• 655 References
• 0 Mention of
Post-Hospital Care
Prescott and Angus, JAMA. 2018.
Early Hospital
Care
After DischargeTowards Discharge
Early Hospital Care: Timely antibiotics, source control, and
resuscitation
Lower-risk population:
Mortality difference non-significant,
but reduced readmissions
Seymour, et al. NEJM. 2017.
Oskam, et al. Lancet Resp Med. 2018.
Increased odds of in-hospital
with each hour delay
2.7% RRR / hr
0.7% ARR / hr2.9% RRR / hr
0.2% ARR / hr
Early Hospital Care: Timely antibiotics, source control, and resuscitation
Seymour, et al. NEJM. 2017.
The sicker the patient,
the more important
early antibiotics are.
For less ill patients
without clear infection,
ok to do more
diagnostic work-up.
Early Hospital Care: Timely antibiotics, source control, and resuscitation
Rhodes, et al. 2016 SSC Guidelines.
SCCM and ACEP Release Joint Statement About the SSC Hour-1 BundleThe Society of Critical Care Medicine (SCCM) and the American College of Emergency
Physicians (ACEP) acknowledge concerns expressed about the recently released Surviving
Sepsis Campaign (SSC) Hour-1 bundle and the appropriateness of implementation in the
United States. Both organizations understand the importance of prompt and optimal sepsis
diagnostics and treatment. SCCM and ACEP along with other involved international experts
are organizing a meeting as soon as possible to carefully review the recommendations, and
provide guidance on bundle implementation and care of potentially septic patients who
present to emergency departments in the United States. We recommend that hospitals not
implement the Hour-1 bundle in its present form in the United States at this time.
Early Hospital Care: Timely antibiotics, source control, and resuscitation
Devlin, et al. CCMed. 2018.
Early Hospital Care: Pain, Agitation, and Delirium Management
Schuler, et al. CCMed. 2018.
Early Hospital Care: Pain, Agitation, and Delirium Management
Schweickert, et al. Lancet. 2009.
Early Hospital Care: Early Mobility
Towards Discharge: De-escalation and De-resuscitation
Stop
Antibiotics
Target
“dry weight”
Prescott, et al. AJRCCM. 2015. Baggs, et al. Clin Infect Dis. 2018.
Lam, et al. Crit Care Med. 2018.
Wirtz, et al. Crit Care. 2018.
Mitchell, et al. AnnalsATS. 2015.
Towards Discharge: De-escalation and De-resuscitation
Towards Discharge: Medication reconciliation & titration
Chronic medications discontinued(e.g. synthroid, gastric acid suppression,
anticoagulants, and statins.)
Acute medications continued(eg. antipsychotics, antidepressants, benzodiazepines,
gastric acid suppression, inhalers)
Bell, et al. JAMA. 2009.
Morandi, et al. J Am Geriatric Soc. 2013.
Scales, et al. J Gen Intern Med. 2016.
Tomicek, et al. Crit Care, 2016.
Ravn-Nielsen, et al. JAMA IM. 2018.
Towards Discharge: Medication reconciliation & titration
23% reduction in composite outcome
(ER visits + re-hospitalization)
Govindan, et al. AnnalsATS. 2014.
Towards Discharge: Counseling, anticipatory guidance
27%
2%
37%
17%
17%Almost Never
Only for the Sickest Patients
It varies widely across practitioners
With many but not all patients
With almost every patient
“Do medical teams in your ICU have formal discussions with patients
or family members regarding challenges or changes to their lives after
ICU discharge?”
https://jamanetwork.com/journals/jama/fullarticle/2667724
Towards Discharge: Counseling, anticipatory guidance
Patient page on
post-sepsis
morbidity at
JAMA.
Towards Discharge: Counseling, anticipatory guidance
Towards Discharge: Counseling, anticipatory guidance
Towards Discharge: Counseling, anticipatory guidance
“When you don’t tell me what to expect, I feel
defeated every time I can’t do something.”
Towards Discharge: Counseling, anticipatory guidance
“When you don’t tell me what to expect, I feel
defeated every time I can’t do something.”
“My family, my doctor, everyone thinks I’m
okay. They tell me it is in my head… but I
don’t feel right.”
Towards Discharge: Counseling, anticipatory guidance
“When you don’t tell me what to expect, I feel
defeated every time I can’t do something.”
“My family, my doctor, everyone thinks I’m
okay. They tell me it is in my head… but I
don’t feel right.”
“No one told me I was going to be short of
breath. I’ve been sitting in my chair, waiting
for it [the dyspnea] to get better…”
After Discharge: Promote functional recovery
• Screen for functional impairment – E.g. ADL limitations, 6 minute walk, Timed Up and Go test
• Address new weakness and functional impairment– Structured exercise program
– Physical therapy
– Occupational therapy
– Cardiac or pulmonary rehabilitation
Graphic adapted from McSparron & Iwashyna in Deutschman and Neligan Evidence-Based Practice in Critical Care (3rd ed.)
Prescott, et al. JAMA. 2015.
After Discharge: Big 5 Potentially Preventable Readmissions
Infection
CHF Exacerbation
Acute Kidney Injury
COPD Exacerbation
Aspiration
• Reconcile and titrate medications
• De-resuscitate targeting new dry weight
• Consider lingering myocardial suppression
• Reconsider and titrate medications
• Consider residual injury and vulnerability, lingering
myocardial suppression
• Consider laboratory monitoring
• Address delirium, cognitive impairment,
swallowing muscle weakness
• Consider temporary Dobb-hoff
• Ensure optimal inhaler regimen and vaccines
• Physical rehabilitation
• De-resuscitate, diurese
• Optimize antibiotic course
• Remove lines, tubes, hardware
• Counsel patients, update vaccines
• Screen and treat promptly
Prescott and Angus. JAMA. 2018.
After Discharge: Big 5 Potentially Preventable Readmissions
Haines, et al. CCMed. 2018.
After Discharge: Peer Support
Enhancing survivorship
Early Hospital Care:• Timely antibiotics, resuscitation, source control
• Pain, agitation, delirium management
• Early mobility
Towards Discharge:• De-escalation and De-resuscitation
• Prepare patients about what to expect
• Reconcile and titrate discharge medications
After Discharge:• Promote functional recovery
• Focus on “Big 5” causes of preventable readmission
• Peer support
Our Patient
Our Patient
• Multiple readmissions for infection
• Returned to work, but never 100%
• Retired early
• Participates in peer-to-peer support group
• Mentor to new sepsis survivors
IQ Testing
Jackson, et al. Southern Med J. 2009.
IQ Testing
Jackson, et al. Southern Med J. 2009.
Early Hospital Care:
• Timely antibiotics, resuscitation, source control
• Pain, agitation, delirium management
• Early mobility
Towards Discharge:
• De-escalation and de-resuscitation
• Prepare patients about what to expect
• Reconcile and titrate discharge medications
After Discharge:
• Promote functional recovery
• Focus on “Big 5” causes of preventable readmission
• Peer support
QuestionsHallie Prescott, MD, MScUniversity of Michigan
VA Ann Arbor Center for Clinical Management Research
@HalliePrescott
• Information and tips to help navigate the ICU from a patient’s admission to discharge.
When A Loved One Has SepsisA Caregivers Guide
To download: www.sepsis.org/resources/caregivers
• Topics such as the different roles of ICU team members and what nurses are checking when they assess their patients.
• Encourages caregivers to take time to care for themselves.
Webinar seriesSepsis: Across the Continuum of Care
Fluid Management and SepsisMarch 28 at 2 pm ET
Register: www.sepsiswebinar.org
Heath Latham, MD, FCCP Mark Piehl, MD
This webinar is made possible with unrestricted educational support from bioMérieux, Inc. and Cheetah Medical
Children’s Hospital Association 2019 Sepsis Webcast Series
Pediatric Prehospital Sepsis Screening and Management
April 10 @ 1 pm ET
Kathleen Brown, MD
George Washington University
Children’s National Health System
Lynn Babcock, MD, MS
University of Cincinnati
Cincinnati Children's Hospital Medical Center
Webinar seriesSepsis: Across the Continuum of Care
The information in this webinar is intended for educational purposes only. The presentations and content are the opinions, experiences, views of the specific authors/presenters and are not statements of advice or opinion of Sepsis Alliance. The presentation has not been prepared, screened, approved, or endorsed by Sepsis Alliance.
This webinar series is made possible with unrestricted educational support from
bioMérieux, Inc.