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Transcript of Sepsis Coordinator Network Webinar Sepsis: Common, Lethal, · PDF file OBJECTIVES...

  • Presenter: Angel Coz, MD, FCCP Associate Professor of Medicine University of Kentucky

    Sepsis Coordinator Network Webinar Sepsis: Common, Lethal, and Unrecognized

  • Copyright © 2019 Sepsis Alliance. All rights reserved.

    Sepsis Coordinator Network

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    Sepsis Alliance Mission

    To save lives and reduce suffering by raising awareness of sepsis as a medical emergency

    https://www.sepsis.org

    https://www.sepsis.org/

  • Copyright © 2019 Sepsis Alliance. All rights reserved.

    Presenter Biography

    Angel Coz, MD, FCCP Associate Professor of Medicine University of Kentucky

    • Pulmonary and Critical Care specialist • Medical Director of the Intensive Care Unit at the Lexington Veterans Affairs Medical Center • Holds multiple leadership positions at the American College of Chest Physicians (CHEST), and has

    been awarded the Distinguished CHEST Educator (DCE) designation two years in a row • Member of the Advisory Board of the Sepsis Alliance • Strong interest in critical care, mechanical ventilation, sepsis resuscitation, and medical education • Has given multiple talks on critical care, sepsis, and pulmonary topics at the national and international

    level.

  • SEPSIS: COMMON, LETHAL AND UNRECOGNIZED

    Angel Coz MD, FCCP, DCE Lexington Veterans Affairs Medical Center

    Associate Professor of Medicine University of Kentucky

    August 27, 2019

  • DISCLOSURES

    • I have no financial disclosures

  • OBJECTIVES

    § Describe emerging severe sepsis prediction algorithms and the impact on patient survival and hospital length of stay

    § Recognize and identify early detection of sepsis through community engagement strategies (i.e. TIME)

    § Summarize severe sepsis treatment and improvement in delivery of care for disease specific populations

  • Compared to Acute MI, the in-hospital mortality from severe sepsis/septic shock is:

    A. About the same

    B. 25 % higher

    C. 50 % higher

    D. 300 % higher

  • SEPSIS

    § Common, Lethal and Underrecognized

    § Every 2 minutes, a person in the US dies of sepsis

  • WHAT CAN WE DO?

    § Early Recognition

    § Early and Appropriate therapy

  • A SYSTEMS APPROACH TO SEPSIS CARE

    Early

    Recognition Antibiotics IV Fluids

    Risk

    Stratification

    Hemodynamic

    Optimization

    Global Tissue

    Hypoxemia

  • A SYSTEMS APPROACH TO SEPSIS CARE

    Early

    Recognition Antibiotics IV Fluids

    Risk

    Stratification

    Hemodynamic

    Optimization

    Global Tissue

    Hypoxemia

  • Crit Care Med 2018; 46:513–516

  • Sepsis

    • Infection +

    • SIRS ≥ 2

    Severe Sepsis

    • Infection +

    • End organ damage

    Septic Shock

    • Infection +

    • Refractory Hypotension

    Sepsis

    • Infection +

    • ↑ SOFA ≥ 2

    Septic Shock

    • Infection +

    • Refractory Hypotension +

    • Lactate ≥ 2

    SEPSIS-1 SEPSIS-2

    SEPSIS-3

  • OUTCOME

    SIRS ≥ 2

    -5-10-15

    qSOFA ≥ 2 ONLY ≈ 50% PATIENTS qSOFA ≥ 2

    Am J Respir Crit Care Med 2017;195(7):906–911

  • Ann Intern Med. 2018;168:266-275

  • SEPSIS DIAGNOSIS

    CHEST 2018; 153(3):646-655

    DEATH

  • A SYSTEMS APPROACH TO SEPSIS CARE

    SIRS ≥ 2 qSOFA

    Early

    Recognition Antibiotics IV Fluids

    Risk

    Stratification

    Hemodynamic

    Optimization

    Global Tissue

    Hypoxemia

  • CAN BOTH SIRS AND Q SOFA BE USED?

    § If SIRS is present à Look for organ dysfunction

    § If qSOFA is present à Patient has a high mortality risk

  • Crit Care Med 2016; 44:368–374

  • Crit Care Med 2016; 44:368–374

  • BMJ Open 2018;8:e017833

    ROC = 0.92 ROC = 0.87 ROC = 0.96

    SEPSIS SEVERE SEPSIS SEPTIC SHOCK

  • BMJ Open 2018;8:e017833

    ROC = 0.85

  • BIOMARKERS

  • • Combination of 3 studies across 7 sites

    • Prospective and observational – 450 patients

    • Objective – Distinguish SIRS from sepsis • Four genes – RT-qPCR assay: CEACAM4, LAMP1, PLAC8, PLA2G7

    • Sepsis diagnosis by adjudication

    Am J Respir Crit Care Med 2018;198(7):903–913

  • Am J Respir Crit Care Med 2018;198(7):903–913

  • SHOCK 2018; 49(4):364–370

    Journal of Applied Laboratory Medicine 2019; 3(4): 724-29

  • WHAT ABOUT ON THE PATIENT SIDE?

  • SEPSIS AWARENESS

    0%

    20%

    40%

    60%

    80%

    100%

    2007 2017

    PUBLIC AWARENESS OF SEPSIS

  • A SYSTEMS APPROACH TO SEPSIS CARE

    Early

    Recognition Antibiotics IV Fluids

    Risk

    Stratification

    Hemodynamic

    Optimization

    Global Tissue

    Hypoxemia

  • Crit Care Med 2006; 34:1589–1596

    Each hour delay = ↓ survival 7.6%

    OR=1.67

    OR=92.5

  • N Engl J Med 2017;376:2235-44

  • AJRCCM 2017:196(7):856–863

  • Crit Care Med 2017; 45:623–629

    Each hour delay = ↑ 8% progression to septic shock

  • CHEST 2019; 155(5):938-946

    OR = 1.10

  • Annals ATS 2019;16(4):426-429

  • A SYSTEMS APPROACH TO SEPSIS CARE

    Early

    Recognition Antibiotics IV Fluids

    Risk

    Stratification

    Hemodynamic

    Optimization

    Global Tissue

    Hypoxemia

  • FLUID THERAPY

    How Much?

    When to give?

    What Type?

    When to stop?

  • 0

    1000

    2000

    3000

    4000

    5000

    6000

    EGDT PBC UC EGDT UC EGDT UC

    PROCESS ARISE PROMISE

    Randomization 6 hours

    30.5 29.2 28.0 34.6 34.7

    IV FLUIDS

  • Intensive Care Med (2017) 43:625–632

  • Am J Respir Crit Care Med 2018;198(11):1406–1412

  • Crit Care Med 2017; 45:1596–1606

  • WHAT ABOUT THEM?

  • • Hemodynamic stable patients with lactate 2-4 mMol/L

    Am J Respir Crit Care 2016;193(11):1264–1270

  • N Engl J Med 2017;376:2235-44

  • Crit Care Med 2017; 45:1596–1606

  • Crit Care Med 2017; 45:1596–1606

  • FLUID THERAPY

    How Much?

    When to give?

    What Type?

    When to stop?

  • N Engl J Med 2018;378:829-39.

  • N Engl J Med 2018;378:829-39.

  • 0%

    10%

    20%

    30%

    40%

    MAKE 30 Overall MAKE 30 Sepsis Mortality

    15.4%

    38.9%

    11.1% 14.3%

    33.8%

    10.3%

    SALINE BALANCED

    P = 0.04

    P = 0.01

    P = 0.06

    N Engl J Med 2018;378:829-39

    NNT = 20

  • A SYSTEMS APPROACH TO SEPSIS CARE

    Early

    Recognition Antibiotics IV Fluids

    Risk

    Stratification

    Hemodynamic

    Optimization

    Global Tissue

    Hypoxemia

  • Lactate ≤ 4

    Lactate > 4

    20%

    25%

    30%

    35%

    40%

    45%

    No Hypotension

    Hypotension

    23.3% 29.3%

    29.0%

    44.5%

    Crit Care Med 2015 Mar;43(3):567-73

  • Crit Care Med. 2009 May;37(5):1670-7

  • CHEST 2018; 154(2):302-308

  • CHEST 2018; 154(2):302-308

  • BLOOD CULTURE LACTATE ANTIBIOTICS FLUIDS

    Crit Care Med 2018; 46:500–505

  • SEP -1 MORTALITY

  • 70%

    88%

    21% 28%

    75%

    0%

    37%

    97% 98%

    77%

    64%

    84% 89%

    20%

    0%

    20%

    40%

    60%

    80%

    100%

    Lactate within 1 h Blood cultures before antibiotics

    Antibiotics within 1h

    IV Fluids (30 ml/Kg)

    Repeat Lactate within 6h

    Vasopressors within 6h

    Mortality

    PAST VS CURRENT STATE

    Before After

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