The Sepsis Timebomb

James Wigfull Critical Care and Anaesthesia Sheffield Teaching Hospitals

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

Sepsis and mortality

Vallés et al. Chest 2003;123:1615–1624

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

Microbial load

Inflammatory response

Toxic burden

Cellular dysfunction/tissue injury

TIME

Sepsis and Septic Shock: An ID View

Shock Threshold

“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

“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

“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

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

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

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

Door to balloon time and mortality in AMI

Adapted from Cannon et al. JAMA 2000; 283: 2941-7.

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.

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

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.

83 72

50 35 26

18

Ab’s given

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

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

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

83

83

78

78

72

72

60

Ab’s given Source control

22 30

46%

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

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

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

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

Key recommendations

Key recommendations

Key recommendations

Key recommendations

Key recommendations

The National Emergency

Laparotomy Audit

Dave Murray

National Clinical Lead

www.nela.org.uk info@nela.org.uk

Audit against standards

–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

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

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

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

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