Dr. Vida Hamilton National Clinical Lead Sepsis www.hse.ie/sepsis So what about SEPSIS? Dr. Vida Hamilton National Clinical Lead Sepsis www.hse.ie/sepsis

Sepsis ‘Final common pathway for death from infection’ National Awareness Survey 2016 25% Doctors & 29% Nurses interviewed  didn’t think you needed infection to develop sepsis

Content Validity Face validity

Epidemiology 2016 14000 cases 70-80% arise in the Community (CDC) 19% Hospital mortality 70-80% arise in the Community (CDC) Increasing in incidence 10 % annually pre 2016 67% over past 12 months Factors that are associated with increasing incidence & high mortality rate?

Epidemiology

Number of cases  with age

Mortality  with age

With co-morbidities

Surgical DRG

Seasonal variation

No gender difference

30%  Mortality

Risk stratification

3.4% hospital cases 25% hospital deaths

Bed occupancy partial offset by 28.5% aLOS

What is sepsis? Infection Triggering an host response Leads to organ dysfunction & death

Pathophysiology

Sepsis 1 & 2: ‘Hyper-inflammatory to dysregulated response’ Bone 1996

Infection Non-specific signs & symptoms SIRS Temperature T > 38.3 or < 36oC Rigors HR > 90 beats/min Anorexia RR > 20 breaths/min Fatigue WCC > 12 or < 4 Myalgia CRP Arthralgia Procalcitonin Vomiting & diarrhoea

Sites of infection Respiratory 35 - 50% Urinary tract 15 - 25% Intra-abdominal 15 - 25% Skin 11% Catheter-related, device-related, intra-articular, boney, post-procedural etc

Clinical signs of organ dysfunction Brain Acute confusion Altered functional state Lungs RR > 30 Hypoxia Heart HR > 130 SBP < 100 or > 40mmHg drop from normal level Kidneys Oligourea Creatinine > 177 Skin Prolonged central capillary refill Purpuric rash Lactate >2mmol/L

Lactate Trzeciak, S et al. Int Care Med 2007; 33(6):870-7.

Sepsis related organ dysfunction

Clinical presentation Micro-organism Virulence Innoculation dose Multi-drug resistance Host Genetic polymorphisms Co-morbidities Age Chronic health status Immuno-modulatory medications

Sepsis-3 ‘A life-threatening organ dysfunction caused by a dysregulated host response to infection’ Advantage: ‘Now that’s sepsis!’ Disadvantage: Move from ‘bedside diagnosis’ definition with SIRS Looking at higher mortality risk condition, ‘badness’, to an ‘outcome’ based definition Risk of time delay to diagnosis qSOFA now widely discredited as a screening tool

SOFA ≥ 2 above baseline consequent to the infection

Sepsis diagnosis

Criteria validity How can the patients who may benefit from early treatment be identified?

Why don’t we just use qSOFA? qSOFA positive if > 1 present RR > 22, SBP < 100, Altered mental status Prognostic indicator Not a diagnostic tool Not a ‘trigger to treat’ tool Not validated in undifferentiated patients Developed in patients already on antimicrobial therapy NEWS consistently outperforms qSOFA

Significant Co-morbidities COPD Frailty Age > 75yrs Diabetes mellitus Chronic kidney disease Chronic liver disease Cancer Immunosuppressed HIV/AIDS infection Trauma or surgery in past 6 weeks

Sepsis 6 bundle

Give 3 Take 3 1.OXYGEN: Titrate O2 to saturations of 94 -98% or 88-92% in chronic lung disease. 1. CULTURES: Take blood cultures before giving antimicrobials (if no significant delay i.e. >45 minutes) and consider source control.  2. FLUIDS: Start IV fluid resuscitation if evidence of hypovolaemia. 500ml bolus of isotonic crystalloid over 15mins & give up to 30ml/kg, reassessing for signs of hypovolaemia, euvolaemia, or fluid overload. 2.BLOODS: Check point of care lactate, FBC, U&E, LFTS, +/- Coag.  Other tests and investigations as per history and examination. 3. ANTIMICROBIALS: Give IV antimicrobials according to local antimicrobial guidelines. 3. URINE OUTPUT: Assess urine output and consider urinary catheterisation for accurate measurement in patients with severe sepsis/septic shock.

Sepsis diagnosis

Translating research into clinical practice Context validity Translating research into clinical practice Or Generalisability

Inter-user, across place and across time Reliabilty Inter-user, across place and across time

Only 56% of sepsis cases were documented as sepsis in the case notes Audit results 2016 n= 1489 With form Without form Diagnosis made and documented 87% 44% Risk stratification correct 74% 24% 1st dose antimicrobials within 1 hour 74.5% 46.5% Only 56% of sepsis cases were documented as sepsis in the case notes

Fluid resuscitation and Mortality Figure 3. Mean hospital mortality among patients with decreased lactate within 8 hours of index test, stratified by total fluid received in increments of 7.5 ml/kg based on medication administration record. Annals ATS, 2013 http://www.atsjournals.org/doi/abs/10.1513/AnnalsATS.201304-099OC

Timeliness

Operationalisation An important feature of our pilot studies Is the CDST useable within the clinical context Triage screen important but a potential added burden ECG in chest pain Does it add or reduce work Benefit needs to out way any burden

If you don’t measure it you can’t change it Measurement If you don’t measure it you can’t change it

Compliance with Sepsis 6 2017 Process audit National Compliance Sepsis documented correctly 60% Antibiotics within the 1st hour 72% Antibiotic as per guideline 64% Blood cultures before antibiotic 80% Lactate taken 75% Repeat lactate (when indicated) 71% Fluid bolus 42%

OECD Health Care Quality Indicators Healthcare Quality Reporting System, Ireland, 2015 Number per annum Mortality Change in Mortality 2004 - 2013 AMI 6,125 6.4%  40% H. Stroke 1,456 26%  I. Stroke 4,485 10%  13.6% Sepsis 14,000 19%  30% (2011)

Thank you www.hse.ie/sepsis