1. Dr Alex Hieatt, EM Consultant MEHT Dr Ron Daniels, Chair of the UK Sepsis Trust and Global Sepsis Alliance (Slides with permission.)

2. Questions 1. What defines the sepsis syndrome? 2. What defines severe sepsis? 3. What defines septic shock? 4. What is the single most important intervention in the management of severe sepsis and septic shock? 5. How often is 4 achieved within an hour? 6. What is the mortality from septic shock?

3. Questions 7. How many patients die each year in the UK from severe sepsis and septic shock? 8. How many people die each year in the UK from lung cancer? 9. How many people die each year in the UK from bowel cancer and breast cancer combined? 10. How much does sepsis cost the UK health economy each year?

5. Answers Sepsis syndrome 2 SIRS criteria HR > 90 RR > 20 T 38⁰C Altered mental status WBC 12 x 10 9 /L BM >7.7 mmol/L in a non diabetic Suspected or newly diagnosed infection

6. Clinical Need for O2 pre hospital or on admission Low blood pressure SBP 40 mmHg from normal OR MAP <65 mmHg OR DBP<60 Not passed urine for > 8 hours OR UO< 0.5 mls/kg/hr for 2 hours Jaundiced New confusion or decreased conscious level Chemical INR > 1.5 OR APTT > 60s Platelets <100 x 10 9 /L Lactate >2 mmol/L Creatinine>177 µmol/L OR Rise of > 50% over baseline Bilirubin > 37 µmol/L Severe Sepsis = Sepsis syndrome + evidence of organ dysfunction

7. Septic Shock Severe Sepsis and: Lactate > 4 mmol/L Refractory hypotension after 30 mls/kg ofvolume resuscitation

8. Dr Ron Daniels http://www.youtube.com/watch?v=poN0uB BJemM

11. Breast cancer

13. Bowel cancer Breast cancer

14. Annual UK sepsis deaths Breast cancer Bowel cancer

15. Global Sepsis Alliance / UK Sepsis Trust

17. The Sepsis Six 1.Give high-flow oxygen via non-rebreathe bag 2.Take blood culturesand consider source control 3.Give IV antibioticsaccording to local protocol 4.Start IV fluid resuscitation Hartmann’s or equivalent 5.Check lactate 6.Monitor hourly urine output consider catheterisation within one hour..plus Critical Care support to complete EGDT

18. Severe SepsisAcute coronary syndrome No. cases per 100,000 per annum 240 208 NNT ‘basic’ care Sepsis Six (our data) 4 First hour antibiotics 6 Clopidogrel 48 β-blockade 42 Aspirin 26 NNT invasive care EGDT (Rivers) 6 Resusc Bundle (SSC) 18 Thrombolysis 15 PCI over thrombolysis 33 Perspective

19. Compliance,GHH (%)

20. Mortality Cohort size (%) Mortality %RRR % (‘NNT’) Total 567 (100)34.7- Sepsis Six  347 (61.2)44.0 Sepsis Six  220 (38.8)20.046.6 (4.16)

22. First hour antibiotics in 27%...

23. Begin IV antibiotics as early as possible, and always within the first hour of recognising severe sepsis (1D) and septic shock. (1B) Citation: Kumar A et al. Crit Care Med 2006: 34(6) Retrospective, 15 years, 14 sites n = 2,154 median 6 h, 50% administered in 6h Only 5% first 30 minutes- survival 87% 12% first hour- survival 84%

24. Kumar et al. CCM. 2006:34:1589-96. time from hypotension onset (hrs) 0-0.50.5-1 1-22-33-44-55-66-9 9-12 12-2424-36 36+ fraction of total patients 0.0 0.2 0.4 0.6 0.8 1.0 survival fraction cumulative antibiotic initiation Effective Antimicrobial Therapy & Survival in Septic Shock

25. Funk and Kumar Critical Care Clinics 2011 (in press) Running average survival in septic shock based on antibiotic delay (n=2154) For each hour’s delay in administering antibiotics in septic shock, mortality increases by 7.6%

26. For each year, for every 100k in the local population.. 20 lives saved 285 fewer bed days 168 fewer CC bed days Direct costs for survivors reduced by £0.25M For Italy, that’s 12,200 lives and €182 million. Every year.

30. Useful Tools http://www.youtube.com/watch?v=CrUHnY IZbpM https://itunes.apple.com/gb/app/nhs- scotland-news-sepsis- screening/id657497806?mt=8 file:///C:/Users/ali/Desktop/S4/Survive%20 Sepsis%20on%20the%20App%20Store%20o n%20iTunes.htm https://itunes.apple.com/gb/app/survive- sepsis/id580791653?mt=8