1. Sepsis- an update Maternal Critical Care Symposium 2016
Dr Judith Joss MRCP, FRCA, DICM, FICM
Consultant in Anaesthesia and Intensive Care Medicine
Ninewells Hospital and Medical School, Dundee
Maternal Critical Care Symposium 2016

2. ‘SEPSIS 3’
The Third International Consensus Definitions for Sepsis and Septic Shock
SCCM, ESICM taskforce JAMA. 2016;315(8):

3. Areas to cover Changes in Sepsis definitions
Old vs New
Why?, How?
The Implications for clinicians and healthcare systems
Brief review of the treatments
The Surviving Sepsis Campaign guidelines and bundles
Sepsis in the Obstetric patient
The unique challenges
Local initiatives and successes (and a small bit about PCT)

4. Have we ever known what sepsis is?
“Advances in the treatment of fever … have not kept pace with the rapid progress in our knowledge of the etiology. In the present condition of bacteriology we may expect great things in the near future, but meanwhile we jog along without any fixed aim, too often carried away by winds of doctrines and wild theories”.
William Osler, The study of the Fevers of the South. JAMA 21, 999–1004 (1896)

5. Back in the days when we thought knew what ‘sepsis’ was
SIRS
Sepsis
Septic Shock
SCCP/SCCM consensus definitions
1991, 2001
Severe Sepsis
Severe sepsis + hypotension
Sepsis + acute organ dysfunction
SIRS + infection
Temp> 38 °C or < 36°C, HR>90, RR>20/min, PaCO2 < 4.2kPa, WCC>12 or <4
Non-specific clinical response

10. Did we need a new definition?
SIRS
Overly non specific
4:5 patients with SIRS dont have infection
1:8 with infection causing organ dysfunction dont have SIRS
New knowledge
Greater understanding of science of infection, cell biology and organ dysfunction
Research
We had a research problem!! With good evidence of inconsistencies in terminology

11. How were the new definitions derived?
SCCM and ESICM convened a panel of 19 experts (2014)
Literature review,
Analysis of huge electronic databases
Delphi process
Peer review
Endorsement by international societies
SEPSIS 3

12. SEPSIS - 3 The new definition of sepsis is:
‘Infection with an increase of two or more SOFA points’
“Life threatening organ dysfunction caused by a dysregulated host response to infection”

13. SEPSIS - 3 The new definition of septic shock is:
“Infection with hypotension requiring vasopressors to maintain MAP >65mmHg
PLUS a Lactate of >2mmol/l”
“A subset of sepsis with particularly profound circulatory, cellular and metabolic abnormalities associated with an increased mortality than sepsis alone”

14. SOFA SCORE

15. Quick SOFA
Patients with suspected infection that are likely to have a prolonged ICU stay or to die in the hospital can be promptly identified at bedside with qSOFA The qSOFA score is less robust than a SOFA score of 2 or greater, but it does not require laboratory tests and can be assessed quickly and repeatedly.

17. Comparison of terminology
SEPSIS 2
SIRS
SEPSIS
SIRS plus Infection
SEVERE SEPSIS
SEPSIS Plus Organ Dysfunction
SEPTIC SHOCK
SEPSIS 3 ?
Infection + SOFA increase 2
Vasopressor + Lactate >2

18. How does this work clinically?
all patients with suspected
INFECTION
SEPSIS
SOFA >2 or qSOFA≥2
(10% Mortality)
SEPTIC SHOCK
(40% mortality)
These patients are sick
They must be identified and treatment started
These patients are very sick
require increased frequency of review
And may require an increased level of care
These patients are on vasopressors and should be in a critical care area

19. May 2016 Scottish Patient Safety Programme
May 2016 Scottish Patient Safety Programme consensus definition of sepsis.
Recommendations
The National Early Warning Score will continue to be the recommended method of
identifying deteriorating patients, including those with sepsis.
Early Warning Scoring System trigger points for sepsis screening and management will
continue to be locally defined. Screening for sepsis should be undertaken with the question
– ‘could this deterioration be due to infection’.
Systemic Inflammatory Response (SIRS) criteria will continue to aid in the general diagnosis
of infection.
The qSOFA criteria may be used as an adjunct to identify patients at increased risk of death
and support decisions about treatment escalation.
All monitoring and screening tools should be viewed as an adjunct to clinical judgement.
Further studies on qSOFA will inform decisions about their potential use as a screening tool
for sepsis.

20. SSC statement in response to SEPSIS 3
Step 1: Screening and Management of Infection Hospitals should continue to use signs and symptoms of infection to promote the early identification of patients with suspected or confirmed infection. management should begin by obtaining blood and other cultures administering tailored antibiotics as appropriate, and simultaneously obtaining laboratory results to Evaluate the patient for infection-related organ dysfunction. Step 2: Screening for Organ Dysfunction and Management of Sepsis (formerly called Severe Sepsis) Patients with sepsis (formerly called severe sepsis) should still be identified by the same organ dysfunction Criteria (including lactate level greater than 2 mmol/L). Organ dysfunction may also be identified in the future using the quick Sepsis-Related Organ Failure Assessment (qSOFA) Practitioners should strongly consider closer monitoring of these at-risk patients. If organ dysfunction is identified, ensuring that the three-hour bundle elements have been initiated continues to be a priority.

21. Step 3: Identification and Management of Initial Hypotension
In those patients who have infection and hypotension or a lactate level greater than or equal to 4 mmol/L, providing 30
mL/kg crystalloid with reassessment of volume responsiveness or tissue perfusion should be implemented. The six-hour
elements of care should be completed. For the six-hour bundle, repeat lactate level is also recommended if initial lactate
level was greater than 2 mmol/L.
Note that:
qSOFA does not define sepsis (but the presence of two qSOFA criteria is a predictor of both increased mortality and ICU
stays of more than three days in non-ICU patients)
Prepare for Change
Hospitals should develop detailed plans
and educate their physician and nursing staff
hospitals should also create detailed plans and educate quality department staff to abstract charts and translate the new
nomenclature into language compatible with the national quality measure, which typically uses the older terminology.
Conclusion
Once hospitals have adequately prepared for change, sepsis team leaders should reinforce the message that the new definitions
Do not change the primary focus of early sepsis identification and initiation of timely treatment in the management of this
Vulnerable patient population

22. SSC Guidelines (2012) 3 Hour Target 6 Hour Target Key Recommendations
Lactate
Blood Cultures
Antibiotics
30ml/kg crystalloid
If ↓BP or lactate>4
6 Hour Target
Vasopressors for ↓BP
MAP>65mmHg
CVP &Scv02
Key Recommendations
FLUIDS
VASOPRESSORS
INOTROPES
STEROIDS
(APC)
ANTIBIOTICS
PCT
Supportive Treatments
Blood
Immunoglobulin
Selenium
Mechanical ventilation
Glucose
Sedation
RRT
Bicarbonate
DVT and stress ulcer
Nutrition
Goal setting

23. Maternal Mortality in the UK

24. CMACE EMERGENT THEME BRIEFING #1: Genital Tract Sepsis September 2010 SAVING MOTHERS’ LIVES : Briefing on genital tract sepsis
During the 2006 – 2008 triennium, sepsis was the leading cause of direct maternal deaths, accounting for 26 direct deaths and a further 3 deaths classified as ‘Late Direct’ Whilst maternal mortality is declining overall, maternal deaths due to sepsis have risen in recent triennia, particularly those associated with Group A streptococcal infection (GAS)
Rate per maternities
0.65
0.85
1.13
Numbers (all organisms) 13 21 29
Numbers (GAS) 3 8

25. Causes of maternal death 2011-13

26. Maternal Deaths – definitions
DIRECT
As a consequence of a disorder specific to pregnancy (Haemorrhage, Pre eclampsia, Genital tract Sepsis)
INDIRECT
Deaths not directly associated with pregnancy state but may be exacerbated by pregnancy (cardiac disease, psychiatric disease, sepsis (pneumonia, flu etc)
COINCIDENTAL
Incidental or accidental deaths not related to pregnancy
LATE
Deaths occurring after 42days but before 1yr following pregnancy

27. Sepsis in the Obstetric Patient
Complex Antenatal decision making
Pregnancy and labour may make detection more difficult
All trials exclude pregnancy
Is Sepsis more challenging in the obstetric patient?
Lack of validation of early warning scores

28. National Maternity Modified SIRS Criteria
Any 2 or more:
- Temp < 36 or > 38 oC
- HR > 100 bpm
- WCC <4 or > 16 x 109/L
- RR > 20 bpm
- Altered mental state

31. Are we ‘over treating’ infection?
Not infected
‘Over’ treatment group
Could we safely stop treatment?
Infection
Appropriate Treatment
How do we monitor for deterioration?
Sepsis
Escalation of treatment
Early identification?
All patients on Sepsis 6

32. The role of biomarkers Procalcitonin
Secreted by most cells in response to bacterial Infection
More specific than most commonly used biomarkers
Rises rapidly (6-12hr), correlates with severity
PCT in Ninewells
Introduced into clinical use 2012 (ICU/sHDU)
Evidence of decreased antibiotic duration in ICU
PCT in Obstetrics
No current evidence base
Novel preliminary work being carried out

33. PCT Algorithm to stop Antibiotics

34. Summary INFECTION Is still a clinical diagnosis
We may still screen with SIRS/EWS
SEPSIS
Is what was previously ‘severe sepsis’
Screen with qSOFA
SEPTIC SHOCK
Vasopressors + Lactate >2mmol/l
40% mortality

35. j.joss@nhs.net Acknowledgements Dr Pamela Johnston
Consultant Anaesthetist
Dr Pauline Lynch
Consultant Obstetrician
Dr Katy Orr
O&G registrar,