1. Revised Sepsis Guidelines and the Impact on Practice

2. Objectives
Consider the impact of sepsis, emphasizing the importance of early recognition & treatment
Review the current sepsis definitions and discuss the proposed changes
Examine key elements of the Surviving Sepsis Guidelines

3. Cleveland Clinic—Fairview Hospital
Cleveland, Ohio

4. Disclosures I have no financial disclosures

6. Sepsis Sepein Septikos Septicus Greek, to rot
Greek, characterized by putrefaction
Septicus
Latin, of or pertaining to putrefaction

7. http://www. montereybayaquarium

10. What percentage of the general public has even heard of sepsis?
19%
31%
43%
55%
67%
However, most people could not place the correct context
Poll Everywhere
Correct answer is D. 55%

11. Sepsis
“Septicemia is a state of microbial invasion from a portal of entry into the bloodstream which causes signs of illness.“
Schottmueller, 1914

12. Sepsis Admissions for sepsis in 2000 621,000
Mortality rate of 28-50%

13. Sepsis
Contributed to 1 in every 2 to 3 hospital deaths, and most of these patients were admitted with sepsis
JAMA July 2, 2014 Volume 312, Number 1, Page 90
The most expensive hospital condition, costing over $24 billion per year
Statistical Brief #204, May, 2016
Healthcare Cost and Utilization Project

14. Sepsis 40% of total ICU expenditure
Davies, et al. 14th Annual Congress of the European Society of Intensive Care Medicine 2001
The number of sepsis patients is projected to increase by 1.5% per year
Angus, et al. Crit Care Med 2001

15. Hospital Readmissions
Patients who survived sepsis to be discharged from the hospital
More than 40% were readmitted within 90 days
Half of these readmissions were deemed possibly preventable
JAMA March 10, 2015 Volume 313, Number 10

16. Hospital Readmissions
Patients who survived sepsis to be discharged from the hospital
The majority of unplanned hospital readmissions after sepsis are due to an infection and identified that many rehospitalized survivors present through the ED with recurrent sepsis
Crit Care Med March 2016 • Volume 44 • Number 3
Sepsis is a leading contributor to excess healthcare costs due to hospital readmissions
Crit Care Med October 2015 • Volume 43 • Number 10

17. Hospital Readmissions
Index admission for heart failure
Pneumonia & sepsis are frequent reasons for readmission
Index admission for acute myocardial infarction
Pneumonia & sepsis
Index admission for pneumonia
Recurrent pneumonia, sepsis, C. diff infection
JAMA January 23/30, 2013—Vol 309, No. 4

18. Mortality MI ~610,000 deaths/year All cancers combined ~600,000
Sepsis ~300,000
Stroke ~140,000
COPD ~135,000
Alzheimer’s ~85,000
Motor vehicle crashes ~35,000
Prescription drug overdose ~35,000
Firearm deaths ~35,000

20. How many deaths could be prevented each year if optimal care is provided to every septic patient?
A. 22,000 B. 37,000 C. 62,000 D. 77,000 E. 92,000 Crit Care Med 2007;35(5):1257
Poll Everywhere
Correct answer: E

21. Definitions Systemic inflammatory response syndrome (SIRS)
Two or more of the following variables:
Temperature greater than 38°C or less than 36°C
Heart rate greater than 90 beats per minute
Respiratory rate greater than 20 breaths per minute or a PaCO2 level of less than 32 mm Hg
Abnormal white blood cell count (>12,000/mL or <4,000/mL or >10% bands)

22. Definitions Sepsis Severe sepsis ICD-10-CM A41.9
SIRS + infection
Severe sepsis ICD-10-CM A41.9
SIRS + infection + new organ dysfunction
Septic shock ICD-10-CM R65.21
Impaired perfusion despite adequate fluid resuscitation

23. Organ Dysfunction Increased thrombosis & decreased fibrinolysis
Microvascular thrombosis
Decreased microvascular flow
Ischemia

24. Organ Dysfunction
Capillary leak Increased interstitial fluid Hypovolemia Edema Decreased cardiac output Acute lung injury Hypovolemic shock Decreased cardiac compliance

25. Increase in nitric oxide production
Organ Dysfunction
Increase in nitric oxide production
Vasodilation Hypotension Distributive shock
Oxidative injury Direct cellular damage
Impaired mitochondrial function

26. Organ Dysfunction Damaged cell membranes Impaired cardiac output
Hypovolemic
Distributive
Cardiogenic
Blockage of microvascular flow
Disordered oxygen metabolism

27. Organ Dysfunction Altered mental status Acute kidney injury
Acute lung injury
Decreased cardiac output
Insulin resistance
Acid-base derangement
Thrombocytopenia
Ileus
Coagulopathy
Adrenal insufficiency

29. Sepsis can be diagnosed by:
Positive blood cultures
Elevated C-reactive protein
Elevated lactic acid
Elevated procalcitonin
All of the above
None of the above
Poll Everywhere
Correct answer is F. None of the above

30. Surviving Sepsis Surviving Sepsis Campaign (2002)
Society of Critical Care Medicine
European Society of Intensive Care Medicine
International Sepsis Forum
Surviving Sepsis Guidelines

31. Surviving Sepsis Routine screening of at-risk patients
Obtain appropriate cultures & imaging
The administration of effective intravenous antimicrobials within the first hour of recognition
Source Control
Initial Resuscitation

32. Lactate
“Measuring lactate levels can risk stratify patients with suspected sepsis, to prompt aggressive early treatment, and help monitor the impact of therapy”
Chee C et al. Crit Care Med 2015

33. Lactate
“The prognostic value of lactate levels exceeds that of blood pressure.”
“Many studies have confirmed the association between initial serum lactate level and mortality independently of clinical signs of organ dysfunction”
Cecconi M, et al. Intensive Care Med 2014;40:1795
“In this multicenter, open-label randomized controlled study, lactate monitoring during the first 8 hours of ICU admission, aimed at reducing lactate levels by at least 20% per 2 hours, significantly reduced ICU length of stay and also ICU and hospital mortality”
Jansen TC, et al. Am J Respir Crit Care Med 2010;182:752

34. Initial Resuscitation
“We recommend the protocolized, quantitative resuscitation of patients with sepsis-induced tissue hypoperfusion”
Surviving Sepsis Guidelines

35. Initial Resuscitation
“We suggest targeting resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion”
Surviving Sepsis Guidelines

36. Surviving Sepsis TIME SENSITIVE!
Identify patients early in their course
Administer antibiotics promptly
Fluid resuscitation—fast & furious

38. The minimum volume of the initial fluid resuscitation for the septic patient is:
250 ml
500 ml
1000 ml
10 ml/kg
30 ml/kg
Poll Everywhere
Correct answer is E

39. Surviving Sepsis Measure lactate level Draw blood cultures
3-hour bundle
6-hour bundle
Measure lactate level
Draw blood cultures
Administer broad spectrum antibiotics
Administer 30 ml/kg crystalloid fluid bolus
If persistent hypotension after initial fluid resuscitation, then:
Add vasopressors
Measure CVP, SvO2
Remeasure lactate

40. Surviving Sepsis
Compliance with the Surviving Sepsis Campaign bundles is associated with improved mortality
Levy MM, et al. Crit Care Med 2015;43:3
Levy MM et al. Intensive Care Med 2010;36:222

41. National Inpatient Quality Measures
Within 3 hours of identification of severe sepsis:
Initial lactate level measurement
Broad spectrum or other antibiotics administered
Blood cultures drawn prior to antibiotics
Within 6 hours:
Repeat lactate measurement if initially elevated

42. National Inpatient Quality Measures
Within 3 hours of identification of septic shock:
Initial lactate level measurement
Broad spectrum or other antibiotics administered
Blood cultures drawn prior to antibiotics
Within 6 hours:
Repeat lactate measurement if initially elevated
Resuscitation with 30 ml/kg crystalloid fluids
Vasopressors if hypotension persists after fluid administration

43. National Inpatient Quality Measures
Reassessment to include OR
A focused exam including:
Vital signs, AND
Cardiopulmonary exam, AND
Capillary refill evaluation, AND
Peripheral pulse evaluation, AND
Skin examination
Any 2 of the following:
Central venous pressure measurement
Central venous oxygen measurement
Bedside Cardiovascular Ultrasound
Passive Leg Raise or Fluid Challenge

44. Challenges Can we screen patients effectively?
Can we measure the lactate quickly?
Can fluids be administered rapidly?
Can the patient be frequently re-assessed?

45. Challenges Can we screen patients effectively?
Can we measure the lactate quickly?
Can fluids be administered rapidly?
Can the patient be frequently re-assessed?
Who’s going to do all of this?

46. Definitions Sepsis Severe sepsis Septic shock
SIRS + infection
Severe sepsis
SIRS + infection + new organ dysfunction
Septic shock
Impaired perfusion despite adequate fluid resuscitation
Many patients with severe sepsis do not have SIRS
Many patients with severe sepsis do not initially have any obvious organ dysfunction
Infection + new organ dysfunction can occur in the absence of severe sepsis

47. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
Definitions of sepsis, severe sepsis, and septic shock revisited
Fair sensitivity & poor specificity of SIRS
Recognition of inflammation as a normal response to infection
JAMA February 23, 2016 Volume 315, Number 8

48. Key Concepts
Difficult to distinguish between “normal” and “dysregulated” inflammatory response
Organ dysfunction may not be obvious
Sepsis might not be the cause of organ dysfunction

49. Key Concepts No “gold standard” diagnostic test for sepsis
Change in approach to screening patients for sepsis
New infectionlook for organ dysfunction
New or worsening organ dysfunctionlook for infection

50. Proposed Definitions
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection
Organ dysfunction can be identified as an acute change in total SOFA score ≥2 points consequent to the infection
JAMA 2016;315(8):

51. Proposed Definitions
Septic shock is defined as a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality
Hypotension requiring vasopressor therapy to maintain mean BP 65mmHg or greater and having a serum lactate level greater than 2 mmol/L after adequate fluid resuscitation
JAMA 2016;315(8):

52. Logistic Organ Dysfunction System LODS
Heart rate
Systolic blood pressure
pO2/fiO2
Glasgow Coma Score
Serum creatinine
Serum urea
Bilirubin
White blood cell count
Prothrombin time
Platelets
JAMA 1996;276(10):

53. Sequential Organ Failure Assessment SOFA
Crit Care Med 1998; 26:

54. qSOFA 0-3 points 1 point each for: Respiratory rate ≥ 22
Glasgow Coma Score ≤ 13
Systolic blood pressure ≤100
JAMA February 23, 2016 Volume 315, Number 8

55. qSOFA
The presence of 2 or more qSOFA points associated with a greater risk of death or prolonged intensive care unit stay
Prompt to identify infected patients outside the ICU who are likely to be septic
JAMA February 23, 2016 Volume 315, Number 8

57. Which are risks factors for sepsis?
Age > 65 years
Age < 1 year
Immunocompromised
Recent surgery
Chronic disease
Wounds
Previous sepsis
Invasive devices
All are risk factors
Poll Everywhere
All are risk factors for sepsis

58. Keys to Surviving Sepsis
Prevention

59. Prevention Central venous catheter maintenance bundle Hand hygiene
Scrub the hub
Aseptic access technique
Daily review of line necessity
Appropriate dressing changes

60. Prevention Minimize the need to access a vascular catheter
Minimize blood draws
Batch blood draws
Convert medications from parenteral to enteral as soon as practical

61. Prevention (maybe) Antimicrobial catheter Antithrombogenic catheter
Antimicrobial patch
Antimicrobial dressing
Sutureless securement device
Disinfecting port protector
Antimicrobial lock
Daily chlorhexidine bath

62. Keys to Surviving Sepsis
Early recognition
New organ dysfunction—look for infection
New infection—look for organ dysfunction
Check the lactate
Antibiotics immediately
Blood cultures prior to antibiotics
Brisk fluid resuscitation
30 ml/kg

63. Sample Sepsis Screening Tool

64. Sample Sepsis Screening Tool

65. Sepsis Screening Look for trends
Leukocytosis & fever
Heart rate increasing
Blood sugars increasing
Platelets decreasing
Monitor for signs of new organ dysfunction
qSOFA

66. Keys to Surviving Sepsis
It is even better to act quickly and err than to hesitate until the time of action is past
Carl von Clausewitz

67. Keys to Surviving Sepsis
Remember—this is a time-sensitive problem, just like MI
Stroke
Trauma

68. Thank You!