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

2. 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

3. Content Validity
Face validity

4. 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?

5. Epidemiology

6. Number of cases  with age

7. Mortality  with age

8. With co-morbidities

9. Surgical DRG

10. Seasonal variation

11. No gender difference

12. 30%  Mortality

13. Risk stratification

14. 3.4% hospital cases 25% hospital deaths

15. Bed occupancy partial offset by 28.5% aLOS

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

17. Pathophysiology

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

19. 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

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

21. 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

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

23. Sepsis related organ dysfunction

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

25. 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

26. SOFA ≥ 2 above baseline consequent to the infection

27. Sepsis diagnosis

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

30. 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

31. 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

33. Sepsis 6 bundle

35. Give 3
Take 3
1.OXYGEN: Titrate O2 to saturations of % 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.

36. Sepsis diagnosis

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

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

43. Only 56% of sepsis cases were documented as sepsis in the case notes
Audit results 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

44. 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

46. Timeliness

47. 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

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

49. 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%

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

52. Thank you