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Presenter: Angel Coz, MD, FCCPAssociate Professor of MedicineUniversity of Kentucky
Sepsis Coordinator Network WebinarSepsis: Common, Lethal, and Unrecognized
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To save lives and reduce suffering by raising awareness of sepsis as a medical emergency
https://www.sepsis.org
Copyright © 2019 Sepsis Alliance. All rights reserved.
Presenter Biography
Angel Coz, MD, FCCPAssociate Professor of MedicineUniversity of Kentucky
• Pulmonary and Critical Care specialist• Medical Director of the Intensive Care Unit at the Lexington Veterans Affairs Medical Center • Holds multiple leadership positions at the American College of Chest Physicians (CHEST), and has
been awarded the Distinguished CHEST Educator (DCE) designation two years in a row• Member of the Advisory Board of the Sepsis Alliance• Strong interest in critical care, mechanical ventilation, sepsis resuscitation, and medical education• Has given multiple talks on critical care, sepsis, and pulmonary topics at the national and international
level.
SEPSIS: COMMON, LETHAL AND UNRECOGNIZED
Angel Coz MD, FCCP, DCELexington Veterans Affairs Medical Center
Associate Professor of MedicineUniversity of Kentucky
August 27, 2019
DISCLOSURES
• I have no financial disclosures
OBJECTIVES
§ Describe emerging severe sepsis prediction algorithms and the impact on patient survival and hospital length of stay
§ Recognize and identify early detection of sepsis through community engagement strategies (i.e. TIME)
§ Summarize severe sepsis treatment and improvement in delivery of care for disease specific populations
Compared to Acute MI, the in-hospital mortality from severe sepsis/septic shock is:
A. About the same
B. 25 % higher
C. 50 % higher
D. 300 % higher
SEPSIS
§ Common, Lethal and Underrecognized
§ Every 2 minutes, a person in the US dies of sepsis
WHAT CAN WE DO?
§ Early Recognition
§ Early and Appropriate therapy
A SYSTEMS APPROACH TO SEPSIS CARE
Early
RecognitionAntibiotics IV Fluids
Risk
Stratification
Hemodynamic
Optimization
Global Tissue
Hypoxemia
A SYSTEMS APPROACH TO SEPSIS CARE
Early
RecognitionAntibiotics IV Fluids
Risk
Stratification
Hemodynamic
Optimization
Global Tissue
Hypoxemia
Crit Care Med 2018; 46:513–516
Sepsis
• Infection +
• SIRS ≥ 2
Severe Sepsis
• Infection +
• End organ damage
Septic Shock
• Infection +
• Refractory Hypotension
Sepsis
• Infection +
• ↑ SOFA ≥ 2
Septic Shock
• Infection +
• Refractory Hypotension +
• Lactate ≥ 2
SEPSIS-1SEPSIS-2
SEPSIS-3
OUTCOME
SIRS ≥ 2
-5-10-15
qSOFA ≥ 2 ONLY ≈ 50% PATIENTSqSOFA ≥ 2
Am J Respir Crit Care Med 2017;195(7):906–911
Ann Intern Med. 2018;168:266-275
SEPSIS DIAGNOSIS
CHEST 2018; 153(3):646-655
DEATH
A SYSTEMS APPROACH TO SEPSIS CARE
SIRS ≥ 2 qSOFA
Early
RecognitionAntibiotics IV Fluids
Risk
Stratification
Hemodynamic
Optimization
Global Tissue
Hypoxemia
CAN BOTH SIRS AND Q SOFA BE USED?
§ If SIRS is present à Look for organ dysfunction
§ If qSOFA is present à Patient has a high mortality risk
Crit Care Med 2016; 44:368–374
Crit Care Med 2016; 44:368–374
BMJ Open 2018;8:e017833
ROC = 0.92 ROC = 0.87 ROC = 0.96
SEPSIS SEVERE SEPSIS SEPTIC SHOCK
BMJ Open 2018;8:e017833
ROC = 0.85
BIOMARKERS
• Combination of 3 studies across 7 sites
• Prospective and observational – 450 patients
• Objective – Distinguish SIRS from sepsis
• Four genes – RT-qPCR assay: CEACAM4, LAMP1, PLAC8, PLA2G7
• Sepsis diagnosis by adjudication
Am J Respir Crit Care Med 2018;198(7):903–913
Am J Respir Crit Care Med 2018;198(7):903–913
SHOCK 2018; 49(4):364–370
Journal of Applied Laboratory Medicine 2019; 3(4): 724-29
WHAT ABOUT ON THE PATIENT SIDE?
SEPSIS AWARENESS
0%
20%
40%
60%
80%
100%
2007 2017
PUBLIC AWARENESS OF SEPSIS
A SYSTEMS APPROACH TO SEPSIS CARE
Early
RecognitionAntibiotics IV Fluids
Risk
Stratification
Hemodynamic
Optimization
Global Tissue
Hypoxemia
Crit Care Med 2006; 34:1589–1596
Each hour delay = ↓ survival 7.6%
OR=1.67
OR=92.5
N Engl J Med 2017;376:2235-44
AJRCCM 2017:196(7):856–863
Crit Care Med 2017; 45:623–629
Each hour delay = ↑ 8% progression to septic shock
CHEST 2019; 155(5):938-946
OR = 1.10
Annals ATS 2019;16(4):426-429
A SYSTEMS APPROACH TO SEPSIS CARE
Early
RecognitionAntibiotics IV Fluids
Risk
Stratification
Hemodynamic
Optimization
Global Tissue
Hypoxemia
FLUID THERAPY
How Much?
When to give?
What Type?
When to stop?
0
1000
2000
3000
4000
5000
6000
EGDT PBC UC EGDT UC EGDT UC
PROCESS ARISE PROMISE
Randomization 6 hours
30.5 29.2 28.0 34.6 34.7
IV FLUIDS
Intensive Care Med (2017) 43:625–632
Am J Respir Crit Care Med 2018;198(11):1406–1412
Crit Care Med 2017; 45:1596–1606
WHAT ABOUT THEM?
• Hemodynamic stable patients with lactate 2-4 mMol/L
Am J Respir Crit Care 2016;193(11):1264–1270
N Engl J Med 2017;376:2235-44
Crit Care Med 2017; 45:1596–1606
Crit Care Med 2017; 45:1596–1606
FLUID THERAPY
How Much?
When to give?
What Type?
When to stop?
N Engl J Med 2018;378:829-39.
N Engl J Med 2018;378:829-39.
0%
10%
20%
30%
40%
MAKE 30 Overall MAKE 30 Sepsis Mortality
15.4%
38.9%
11.1%14.3%
33.8%
10.3%
SALINE BALANCED
P = 0.04
P = 0.01
P = 0.06
N Engl J Med 2018;378:829-39
NNT = 20
A SYSTEMS APPROACH TO SEPSIS CARE
Early
RecognitionAntibiotics IV Fluids
Risk
Stratification
Hemodynamic
Optimization
Global Tissue
Hypoxemia
Lactate ≤ 4
Lactate > 4
20%
25%
30%
35%
40%
45%
No Hypotension
Hypotension
23.3%29.3%
29.0%
44.5%
Crit Care Med 2015 Mar;43(3):567-73
Crit Care Med. 2009 May;37(5):1670-7
CHEST 2018; 154(2):302-308
CHEST 2018; 154(2):302-308
BLOOD CULTURE LACTATE ANTIBIOTICS FLUIDS
Crit Care Med 2018; 46:500–505
SEP -1 MORTALITY
70%
88%
21%28%
75%
0%
37%
97% 98%
77%
64%
84%89%
20%
0%
20%
40%
60%
80%
100%
Lactate within 1 h Blood culturesbefore antibiotics
Antibiotics within1h
IV Fluids (30ml/Kg)
Repeat Lactatewithin 6h
Vasopressorswithin 6h
Mortality
PAST VS CURRENT STATE
Before After
angel.coz@uky.eduacoz@sepsis.org
Sepsis.org
Questions?
Copyright © 2019 Sepsis Alliance. All rights reserved.
Sepsis Awareness Month
• Launched in 2011 by Sepsis Alliance• State designations• Community events• Sepsis Superhero™ Challenge• Toolkits for healthcare providers
ØPrintable Posters and InfographicsØDigital and Social Media toolsØIdeas to get involvedØTemplate messaging
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Sepsis Heroes
• Annual celebration of sepsis leadership across the country• September 12, 2019 • Marquee New York City
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GE Sponsored Webinar
Series: Can We Help ‘Solve’ Sepsis Together? “Biomarkers: We Just Need To Be Better Listeners”September 18 at 2-2:45 pm ET
Register at SepsisWebinar.org
Speaker:Dr. Eric GluckSwedish Covenant Hospital
Sepsis Alliance gratefully acknowledges the support provided by GE Healthcare.
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Sepsis: Across the Continuum of Care Webinar
The Blind Spot of Antibiotic Stewardship: Antibiotic Overuse at DischargeSeptember 24 at 2-3 pm ET
Register at SepsisWebinar.org
Speaker:Valerie Vaughn, MD, MScAssistant Professor University of Michigan Medical School
Sepsis Alliance gratefully acknowledges the support provided for this webinar by Thermo Fisher Scientific.
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Disclaimer
The information in this webinar is intended for educational purposes only. The presentations and content are the opinions, experiences, views of the specific authors/presenters and are not statements of advice or opinion of Sepsis Alliance. The presentation has not been prepared, screened, approved, or endorsed by Sepsis Alliance.
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