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Diagnosis and Management of Sepsis
David Shimabukuro, MDCMMedical Director, 13 ICU
Physician Lead, UCSF Sepsis Bundle Compliance and Mortality Reduction
Disclosures
• I have no disclosures
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the allotted time
Agenda
• Epidemiology
• Definitions and Diagnosis
• Treatment
– Definitive
– End‐organ support
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Agenda
• Epidemiology
• Definitions and Diagnosis
• Treatment
– Definitive
– End‐organ support
Epidemiology
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Epidemiology
Epidemiology
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Death rate over time
0
50
100
150
200
250
300
2000 2002 2004 2006 2008 2010
Heart Disease
Malignant Neoplasms
Cerebrovascular Disease
Septicemia
National Vital Statistics Reports, vol 6, no 4, May 08, 2013
Epidemiology
38%
20%
8%
8%
14% 12%
Cause
Lung
Blood
Skin/Soft Tissue
Abdominal
Genitourinary
Other
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Agenda
• Epidemiology
• Definitions and Diagnosis
• Treatment
– Definitive
– End‐organ support
CASE
Mrs. M is an 82 year‐old woman with a past medical history significant for Alzheimer’s, hypothyroidism, and hypertension, was admitted to the floor from a skilled nursing facility with dysarthria from an acute CVA.
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CASE
On hospital day 2, she is quite somnolent but arouses with tactile stimulation. Her vitals are BP 120/76, HR 78, RR 30, Temp 38, and oxygen saturation 90% on 6LNC (she was on RA yesterday evening). Her WBC this morning has increased to 11.1 from 8.9.
CASE
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Does she have…
1. Systemic inflammatory response syndrome
2. Sepsis
3. Severe Sepsis
4. Septic shock
5. None of the above
I would order a lactate?
1. No
2. Yes
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CASE
Her lactate level returns at 4.4 mmol/L.
Does she have…
1. Systemic inflammatory response syndrome
2. Sepsis
3. Severe Sepsis
4. Septic shock
5. None of the above
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I would transfer her to the ICU
1. No
2. Yes
I would place a central venous catheter
1. No
2. Yes
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Sepsis Definitions
• SIRS
• Sepsis
• Severe Sepsis
• Septic Shock
Septic Shock
SEVERE SEPSIS plushypotension (Systolicblood pressure < 90 orMean Arterial Blood Pressure < 65) OR Lactate > 4
Severe Sepsis
SEPSIS plus evidenceof at least one alteration in organ perfusion
Sepsis
SIRS plus confirmed or suspected infection
Sepsis: ACCP/SCCM Definitions
SIRS
T > 38.3 C or < 36 CHR > 90 beats/minTachypneaWBC > 12K or < 4K
SIRS
T > 38.3 C or < 36 CHR > 90 beats/minTachypneaWBC > 12K or < 4K
SIRS
T > 38.3 C or < 36 CHR > 90 beats/minTachypneaWBC > 12K or < 4K
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Severe Sepsis Definition
Crit Care Med February 2013 Volume 41 Number 2 pp. 580‐637
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San Francisco Definition
Sepsis is defined as a life‐threatening organ dysfunction due to a dysregulated host response to infection.
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What is Sepsis??
• A variable condition that affects each of us differently and is initiated by a known or suspected infectious insult.
Is catching it earlier better??
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Sepsis Screening
Crit Care Med February 2013 Volume 41 Number 2 pp. 580‐637
Sepsis Screening
Crit Care Med February 2013 Volume 41 Number 2 pp. 580‐637
Great….but when should we do it and how should it be done!!!!
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Sepsis Screening
Sepsis Screening
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Sepsis Screening
• Important to have one that works for your hospital
• Should probably do once a shift (no clear data)
• Screening works as a reminder for continued awareness and vigilance
• (Determine time of presentation)
Agenda
• Epidemiology
• Definitions and Diagnosis
• Treatment
– Definitive
– End‐organ support
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Definitive Treatment
• Antibiotics
• Source Control
Management of Severe Sepsis and Septic Shock
Crit Care Med February 2013 Volume 41 Number 2 pp. 580‐637
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Management of Severe Sepsis and Septic Shock
1
Crit Care Med 2006 Vol. 34, No. 6
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End‐organ support (by improving tissue perfusion)…
Management of Severe Sepsis and Septic Shock
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Management of Severe Sepsis and Septic Shock
• Fluid Therapy
– Crystalloids are first choice for the overwhelming majority of patients
– Albumin can be used to reduce volume from crystalloids
– Hydroxyethyl starches should not be used
Management of Severe Sepsis and Septic Shock
• Fluid Therapy
– WATCH OUT!!!!!
– Too much fluid is bad and not enough is bad…
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Management of Severe Sepsis and Septic Shock
Management of Severe Sepsis and Septic Shock
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Management of Severe Sepsis and Septic Shock
Beyond the 6‐hour resuscitation
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Management of Severe Sepsis and Septic Shock
• Lung Injury
– All patients at risk
– Low‐tidal volume ( 6cc/kg IBW)
– Plateau pressure < 30 cm H20
– Permissive hypercapnia
– FIO2:PEEP strategy
Management of Severe Sepsis and Septic Shock
• Corticosteroids
– For refractory hypotension despite fluids and vasopressors/inotropes
– Do not perform ACTH stimulation test
• Glucose
– Target level to less than 180 mg/dL
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Management of Severe Sepsis and Septic Shock
• Blood Products
– HGB level 7.0 – 9.0 g/dL after hypoperfusion has resolved
– FFP not to be used unless bleeding is present or for planned invasive procedure
– PLT to be given prophylactically when <10K in absence of bleeding
Management of Severe Sepsis and Septic Shock
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EGDT
Management of Severe Sepsis and Septic Shock
Does this bundle actually work??
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Management of Severe Sepsis and Septic Shock
yes…
no…
Crit Care Med 2010 Vol 38 No 2 pp 367‐374
Management of Severe Sepsis and Septic Shock
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Management of Severe Sepsis and Septic Shock
Management of Severe Sepsis and Septic Shock
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Management of Severe Sepsis and Septic Shock
Management of Severe Sepsis and Septic Shock
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Original Article
A Randomized Trial of Protocol-Based Care for Early Septic Shock
The ProCESS Investigators
N Engl J MedVolume 370(18):1683-1693
May 1, 2014
Cumulative Mortality.
The ProCESS Investigators. N Engl J Med 2014;370:1683-1693
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Conclusions
• In a multicenter trial conducted in the tertiary care setting, protocol-based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes.
Original Article
Goal-Directed Resuscitation for Patients with Early Septic Shock
The ARISE Investigators and the ANZICS Clinical Trials Group
N Engl J MedVolume 371(16):1496-1506
October 16, 2014
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Probability of Survival and Subgroup Analyses of the Risk of Death at 90 Days.
The ARISE Investigators and the ANZICS Clinical Trials Group. N Engl J Med 2014;371:1496-1506
Conclusions
• In critically ill patients presenting to the emergency department with early septic shock, EGDT did not reduce all-cause mortality at 90 days.
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Original Article
Trial of Early, Goal-Directed Resuscitation for Septic Shock
Paul R. Mouncey, M.Sc., Tiffany M. Osborn, M.D., G. Sarah Power, M.Sc., David A. Harrison, Ph.D., M. Zia Sadique, Ph.D., Richard D. Grieve, Ph.D., Rahi Jahan, B.A.,
Sheila E. Harvey, Ph.D., Derek Bell, M.D., Julian F. Bion, M.D., Timothy J. Coats, M.D., Mervyn Singer, M.D., J. Duncan Young, D.M., Kathryn M. Rowan, Ph.D.,
for the ProMISe Trial Investigators
N Engl J MedVolume 372(14):1301-1311
April 2, 2015
Kaplan–Meier Survival Estimates.
Mouncey PR et al. N Engl J Med 2015;372:1301-1311
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Conclusions
• In patients with septic shock who were identified early and received intravenous antibiotics and adequate fluid resuscitation, hemodynamic management according to a strict EGDT protocol did not lead to an improvement in outcome.
Changes…
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Surviving Sepsis Campaign Bundle Revision 2015
Surviving Sepsis Campaign Bundle Revision 2015
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Summary
• A very heterogeneous disease that is difficult to diagnose in its early stages and difficult to treat in its later stages.
• Routine screening can allow for earlier identification
• Early intervention can attenuate its course
Summary
• Definitive treatment involves rapid appropriate antibiotic administration and source control
• Supportive care for end‐organ dysfunction is the mainstay of treatment
• Management bundle continues to evolve
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UCSF Experience
Leveraging data in the EMR
• Vital signs/assessments
• Laboratory values
• Problem list
• Medication list
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Leveraging data in the EMR
• 6 different algorithms based on patient location
– ED
– Medical/Surgical ward
– Medical/Surgical ICU
– Hematology/Oncology
– CVT ward
– CVT ICU
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• Code Sepsis
• UCSF Sepsis Bundle
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Sepsis Updates80
UHC Sepsis Mortality Index
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