Transcript Sepsis PowerPoint Slide Presentation

Tiffany M. Osborn, MD
University of Virginia
ACEP Chair Critical Care
Section
ACEP Representative
Surviving Sepsis Campaign
Purpose for Existence?
Today
Future
600,000
Severe Sepsis Cases
US Population
1,600,000
500,000
Sepsis Cases
>750,000
cases of severe
sepsis/year
in the US*
1,400,000
1,200,000
400,000
1,000,000
300,000
800,000
200,000
600,000
400,000
200,000
Incidence projected to
increase by 1.5% per year
2001
2025
Year
Angus DC. Crit Care Med. 2001;29(7):1303-1310.
100,000
2050
Total US Population/1,000
1,800,000
Comparison With
Other Major Diseases
Incidence of Severe Sepsis
Mortality of Severe Sepsis
250,000
250
200
150
100
200,000
Deaths/Year
Cases/100,000
300
150,000
100,000
50,000
50
0
AIDS* Colon Breast CHF† Severe
Cancer§
Sepsis‡
†National
0
AIDS*
Breast AMI†
Cancer§
Severe
Sepsis‡
Center for Health Statistics, 2001. §American Cancer Society, 2001. *American Heart Association.
2000. ‡Angus DC et al. Crit Care Med. 2001;29(7):1303-1310.
Comparable Global
Epidemiology
• 95 cases per 100,000
– 2 week surveillance
– 206 French ICUs
• 95 cases per 100,000
– 3 month survey
– 23 Australian/New
Zealand ICUs
• 51 cases per 100,000
– England, Wales and
Northern Ireland.
Emergency Department Critical
Care Volume Increases
• 102 million National ED visits in 1999
•17% (17.5 million) “immediately life threatening”1
• 57 California Emergency Departments (1990-1999)2
• 50% (387,616) Severe Sepsis Cases Initially Present ED
Visits / ED (% Change)
70
Total visits/ED
Critical Care
Urgent
Nonurgent
50
30
P < 0.001 for all groups
10
1.
-10
2.
3.
Visits/ED
National Center for Health Statistics;
2001
Ann Emerg Med 2002;39:389-96
Curr Opin Crit Care Dec.2002
Surviving Sepsis Campaign
A global program to:
• Reduce mortality rates
•Improve standards of care
•Secure adequate funding
Surviving Sepsis
Phase 1 Barcelona declaration
Phase 2 Evidence based guidelines
Phase 3 Implementation and education
Surviving Sepsis
Phase 1 Barcelona declaration
Phase 2 Evidence based guidelines
Phase 3 Implementation and education
Sponsoring Organizations
• American Association of
Critical-Care Nurses
• American College of Chest
Physicians
• American College of
Emergency Physicians
• American Thoracic
Society
• Australian and New
Zealand Intensive Care
Society
• Episepsis
• European Society of
Clinical Microbiology and
Infectious Diseases
• European Society of
Intensive Care Medicine
• European Respiratory
Society
• German Sepsis Society
• Indian Society of Critical
Care Medicine
• International Sepsis
Forum
• Society of Critical Care
Medicine
• Surgical Infection Society
Surviving Sepsis
Phase 1 Barcelona declaration
Phase 2 Evidence based guidelines
Phase 3 Implementation and education
Clinical Inertia: Tales from
the Past
• National Registry MI 2
– 84,663 MI patients
eligible for reperfusion
– 24% got NO form of
reperfusion
• 10 years after therapy
shown to save lives
– 1 of 4 not treated
– 10,000 lives lost/year
– Estimated 100,000 lives
lost due to failure to treat
Barron, HV. Circulation. 1998;97:1150-1156.
25,886 patients enrolled in GUSTO-1
• 659 hospitals, 22 SAVE sites
• SAVE: Survival and
Ventricular Enlargement, ACE
(angiotensin-converting enzyme)
benefits post-MI patients with LV
dysfunction
Majumdar SR, et al. Am J Med 2002;113:140-5
ACE inhibitor use (%)
• Cross-sectional analysis of
ACE inhibitor use (%)
Clinical Inertia: Low Levels of
Compliance at Research Centers
SAVE site
Non-SAVE site
Pre-SAVE
Post-SAVE
20
15
10
5
0
20
15
10
5
0
Clinical Inertia: Low Levels of
Compliance at Research Centers
“If those who generated the evidence
are slow to translate it into practice, it
is unlikely that passive forms of
dissemination can improve the quality
of care. To accelerate adoption of new
evidence, we need to understand
factors other than knowledge and
awareness that influence practice”.
Majumdar SR, et al. Am J Med 2002;113:140-5
Phase 3: Collaboration for
Implementation
• Partner with Institute for
Healthcare Improvement
(IHI) www.IHI.org
• Non-profit organization
– Healthcare improvement
– Quality based initiatives
• Set Quality Benchmarks
– JCAHO
– Medicare
– Medicaid
– 3rd party payers
What is a Bundle?
• Specifically selected
care elements
– From evidence based
guidelines
– Implemented together
provide improved
outcomes compared to
individual elements
alone
SSC Steering Committee:
Global Consensus
13 September 2004
Catania, Sicily
• Steering
Committee Met
• 6 hour bundle
formed
• 24 hour bundle
formed
Gaining Consensus:
Finding Nemo
6 Hour Resuscitation Bundle
• Early Identification
• Early Antibiotics and
Cultures
• Early Goal Directed
Therapy
6 - hour Severe Sepsis/
Septic Shock Bundle
•
•
•
•
• Vasopressors:
Early Detection:
– Hypotension not
– Obtain serum lactate level.
responding to fluid
– Titrate to MAP > 65
Early Blood Cx/Antibiotics:
mmHg.
– within 3 hours of
• Septic shock or lactate > 4
presentation.
mmol/L:
– CVP and ScvO2 measured.
Early EGDT:
– CVP maintained >8 mmHg.
Hypotension (SBP < 90, MAP
– MAP maintain > 65 mmHg.
< 65) or lactate > 4 mmol/L:
– initial fluid bolus 20-40 ml of
• ScvO2<70%with CVP > 8
crystalloid (or colloid equivalent)
mmHg, MAP > 65 mmHg:
per kg of body weight.
– PRBCs if hematocrit < 30%.
– Inotropes.
Rhode Island Hospital EGDT Data
Time from Entering ED
to Receiving Antibiotics
Time from Entering ED
to Catheter Insertion
Reduced by 42%
Reduced by 60%
Time from Entering ED
to Transfer to MICU
Reduced by 51%
200
350
185
500
180
300
160
148
400
250
140
11
120
100
80
60
106
90
200
95
350
300
250
150
200
100
150
100
40
50
20
450
50
24 - hour Severe Sepsis
and Septic Shock Bundle
•
•
•
•
Glucose control:
– maintained on average <150 mg/dL (8.3 mmol/L)
Drotrecogin alfa (activated):
– administered in accordance with hospital guidelines
Steroids:
– for septic shock requiring continued use of vasopressors
for equal to or greater than 6 hours.
Lung protective strategy:
– Maintain plateau pressures < 30 cm H2O for
mechanically ventilated patients
Phase 3: Collaboration
for Implementation
• Partner with Institute for
Healthcare Improvement
(IHI)
– Develop sepsis
management “change
bundles”
– Provide tools and
systems for
implementation and
improvement
– Enhanced quality
– Improved mechanisms
SSC Educational Tool Kit
• Implementation Sepsis
Bundles
• Web-based and CD rom
• IHI Website (IHI.org)
• Tool Kit
– Educational material
– Process for developing
“Change teams”
– Data collection tools and
descriptions (database)
– Taylor: Culture Specific
The Future: ED and ICU
Interface
• Collaboration:
Emergency Medicine
and Critical Care
– Defining patient care
globally
– Setting standards for
ED/ICU collaborations
– Establishing new format
to change clinical
practice and improve
outcomes
• Providing tools
– JCAHO, Medicare
THANK YOU!!