Transcript Maternal Sepsis - Kenyatta National Hospital

Maternal Sepsis
Dr. Maureen Owiti
Medical Specialist
Reproductive Health Department- KNH
The microorganisms that seem to have
it in for us..turn out..to be rather more
like bystanders..it is our response to
their presence that makes the disease
Lewis Thomas NEJM 1972
Definitions
• Sepsis : the systemic inflammatory response
syndrome that occurs during infection (Society
Critical Care Medicine 2001 consensus
statement)
• Septic shock: vascular collapse secondary to an
infectious process
• Usually components of hypovolemic and
cardiogenic shock
Concept of Septic Shock in
2013
• Early in sepsis there is an increase in
inflammatory mediators
• Mid- to late sepsis consistent with
immunosuppression
Physiological changes in
pregnancy: White blood cells
• 1st trimester, the mean count is 8000/mm3 NI (5,1109,900/mm3)
• 2nd & 3rd trimester, the mean is 8,500/mm3 NI(5,60012,200/mm3)
• In labour rise to 20,000-30,000/mm3
• Largely due to increase in segmented neutrophils and
granulocytes
• Caused by elevated estrogen and cortisol levels
• Returns to normal within 1-2 weeks
• associated with suppression humoral and cellmediated immunological functions
• involve suppression of T-helper (Th) 1 and Tcytotoxic (Tc) 1 cells, which decreases secretion of
interleukin-2 (IL-2), interferon- , and tumor necrosis
factor- (TNF-)
• upregulation of Th2 cells to increase secretion of IL4, IL-6, and IL-13.
• In cervical mucus,immunoglobulins A and G (IgA and
IgG) are significantly higher
7/20/2015
Physiological changes in
pregnancy: Immunologic system
Maternal Sepsis: Incidence
• Septic shock: 0.002-0.01% of all deliveries
• 0.3-0.6% of all septic patients are pregnant
• Has increased over the last decade
• Older maternal age at delivery
• Obesity, diabetes, CHTN, placental abruption and placenta accreta
• ART and multi-fetal gestation
• Obesity
• HTN, DM, Cesarean, cardiopulmonary complications
Burton and Sibai 2012
Maternal Sepsis Mortality and Morbidity
During Hospitalization for Delivery
• Bauer et al Anesth Analg 2013
• 44,999,260 hospitalizations for delivery
• Sepsis complicated 1:3333 deliveries
• Severe sepsis 1:10,823 deliveries
• Sepsis related death 1:105,384 deliveries
• Overall frequency of sepsis stayed the same
during the study period
• Severe sepsis and death odds increased 10%
per year
Maternal death due to sepsis
KNH 2008
•
•
•
•
•
•
•
Worldwide 15% maternal deaths due to infection
Study period July-Oct 2008
3013 deliveries
25 deaths
4 deaths due to sepsis
16% deaths secondary to sepsis
Death from sepsis accounts for 0.13% of deliveries
Admissions for infections in KNH
Wd 1D 2013
Ward 1 D
• Pueperal sepsis – 53 admissions
• Post-op wound sepsis – 36 admissions
• Higher number of cases noted as from September (Free
Maternity, new students??)
• NB: Assumption is that correct diagnosis at admission and no
mechanism to track in-patient development of the same
• Under-reporting using routine registration
data, compounded by misclassification
and unreported deaths, results in
significant underestimation of the burden
of maternal death from sepsis.
Maternal Sepsis Mortality and Morbidity
During Hospitalization for Delivery
• Bauer et al Anesth Analg 2013
• Independent risk factors for severe sepsis
Age >35
Chronic renal failure
AA Race
Medicaid
Retained POCs
PROM
CHF
HIV infection
SLE
Multiple gestation
Cerclage
Chronic liver failure
Bacterial Infections in Obstetrics
• Postpartum endometritis
• Lower tract UTI
• Septic abortion
• Pyelonephritis
• Chorioamnionitis
• Necrotizing fasciitis
• Toxic shock syndrome
15-87 %
1-4 %
1-4 %
1-2 %
1-2 %
0.5 - 1 %
<1%
<1
Creasy, Resnick and Iams 2010
• Cesarean delivery
• Vaginal delivery
Common Bacterial Isolates from OB Patients
with Septic Shock
Escherichia coli
Group B streptococci
Bacteroides spp.
Peptostreptococcus
Peptococcus spp.
Clostridium perfringens
Group A streptococci
Entercoccus spp.
Staphylococcus aureus
Listeria monocytogenes
Klebsiella pneumoniae
Pseudomonas aeruginosa
Enterbacter spp.
Proteus spp.
Maternal Sepsis Mortality and Morbidity
During Hospitalization for Delivery
• Bauer et al Anesth Analg 2013
• 1680 Women with severe sepsis had a ICD9 code for a
known organism
• E. coli septicemia
27%
• Staphylococcal septicemia 22%
• Streptococcal septicemia
20%
• Gram negative septicemia 19%
• Pneumococcal speticemia 4%
• Pseudomonal septicemia
2.4%
• Anaerobic septicemia
2%
Maternal Sepsis Mortality and Morbidity
During Hospitalization for Delivery
• Bauer et al Anesth Analg 2013
• Concurrent infections in women with severe sepsis
• Pneumonia
30%
• GU infections
30%
• Chorioamnionitis
18%
• Endometritis
9%
• Pyelonephritis
6%
• Wound Infection
5%
• Endocarditis
2%
• Meningitis
1%
Lower Mortality in the Obstetric Patient
• 0-28 % versus 10-81% in the non-pregnant
population
• Factors associated with the decreased mortality
• Younger age
• Types of organisms
• Overall healthy population
• Pelvis amenable to surgical and medical
intervention
• Transient bacteremia
Creasy, Resnick and Iams 2008
National Guidelines for the NonPregnant Individual
• There are several “scoring systems” and national
guidelines to help determine admission to the ICU,
treatment regimens and predict morbidity and
mortality.
• Modified Early Warning System
• SIRS Criteria
• APACHE
• Unfortunately not validated for the pregnant and
non-pregnant woman
Surviving Sepsis Campaign
2012
• Update of Guidelines for management of severe
sepsis and septic shock of 2008
• 3 categories
1. Directly targeting severe sepsis
2. Targeting general care of critically ill patient and
considered high priority in severe sepsis
3. Paediatric considerations
SSC - Diagnostic criteria for sepsis:
General Variables
• Fever (>38.3oC)
• Hypothermia (core temperature <36oC)
• Heart rate >90/min or greater than 2SD above
the normal value for age
• Tachypnoea
• Altered mental status
• Significant oedema or positive fluid balance
(>20mL/kg over 24 hrs)
• Hyperglycaemia (plasma glucose >7.7mmol/L in
the absence of diabetes)
SSC - Diagnostic criteria for sepsis:
Inflamatory variables
• Leucocytosis (WBC count >12,000 mm3)
• Leucopenia (WBC count <4,000/mm3)
• Normal WBC count with greater than 10%
immature forms
• Plasma C-reactive protein more than two SD
above the normal value
• Plasma procalcitonin more than two SD above
the normal value
SSC - Diagnostic criteria for sepsis:
Haemodynamic variables
Arterial hypotension
• SBP<90mmHg
• MAP<70mmHg
• SBP decrease >40mmHg in adults or less than
two SD below normal for age
SSC - Diagnostic Criteria for sepsis:
Organ dysfunciton variables
• Arterial hypoxemia (PaO2/FiO2 <300)
• Acute oliguria (urine output<0.5mL/kg/hr for at
least 2 hrs despite adequate fluid resuscitation
• Creatinine increase>0.5mg/dl or 44.2µmol/L
• Coagulation abnormalities (INR>1.5 or aPTT>60s)
• Ileus (absent bowel sounds)
• Thrombocytopenia(platelet count <100,000 µL-1)
• Hyperbilirubinemia (plasma total
bilirubin>4mg/dl or 60 µmol/L)
SSC - Diagnostic criteria for sepsis:
Tissue perfusion variables
• Hyperlactatemia (>1mmol/L)
• Decreased capillary refill or mottling
Management of septic shock
• Multi-disciplinary approach
Management of Septic Shock
• Overall goals
• Treat the mother!
• Resuscitating the mother will resuscitate the
fetus
• Delivery attempts increase maternal and fetal
mortality assuming the source is not intrauterine
• Improve functional intravascular volume
• Establish and maintain an adequate airway
• Determine the septic foci: blood culture and
imaging studies
• Empiric antibiotic therapy
Creasy and Resnick 2008
Management of Septic Shock
• Volume resuscitation
• Aggressive therapy will optimize afterload,
preload and cardiac contractility
• Normalize mixed venous oxygen saturation,
lactate concentrations, base deficit and pH
• Initial resuscitation with crystalloids,
consideration of addition of albumin &
avoidance of hetastarch formulations
• Central venous access recommended
Management of Septic Shock
• Oxygenation/Ventilation
• Mechanical ventilation usually required
• ARDS : hypoxemia, normal PCWP, diffuse infiltrates
and decreased pulmonary compliance
• PEEP
• Keep at or above 96% if possible during pregnancy
• Blood transfusion can increase O2 content : target
Hgb >7 g/dl
Management of Septic Shock
• Inotropic agents
• Norepinephrine – now considered first line therapy
• Increases mean arterial pressure
• Can reduce uterine artery blood flow
• Vasopressin can be added
• Dobutamine only in selected cases like myocardial
dysfunction
• Dopamine hydrochloride (a-adrenergic and badrenergic effects) not recommended
Management of Septic Shock
• Empiric antibiotic therapy
• Find the underlying etiology of the sepsis
• Start broad spectrum antibiotics immediately after drawing
cultures within 1 hr of diagnosis
• Penicillin (if Staphylococcus aureus suspected, consider
Vancomycin) or derivative PLUS aminoglycoside PLUS
Clindamycin
• Vancomycin and Piperacillin/Tazobactam
• Alter regimen as culture and sensitivity results available
• Daily reassessment of antibiotic for de-escalation when
necessary
Management of Septic Shock
• Surgical drainage or removal of infected tissues
• uterine evacuation, hysterectomy, abscess
drainage, etc depending on the etiology
• Corticosteroids: only use in cases not responsive
to fluid resuscitation and inotpric agents. High
doses do not increase survival. Physiologic doses
may be beneficial in extremely ill patients (relative
adrenal insufficiency)
Management of Septic Shock
• Activated Protein C
• First anti-inflammatory agent effective in the
treatment of septic shock (NEJM 2001)
• Inactivates Factors Va and VIIIa, preventing thrombin
generation
• 3.5% risk of serious hemorrhage
• However, U.S. FDA, based on the PROWESS-SHOCK
clinical trial, issued a statement in 2011 that it should
not be started in new patients with sepsis because it
failed to show a survival benefit
Management of Septic Shock
• Insulin therapy with a goal of blood sugar <180
mg/dl
• hyperglycemia impairs phagocytotic effects
• More aggressive control increases risk of
hypoglycemia
• RBC transfusion: target Hgb 7.0 g/dL or greater
• NUTRITION oral or enteral feeding as necessary
Management of septic shock
• DVT prophylaxis
• Stress ulcer prophylaxis
• Protocols for weaning & sedation
• No neuromuscular blocade if no ARDS
• Adressing goals of care within 72 hrs of ICU
admission (treatment plans and end-of-life
planning as appropriate)
Surviving Sepsis Campaign Bundles:
TO BE COMPLETED WITHIN 3 HRS
1) Measure lactate level
2) Obtain blood cultures prior to administration of
antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30mL/kg crystalloid for hypotension
or lactate ≥4mmol/L
Surviving Sepsis Campaign Bundles:
TO BE COMPLETED WITHIN 6HRS
5) Apply vasopressor (for hypotension that does not
respond to initial fluid resuscitation)
6) In the event of persistent arterial hypotension
despite volume resuscitation (septic shock) or
initial lactate ≥4mmol/L (36mg/dl)
• Measure central venous pressure (SVP) *
• Measure central venous oxygen saturation
(Scvo2) *
7) Remeasure lactate if initial lactate was elevated *
*Targets for quantitative resuscitation included in the
guidelines are CVP of ≥ 8mm Hg, Scvo2 of ≥ 70%, and
normalization of lactate
Gaps and Challenges in
hospital setting……
• Recognition
• ? Ad-hoc /Empiric treatment (do we know most
common pathogens)
• Prophylactic antibiotics (sterile cultures)
• Linkage of available knowledge in common
database
• Quality of drugs
• Connection between maternal infection &
neonatal morbidity
• Data collection (KIPMAT, ABD-Kilifi district
hospital)
Prevention is Key
• Controlling chronic disease
• Observing infection prevention practices (hand
washing!!!)
• Antimicrobial prophylaxis
• Repeat if case > 4 hours
• Increase dose in obese patients
• Obesity epidemic ???
• Appropriate vaccination
• Septic abortions????
Maternal Sepsis: Call to
Action
• A standardized approach should be formulated for
pregnant women with suspected sepsis
• Admission disposition protocol e.g. ICU, labor and
delivery
• Early diagnosis procedures
• Management protocol to include both maternal and
fetal evaluation and treatment
• Prevention strategies
acknowledgements
•
•
•
•
•
Dr. K. Lubano
Dr. J. Machira
Dr R. Kosgei
Dr. N. Bosire
Dr. W. Nduhiu
THANK YOU!!