Transcript Severe Sepsis and Septic Shock Management

Dr Alex Hieatt, EM Consultant MEHT
Dr Ron Daniels, Chair of the UK Sepsis Trust and
Global Sepsis Alliance
(Slides with permission.)
Questions
1.
2.
3.
4.
5.
6.
What defines the sepsis syndrome?
What defines severe sepsis?
What defines septic shock?
What is the single most important intervention in
the management of severe sepsis and septic shock?
How often is 4 achieved within an hour?
What is the mortality from septic shock?
Questions
7. How many patients die each year in the UK from
severe sepsis and septic shock?
8. How many people die each year in the UK from lung
cancer?
9. How many people die each year in the UK from
bowel cancer and breast cancer combined?
10. How much does sepsis cost the UK health economy
each year?
Answers
 Sepsis syndrome
 2 SIRS criteria






HR > 90
RR > 20
T <36 or >38⁰C
Altered mental status
WBC <4 or >12 x 109 /L
BM >7.7 mmol/L in a non diabetic
 Suspected or newly diagnosed infection
Severe Sepsis =
Sepsis syndrome + evidence of organ
dysfunction
Clinical
 Need for O2 pre hospital




or on admission
Low blood pressure
SBP<90 mmHg OR SBP
drop >40 mmHg from
normal OR MAP <65
mmHg OR DBP<60
Not passed urine for > 8
hours OR UO< 0.5
mls/kg/hr for 2 hours
Jaundiced
New confusion or
decreased conscious level
Chemical
 INR > 1.5 OR APTT > 60s
 Platelets <100 x 109 /L
 Lactate >2 mmol/L
 Creatinine>177 µmol/L OR
Rise of > 50% over baseline
 Bilirubin > 37 µmol/L
Septic Shock
 Severe Sepsis and:
 Lactate > 4 mmol/L
 Refractory hypotension after 30 mls/kg ofvolume
resuscitation
Dr Ron Daniels
http://www.youtube.com/watch?v=poN0uB
BJemM
Breast cancer
Breast cancer
Breast cancer
Breast cancer
Global Sepsis Alliance / UK Sepsis Trust
The Sepsis Six
1.
Give high-flow oxygen
via non-rebreathe bag
2.
Take blood cultures
and consider source control
3.
Give IV antibiotics
according to local protocol
4.
Start IV fluid resuscitation
Hartmann’s or equivalent
5.
Check lactate
6.
Monitor hourly urine output
consider catheterisation
within one hour
..plus Critical Care support to complete EGDT
Perspective
Severe Sepsis
240
No. cases per 100,000
per annum
NNT ‘basic’ care
NNT invasive care
Acute coronary
syndrome
208
Sepsis Six (our data)
4
Clopidogrel
48
First hour antibiotics
6
β-blockade
42
Aspirin
26
Thrombolysis
15
PCI over thrombolysis
33
EGDT (Rivers)
Resusc Bundle (SSC)
6
18
Compliance,GHH (%)
70
60
50
Sepsis 6
40
Resusc
Both
30
Mortality
20
10
0
Apr-09
Jun-09
Aug-09
Oct-09
Mortality
Total
Cohort size
(%)
Mortality %
567 (100)
34.7
Sepsis Six

347 (61.2)
44.0
Sepsis Six

220 (38.8)
20.0
RRR %
(‘NNT’)
-
46.6
(4.16)
First hour antibiotics in 27%...
Begin IV antibiotics as early as possible, and always within the first
hour of recognising severe sepsis (1D) and septic shock. (1B)
Citation: Kumar A et al. Crit Care Med 2006: 34(6)
Retrospective, 15 years, 14 sites
n = 2,154
median 6 h, 50% administered in 6h
Only 5% first 30 minutes- survival 87%
12% first hour- survival 84%
Effective Antimicrobial Therapy &
Survival in Septic Shock
1.0
survival fraction
fraction of total patients
cumulative antibiotic initiation
0.8
0.6
0.4
0.2
0.0
time from hypotension onset (hrs)
Kumar et al. CCM. 2006:34:1589-96.
Running average survival in septic shock
based on antibiotic delay (n=2154)
For each hour’s delay in
administering antibiotics in septic
shock, mortality increases by 7.6%
Funk and Kumar
Critical Care Clinics 2011 (in press)
For each year, for every 100k in the local population..
20 lives saved
285 fewer bed days
168 fewer CC bed days
Direct costs for survivors reduced by £0.25M
For Italy, that’s 12,200 lives and €182 million.
Every year.
Useful Tools
file:///C:/Users/ali/Desktop/S4/Survive%20
Sepsis%20on%20the%20App%20Store%20o
n%20iTunes.htm
https://itunes.apple.com/gb/app/survivesepsis/id580791653?mt=8
http://www.youtube.com/watch?v=CrUHnY
IZbpM
https://itunes.apple.com/gb/app/nhsscotland-news-sepsisscreening/id657497806?mt=8