Sepsis Resuscitation Bundle (To be started immediately an

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Sepsis...improving reliability and outcomes
Dr Ron Daniels Executive Director, Global Sepsis
Alliance Fellow NHS Improvement Faculty Chair
United Kingdom Sepsis Group, Sepsis Trust UK
SSC NHS Scotland, 18th January 2012
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Sepsis is under-appreciated. Sepsis is
under-funded. We (us doctors) over-complicate
sepsis care. I have less to offer septic patients
once theyre in my ICU. It is inevitable that
we will get our act together.
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Sepsis is under-appreciated. Sepsis is
under-funded. We (us doctors) over-complicate
sepsis care. I have less to offer septic patients
once theyre in my ICU. It is inevitable that
we will get our act together. Only question is,
how many of our patients will die first?
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What we need to do

• Work out why ideal sepsis care continues to elude
  us
• Move from recognizing sepsis to suspecting
  it
• Make the case for simplifying sepsis care
• Establish sepsis as a medical emergency
• And not forgetting

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A U.K. Perspective
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A U.K. Perspective
North Stand
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A U.K. Perspective
Breast cancer
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A U.K. Perspective
Breast cancer
Trinity Road Stand
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A U.K. Perspective
Breast cancer
Bowel cancer
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A U.K. Perspective
Annual UK sepsis deaths
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Why do we need to simplify sepsis care?
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Revision due 2012 No Management Bundle!!
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Standards currently achieved for 14 of UK
patients39 in my hospitalHow many in yours???
Source UK SSC data
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Comparison with ACS
75 in 30 mins
80
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Perspective
Severe Sepsis Acute coronary syndrome
No. cases per 100,000 per annum 127 200
NNT basic care Sepsis Six (our data) 6 First hour antibiotics 5 Clopidogrel 48 ß-blockade 42 Aspirin 26
NNT invasive care EGDT (Rivers) 6 Resusc Bundle (SSC) 18 Thrombolysis 15 PCI over thrombolysis 33
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Early, appropriate antibiotics the key to
sepsis improvement
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Will antibiotics prevent sepsis?
Antimicrobials
CARS
Infective insult
SIRS
Organ dysfunction
Time
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Septic shock the golden hour
Organ injury
Inflammatory response Toxic
load Microbial load
Shock threshold
Acknowledgement to Anand Kumar
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Septic shock the golden hour
Antimicrobials
Shock threshold
Organ injury
Inflammatory response Toxic
load Microbial load
Acknowledgement to Anand Kumar
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SSC- antibiotics

• Begin IV antibiotics as early as possible, and
  always within the first hour of recognising
  severe sepsis (1D) and septic shock. (1B)
• Broad-spectrum one or more agents active against
  likely bacterial/ fungal pathogens and with good
  penetration into presumed source. (1B)
• Reassess antimicrobial regimen daily to optimise
  efficacy, prevent resistance, avoid toxicity
  minimise costs. (1C)

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Cumulative Initiation of Effective Antimicrobial
Therapy and Survival in Septic Shock
1.0
survival fraction
cumulative antibiotic initiation

0.8
0.6
fraction of total patients
0.4
0.2
0.0
12-24
24-36
0-0.5
0.5-1
9-12
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1-2
2-3
3-4
4-5
5-6
6-9
time from hypotension onset (hrs)
Kumar et al. CCM. 2006341589-96.
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Running average survival in septic shock based on
antibiotic delay (n2154)
For each hours delay in administering
antibiotics in septic shock, mortality increases
by 7.6
Funk and Kumar Critical Care Clinics 2011 (in
press)
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• 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

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Early antibiotics are good...
Author n Setting Median time (mins) Odds Ratio for death
Gaieski Crit Care Med 2010 381045-53 261 ED, USA (Shock) 119 0.30 (first hour vs all times)
Daniels Emerg Med J 2010 doi10.1136 567 Whole hospital, UK 121 0.62 (first hour vs all times)
Kumar Crit Care Med 2006 34(6)1589-1596 2154 ED, Canada (Shock) 360 0.59 (first hour vs second hour)
Appelboam Critical Care 2010 14(Suppl 1) 50 375 Whole hospital, UK 240 0.74 (first 3 hours vs delayed)
Levy Crit Care Med 2010 38 (2) 1-8 15022 Multi-centre 0.86 (first 3 hours vs delayed)
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Running average survival in septic shock based on
antibiotic delay (n4195)
Funk and Kumar Critical Care Clinics 2011 (in
press)
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• Adequacy of initial spectrum and timing of first
  delivery and achievement of MIC are collectively
  the key
• Reduce microbial and toxic load
• ...so hit hard and hit fast
• .... BUT....

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• How do we know which septic patient is going to
  organ failure?
• We often dont know the source, let alone the
  bug....
• We dont adhere to guidelines, and the guidelines
  arent much good
• Were not very good with our timing
• So...

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Should we have, for first dose, the Sepsis
Antibiotic?
Pip/ taz? Meropenem? Linezolid? Forget severe
sepsis??
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How to simplify sepsis care ..community-acquired
sepsis
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Sepsis Resuscitation Bundle (To be started
immediately and completed within 6 hours)

• Serum lactate measured
• Blood cultures obtained prior to antibiotic
  administration
• From the time of presentation, broad-spectrum
  antibiotics to be given within 1 hour
• Control infective source
• In the event of hypotension and/or lactate
  gt4mmol/L (36mg/dl)
• Deliver an initial minimum of 20 ml/kg of
  crystalloid (or colloid equivalent)
• Give vasopressors for hypotension not responding
  to initial fluid resuscitation to maintain mean
  arterial pressure (MAP) gt 65 mm Hg.
• In the event of persistent arterial hypotension
  despite volume resuscitation (septic shock)
  and/or initial lactate gt4 mmol/l (36 mg/dl)
  
• Achieve central venous pressure (CVP) of gt8 mm
  Hg
• Achieve central venous oxygen saturation (ScvO2)
  gt70

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Sepsis Resuscitation Bundle (To be started
immediately and completed within 6 hours)

• Serum lactate measured
• Blood cultures obtained prior to antibiotic
  administration
• From the time of presentation, broad-spectrum
  antibiotics to be given within 1 hour
• Control infective source
• In the event of hypotension and/or lactate
  gt4mmol/L (36mg/dl)
• Deliver an initial minimum of 20 ml/kg of
  crystalloid (or colloid equivalent)
• Give vasopressors for hypotension not responding
  to initial fluid resuscitation to maintain mean
  arterial pressure (MAP) gt 65 mm Hg.
• In the event of persistent arterial hypotension
  despite volume resuscitation (septic shock)
  and/or initial lactate gt4 mmol/l (36 mg/dl)
  
• Achieve central venous pressure (CVP) of gt8 mm
  Hg
• Achieve central venous oxygen saturation (ScvO2)
  gt70

No, No, No!!
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USA work

• EMS- transported sepsis patients
• Sicker
• Shorter time to antibiotics 119 vs 160 mins
• 116 vs 152 mins
• Shorter still if EMS provider SAID SEPSIS

Studnek JR et al 2010
Band RA et al 2011
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How to simplify sepsis care ..hospital-acquired
sepsis (not necessarily HCAIs!!)
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Know your reliability
Resuscitation bundle item Achieved Failed 2005 Data
Blood cultures taken 94 6 91
Antibiotics as per guidelines in lt1hr 28 72 28
Lactate measured 48 52 59
Adequate fluid resuscitation 69 31 57
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Know your processes
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Compliance at Good Hope Hospital ()
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Compliance at Good Hope Hospital ()
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Mortality by Sepsis Six
Cohort size Mortality RRR
Total 567 34.7
Sepsis Six Oxygen therapy Blood culture Antibiotic administration Fluid challenges Lactate and haemoglobin measurement Urine output monitoring. within one hour Sepsis Six Oxygen therapy Blood culture Antibiotic administration Fluid challenges Lactate and haemoglobin measurement Urine output monitoring. within one hour Sepsis Six Oxygen therapy Blood culture Antibiotic administration Fluid challenges Lactate and haemoglobin measurement Urine output monitoring. within one hour Sepsis Six Oxygen therapy Blood culture Antibiotic administration Fluid challenges Lactate and haemoglobin measurement Urine output monitoring. within one hour
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Mortality by Sepsis Six
Cohort size () Mortality RRR (NNT)
Total 567 (100) 34.7 -
Sepsis Six? 347 (61.2) 44.0
Sepsis Six? 220 (38.8) 20.0 46.6 (4.16)
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Mortality by antibiotics
Cohort size Mortality RRR (NNT)
Total 567 (100) 34.7 -
Delayed Antibiotics 217 (38.4) 45.4
Antibiotics within 1 h 350 (61.6) 28.1 38.1 (5.77)
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Mortality by fluid challenges
Cohort size Mortality RRR (NNT)
Total 567 (100) 34.7 -
No fluids in 1h 183 (32.3) 44.8
Fluids in 1h 384 (67.7) 30.0 33.0 (6.73)
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For patients receiving the Sepsis Six

• 2.0 fewer Critical Care bed days
• 3.4 fewer hospital bed days
• Compared with other survivors
• Equates to c. 5,000 cost saving

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The clincher
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Achieving 80 reliability

• For each year, for every 500 beds..
• 62 lives saved
• 883 fewer bed days
• 520 fewer CC bed days
• Direct costs for survivors reduced by 0.78M

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The global effort World Sepsis Declaration World
Sepsis Day
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Summary

• Sepsis is a medical emergency- and a big killer
• Awareness and recognition are the key
• Early antibiotics and fluids will save more lives
  than Critical Care
• Pre-hospital recognition may improve the
  reliability of basic interventions
• We need to get the balance right, together

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sepsisteam_at_gmail.com _at_sepsisuk www.uksepsis
.org www.survivesepsis.org