The Surviving Sepsis Campaign: The Sepsis Epidemic: How to Win

1. The Surviving Sepsis Campaign:The Sepsis Epidemic: How to Win

2. Time Sensitive Interventions • AMI – “Door to PCI” • Focus on the timely return of blood flow to the affected areas of the heart. • Stroke – “Time is Brain” • The sooner that treatment begins, the better are one’s chances of survival without disability. • Trauma – “The Golden Hour” • Requires immediate response and medical care “on the scene.” • Patients typically transferred to a qualified trauma center for care.

3. SevereSepsisvs. CurrentCarePriorities Source: (1) Ryan TJ, et al. ACC/AHA Guidelines for management of patients with AMI. JACC. 1996; 28: 1328-1428. (2) American Heart Association. Heart Disease and Stroke Statistics – 2005 Update. Available at: www.americanheart.org. (3) National Highway Traffic Safety Administration. Traffic Safety Facts 2003: A Compilation of Motor Vehicle Crash Data from the Fatality Analysis Reporting System and the General Estimates System. Available at http://www.nhtsa.dot.gov/. (4) Angus DC et al. Crit Care Med 2001;29(7): 1303-1310.

4. The Surviving Sepsis Campaign • = ~ 50,000 people in the US each year. • = ~ 1,100,000 individuals worldwide each year. 25%Reduction In Sepsis Mortality By2009 Angus DC, et al. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Critical Care Medicine. Jul 2001;29(7):1303-1310.

5. A Major Study of “Reliability” in American Health Care… • McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003) • 439 indicators of clinical quality of care • 30 acute and chronic conditions • Medical records for 6712 patients • Participants had received 54.9% of scientifically indicated care (Acute: 53.5%; Chronic 56.1%; Preventative 54.9%) • Conclusion: The Defect Rate in technical quality of American health care is approximately 45%

6. 100 Interview Audit 92 79 80 67 % 60 46 40 31 18 20 9 4 0 ScvO2 Glycaemic control Hydrocortisone septic shock Low tidal ventilation Supportive and Adjunctive Therapies Results of the German “Prevalence” Study Brunkhorst FM, Engel C, Ragaller M, Welte T, Rossaint R, Gerlach H,Mayer K, John S, Stuber F, Weiler N, Oppert M, Moerer O, Bogatsch H,Hartog C, Loeffler M, Reinhart K for the German Competence Network Sepsis (SepNet). (2008) Practice and Perception - A Nationwide Survey of Therapy Habits in Sepsis. Crit Care Med (in press).

7. Surviving SepsisCampaign What steps can we take?

8. The Surviving Sepsis Campaign Early goal directed therapy reduced mortality from46.5%to30.5%. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine. 2001;345(19):1368-1377.

9. Standard therapy 60 EGDT 50 40 Mortality (%) 30 20 10 0 In-hospital mortality (all patients) 60-day mortality 28-day mortality Early Goal-Directed Therapy for Sepsis Induced Hypoperfusion NNT to prevent 1 event (death) = 6-8 Rivers E, et al. N Engl J Med 2001;345:1368-77

10. The Surviving Sepsis Campaign Low dose hydrocortisone prolonged survival in septic shock for patients with RAI. Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. Journal of the American Medical Association. 2002;288(7):862–871.

11. Annane et al. JAMA 2002; 288:862-871

12. The Surviving Sepsis Campaign Low tidal volume ventilation reduced mortality from39.8%to31%. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. New England Journal of Medicine. 2000;342(18):1301–1308.

13. ARDSnet Mechanical Ventilation Protocol Results:Mortality %Mortality The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000;342:1301-1378

14. The Surviving Sepsis Campaign Recombinant Human Activated Protein C reduced mortality from30.8%to24.7%. Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. New England Journal of Medicine. 2001; 344(10):699–709.

15. 60 50 40 30 20 10 Placebo 0 1 2 3 4 5 Number of Organs Failing at Entry Mortality and Numbers of Organs Failing Percent Mortality rhAPC NEJM 2001;344:699

16. The Surviving Sepsis Campaign Tight glycemic control reduced mortality from 8% to 4.6% and reduced mortality from sepsis overall regardless of cause. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. New England Journal of Medicine. 2001;345(19):1359-1367.

17. 100 96 Intensive treatment 92 P=0.01 In-hospital survival (%) 88 Conventional treatment 84 80 0 0 50 100 150 200 250 Days after admission The Role of Intensive InsulinTherapy in the Critically Ill • At 12 months, intensive insulin therapy reduced mortality by 3.4% (P<0.04) van den Berghe G, et al. N Engl J Med 2001;345:1359-67

18. The Surviving Sepsis Campaign Timely and appropriate antibiotics reduce mortality in critically ill patients. Iregui M, Ward S, Sherman G, Fraser VJ, Kollef MH. Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia. Chest Journal. Jul 2002;122(1):262-268. Leibovici L, Shraga I, Drucker M, et al: The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection. Journal of Internal Medicine. 1998;244(5):379–386.

19. The Surviving Sepsis Campaign • What if we did them • all together?

20. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008 Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL; International Surviving Sepsis Campaign Guidelines Committee. Crit Care Med. 2008 Jan;36(1):296-327. Erratum in: Crit Care Med. 2008 Apr;36(4):1394-6. www.survivingsepsis.org

21. Sepsis Resuscitation Bundle (6 hours): • Serum lactate measured. • Blood cultures obtained prior to antibiotic administration. • From the time of presentation, broad-spectrum antibiotics • administered within 3 hours for ED admissions and 1 hour for non-ED • ICU admissions. • In the event of hypotension and/or lactate > 4 mmol/L (36 mg/dl): • a) Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent). • b) Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. • In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L (36 mg/dl): • a) Achieve central venous pressure (CVP) of > 8 mm Hg. • b) Achieve central venous oxygen saturation (ScvO2) of > 70%.* • * Achieving a mixed venous oxygen saturation (SvO2) of 65% is an acceptable alternative.

22. Sepsis Management Bundle(24 hours): • Low-dose steroids administered for septic shock in accordance with a standardized ICU policy. • Recombinant Activated Protein C administered in accordance with a standardized ICU policy. • Glucose control maintained > lower limit of normal, but < 150 mg/dl (8.3 mmol/L). • Inspiratory plateau pressures maintained < 30 cm H2O for mechanically ventilated patients.

23. Identification: Segmentation • Segment is a part of a whole. • Define a situation that in which you should have (some) control. • Make that your first segment.

24. Segments ICU ED ICU Wards Wards ICU Emergency