5/13/2014
1
CODE SEPSIS(not now…maybe later)
David Shimabukuro, MDCMAssociate Professor
Medical Director, 13 ICUPhysician Lead, UCSF DSRIP Sepsis Project
Disclosures
• I have no disclosures
Agenda
• Epidemiology
• The “Surviving Sepsis Campaign Bundles”
• The UCSF Experience
• Future considerations
Agenda
• Epidemiology
• The “Surviving Sepsis Campaign Bundles”
• The UCSF Experience
• Future considerations
5/13/2014
2
Epidemiology
• By the numbers…
– Greater than 750,000 adults every year
– Greater then $10 billion a year in associated costs
– US mortality rate between 25‐30%
Compared to other major diseases
†National Center for Health Statistics, 2001. §American Cancer Society, 2001. *American Heart Association. 2000. ‡Angus DC et al. Crit Care Med. 2001 .
0
50
100
150
200
250
300
AIDS* Colon Breast
Cancer§CHF† Severe
Sepsis‡
Cas
es/1
00,0
00
Incidence of Severe Sepsis
US Death rate over time
0
50
100
150
200
250
300
2000 2002 2004 2006 2008 2010
Heart Disease
Malignant Neoplasms
Cerebrovascular Disease
Septicemia
National Vital Statistics Reports, vol 6, no 4, May 08, 2013
Agenda
• Epidemiology
• The “Surviving Sepsis Campaign Bundles”
• The UCSF Experience
• Future considerations
5/13/2014
3
What is Sepsis??
• A variable condition that affects each of us differently and is initiated by an infectious insult.
• Involves the systemic activation of the inflammatory response and an unbalancing of the coagulation cascade
Septic Shock
SEVERE SEPSIS plushypotension (Systolicblood pressure < 90 orMean Arterial Blood Pressure < 65) OR Lactate > 4
Severe Sepsis
SEPSIS plus evidenceof at least one alteration in organ perfusion
Sepsis
SIRS plus confirmed or suspected infection
Sepsis: ACCP/SCCM Definitions
SIRS
T > 38.3 C or < 36 CHR > 90 beats/minTachypneaWBC > 12K or < 4K
SIRS
T > 38.3 C or < 36 CHR > 90 beats/minTachypneaWBC > 12K or < 4K
SIRS
T > 38.3 C or < 36 CHR > 90 beats/minTachypneaWBC > 12K or < 4K
Severe Sepsis Definition
Crit Care Med February 2013 Volume 41 Number 2 pp. 580‐637
Management of Severe Sepsis and Septic Shock
Crit Care Med February 2013 Volume 41 Number 2 pp. 580‐637
5/13/2014
4
Management of Severe Sepsis and Septic Shock
1
Management of Severe Sepsis and Septic Shock
• Blood cultures should not delay administration of antibiotics.
• It is not uncommon for blood cultures to be negative despite the presence of a severe infection.
Crit Care Med 2006 Vol. 34, No. 6
5/13/2014
5
Management of Severe Sepsis and Septic Shock
Management of Severe Sepsis and Septic Shock
• Normalization of lactate as a resuscitation goal is suggested
– Use of rate of lactate clearance is mentioned, but not endorsed as a sole target
Management of Severe Sepsis and Septic Shock
• Fluid Therapy
– Crystalloids are first choice for the overwhelming majority of patients
– Albumin can be used to reduce volume from crystalloids, but no difference on mortality
– Hydroxyethyl starches should not be used
5/13/2014
6
Management of Severe Sepsis and Septic Shock
Management of Severe Sepsis and Septic Shock
• Corticosteroids
– For refractory hypotension despite fluids and vasopressors/inotropes
– Do not perform ACTH stimulation test
• Glucose
– Target level to less than 180 mg/dL
Management of Severe Sepsis and Septic Shock
• Blood Products
– HGB level 7.0 – 9.0 g/dL after hypoperfusion has resolved
– FFP not to be used unless bleeding is present or for planned invasive procedure
– PLT to be given prophylactically when <10K in absence of bleeding
Management of Severe Sepsis and Septic Shock
• More recommendations…refer to original paper
5/13/2014
7
How do we find it??
Sepsis Screening
Crit Care Med February 2013 Volume 41 Number 2 pp. 580‐637
Great….but when should we do it and how should it be done!!!!
Sepsis Screening Sepsis Screening
5/13/2014
8
Sepsis Screening
• Important to have one that works for the hospital
• Should probably do once a shift (no clear data)
• Screening works as a reminder for continued vigilance
Agenda
• Epidemiology
• The “Surviving Sepsis Campaign Bundles”
• The UCSF Experience
• Future considerations
UCSF Sepsis Work To Date
• Sepsis Work Group
– Literature review and analysis of Sepsis Resuscitation and Management Bundles
– Consensus on bundle elements
– Sepsis Screening Tool
– APeX Sepsis Accordion
– Code Sepsis
31
Severe Sepsis Resuscitation Goals*• Lactate
– Within 6 hours from time of presentation (TOP)
• Blood Cultures– Drawn before an antibiotic is given
• Antibiotics– Start of administration within 1 hour of the TOP (non ED), 3
hours (ED)
• Fluid Resuscitation– 20‐30 mL/kg or a minimum of 1000 mL of crystalloid (or
albumin equivalent) administered as a bolus within 1 hour of TOP for hypotension or lactate > 4 mmol/L
• Vasopressors– Hypotension unresponsive to initial fluid bolus
• CA 1115 Waiver, DSRIP Category 4, Superset of Interventions, Severe Sepsis• Dellinger et al. (2008). Surviving Sepsis Campaign: International guidelines for management
of severe sepsis and septic shock: 2008. Crit Care Med,1, 296‐327.
5/13/2014
9
Chest 2008; 134: 172‐178
Controversies
Crit Care Med 2010 Vol 38 No 2 pp 367‐374
Controversies Controversies
5/13/2014
10
JAMA February 24, 2010 Vol 303 No 8 pp 739‐746
Controversies Code Sepsis
What is a Code Sepsis?
– A silent alert sent by pager to a designated team that includes a Pharmacist, the RRT and the ICU Fellow
– Purpose is to expedite sepsis resuscitation
When is a Code Sepsis Activated?
– Positive screen with SIRS and lactate > 2
– Positive screen with organ dysfunction
Code Sepsis
Who should activate a Code Sepsis?
– RNs & MDs caring for patients
How is a Code Sepsis Activated?
– Pager Box: Code Sepsis Activation
Roles and Responsibilities
• Bedside RN
– Activates Code Sepsis & notifies Primary Team
– Presents patient conditions
– Assists with sepsis resuscitation
• Primary Team
– Responds to patient’s bedside
– Collaborate on treatment decisions
– Write orders as needed
5/13/2014
11
Roles and Responsibilities• RRT
– Validate positive screen
– Support timely blood culture collection and administration of antibiotics and fluids
– Maintain time to assure resuscitation in 60 minutes
• Pharmacist– Facilitate verification, dispensing & delivery of antibiotics
– Follow‐up with primary team for subsequent dosing
• ICU Fellow– Assist with selection/ordering of antibiotics, fluids, vasopressors
– Assist with blood culture collection as needed
– Assist with determining level of care
Our data
Agenda
• Epidemiology
• The “Surviving Sepsis Campaign Bundles”
• The UCSF Experience
• Future considerations
Future Considerations
• State mandates
• NQF
• CMS
– TJC
– Leapfrog
5/13/2014
12
Summary
• A very heterogeneous disease that is difficult to diagnose in its early stages and difficult to treat in its later stages.
• Routine screening can allow for earlier identification
• Early intervention can attenuate its course, but the mainstay of treatment is supportive care.