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5/13/2014 1 CODE SEPSIS (not now…maybe later) David Shimabukuro, MDCM Associate Professor Medical Director, 13 ICU Physician 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
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Page 1: Code Sepsis CCM Conference 2014 copy syllabus.pptx [Read-Only] › 2014 › MAN14002 › slides › 13.Code Sepsis... · 2014-05-21 · 5/13/2014 1 CODE SEPSIS (not now…maybe later)

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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

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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

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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

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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

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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

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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

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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

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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

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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. 

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Chest 2008; 134: 172‐178

Controversies

Crit Care Med 2010 Vol 38 No 2 pp 367‐374

Controversies Controversies

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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

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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

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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.


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