SURVIVING SEPSIS: STATE OF THE ART

Thursday, May 8 2014 Jeudi 8 mai 2014

Your Hosts & Presenters Vos hôtes et présentateurs

Bruce Harries, Moderator

Denny Laporta, MD, FRCPC, CSPQ

Ardis Eliason, Technical Host

John C. Marshall, MD, FRCSC, FACS

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Nurse MD

Educator / Quality Improvement Professional

Infection Control

Administrator / Senior Leader

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Respiratory Therapist

Nutritionist

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Dr. John C. Marshall

Surviving Sepsis: State of the Art

The Surviving Sepsis Campaign:

State of the Art

St. Michael’s Hospital University of Toronto

John C. Marshall MD FACS

Safer Healthcare Now May 8, 2014

Paris, 1997 …

• Definitions • Diagnosis of infection • Antibiotics • Hemodynamic support • Source control • ICU care • Adjunctive therapies • Novel therapies

Phase 1 Barcelona declaration Phase 2 Evidence-based guidelines Phase 3 Implementation and evaluation

A global program to reduce mortality rates in severe sepsis

ESICM, ISF and SCCM

Partially funded by unrestricted educational grants

from Baxter, Edwards, Philips and Lilly

Sponsoring Organizations • American Association of Critical Care Nurses • American College of Chest Physicians • American College of Emergency Physicians • American Thoracic Society • Australian and New Zealand Intensive Care Society • European Society of Clinical Microbiology and Infectious

Diseases • European Society of Intensive Care Medicine • European Respiratory Society • International Sepsis Forum • Society of Critical Care Medicine • Surgical Infection Society

Guidelines Meeting

London, England

June 2003

- Crit Care Med 32:858, 2004

The Sepsis Bundles

• Institute for Healthcare Improvement (IHI)

• Measurable activities that indicate compliance with guidelines

- N Engl J Med 355:1640, 2006

San Francisco, January 2006

American Association of Critical-Care Nurses American College of Chest Physicians American College of Emergency Physicians American Thoracic Society Canadian Critical Care Society European Society of Clinical Microbiology and Infectious Diseases European Society of Intensive Care Medicine European Respiratory Society International Sepsis Forum Society of Critical Care Medicine Japanese Association for Acute Medicine Japanese Society of Intensive Care Medicine Surgical Infection Society Participation and endorsement by the German Sepsis Society and the Latin American Sepsis Institute.

Sponsors 2006

- Crit Care Med 36:296, 2008

Miami 2010

- Crit Care Med 41:580, 2013

Grading of Recommendations

Assessment, Development, and Evaluation

• Strength of the Evidence

• Strength of the Recommendation

Improving Sepsis Care

• Recognition

• Resuscitation

• Diagnosis and treatment of infection

• Physiologic support

Improving Sepsis Care

• Recognition

• Resuscitation

• Diagnosis and treatment of infection

• Physiologic support

Rates of Sepsis, U.S. 1979 - 2001

- Martin, N Engl J Med 348:1546, 2003

Sepsis in the Emergency Department

• Acute change in health status

• Unexplained organ dysfunction

• Febrile illness

• Underlying co-morbidities

Sepsis on the

Hospital Ward

• Fever, tachycardia

• Altered mental status

• Fluid retention

• New organ dysfunction

• Often subtle presentation

Sepsis

Think of it!

Improving Sepsis Care

• Recognition

• Resuscitation

• Diagnosis and treatment of infection

• Physiologic support

Optimize Oxygen Delivery to Tissues

• Restore intravascular volume

• Support cardiac function

• Provide oxygen

• Enhance O2 carrying capacity

Lactate Metabolism

Anerobic

Aerobic

Resuscitation

Early Goal-directed Therapy for Septic Shock

Standard Goal-Directed (N=133) (N=130) MVO2 65.3+11.4 70.4+10.7* APACHE II 15.9+6.4 13.0+6.3* Mortality 46.5% 30.5%*

* p<0.02 - Rivers, N Engl J Med 345:1368, 2001

CVP

Mean Arterial Pressure > 8

<8 Fluids

ScvO2

> 65 <65

Pressors

Goals achieved > 70 Transfusion,

Inotropes

- Angus, N Engl J Med 370:1683, 2014

The SAFE Study Investigators, N Engl J Med 2004;350:2247

Saline and Albumin are Equally Efficacious

Mortality is Increased with Starches

- Zarychanski, JAMA 309:678, 2013

- N Engl J Med 370:1583, 2014

- N Engl J Med 370:1583, 2014

Improving Sepsis Care

• Recognition

• Resuscitation

• Diagnosis and treatment of infection

• Physiologic support

Diagnosis

Antibiotics

Source Control

Odd

s R

atio

for D

eath

(9

5% C

I)

1

10

100

Time from Onset of Hypotension (Hours)

-Kumar, Crit Care Med 34:1589, 2006

Impact of Delayed Antibiotic Therapy on Clinical Outcome

“Early versus late necrosectomy in severe necrotizing pancreatitis”

Number Mortality Early 25 58% Late 11 27%

- Mier et al Am.J.Surg 173:71, 1997

Improving Sepsis Care

• Recognition

• Resuscitation

• Diagnosis and treatment of infection

• Physiologic support

Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury

and the acute respiratory distress syndrome

Mortality (%) Controls 39.8

Volume-limited 31.0*

ARDSNet; NEJM 342:1301, 2000

*P=0.007

Impact of Fluid Strategy in ARDS

Conservative Liberal p. (N=503) (N=497) 60 day mortality 25.5% 28.4% 0.30 Ventilator-free days 14.6±0.5 12.1±0.5 <0.001 ICU-free days 13.4±0.4 11.2±0.4 <0.001 CNS failure FD 18.8±0.5 17.2±0.5 0.03

- ARDSNet, N Engl J Med 354:2564, 2006

Survival in NICE/SUGAR

Drotrecogin alfa was ineffective in low risk patients …

Abraham E N Engl J Med 2005;353:1332

Time to Shock Reversal

Survival Sprung et al, N Engl J

Med 358:111,2008

CORTICUS

N=499

Has It Made a Difference?

• Global process change initiative based on “sepsis bundles”

• 15,022 patients enrolled

• 7% absolute, 5.4% relative mortality reduction (p<0.001)

Surviving Sepsis Campaign

Unadjusted Risk-adjusted

Bundle target Population N OR p-value

OR 95% CI p-value

Measure Lactate All 15,022 0.86 <0.0001

0.97 [0.90, 1.05] 0.48

Obtain blood cultures before antibiotics All 15,022

0.70 <0.0001 0.76 [0.70, 0.83] <0.0001

Commence broad-spectrum antibiotics All 15,022

0.78 <0.0001 0.86 [0.79, 0.93] <0.0001

Achieve tight glucose control All 15,022 0.65 <0.0001

0.67 [0.62, 0.71] <0.0001

Administer drotrecogin alfa Multi-organ failure 8,733 0.90 0.26

0.84 [0.69, 1.02] 0.07

Administer drotrecogin alfa Shock despite fluids 7,854 0.91 0.30

0.81 [0.68, 0.96] 0.02

Administer low-dose steroids Shock despite fluids 7,854 1.06 0.18

1.06 [0.96, 1.17] 0.24

Demonstrate CVP ≥ 8 mm Hg Shock despite fluids 7,854 1.08 0.10

1.00 [0.89, 1.12] 0.98

Demonstrate ScvO2 ≥ 70% Shock despite fluids 7,854 0.94 0.24

0.98 [0.86, 1.10] 0.69

Achieve low plateau pressure control Mechanical ventilation 7,860 0.67 <0.0001

0.70 [0.62, 0.78] <0.0001

- Kaukonen et al JAMA 2014

Survival in Sepsis is Improving

Conclusions • The SSC has raised awareness regarding sepsis management and defined optimal approaches to care

• This has been associated with improved survival

• But the elements responsible for that improvement need further study

Thank You!!

QUESTIONS?

RAISE YOUR HAND / LEVEZ LA MAIN

OR/OU

CHAT TO “ALL PARTICIPANTS”

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a Canadian Critical Care Knowledge Translation Network

“aC3KTion Net”

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aC3KTion Net • Network of ICUs (Networks) from across

Canada • Academic • Community

• Primary activity will be Knowledge Translation and development of Critical Care Knowledge Synthesis products

• Not KT Research

• Measurement of uptake/outcomes

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Network Activities • Measurement of current practice • Knowledge Synthesis: Development of clinical practice guidelines,

evidence syntheses and scoping reviews.

• Testing of Knowledge Products: Reviewed and tested before implementation, to ensure acceptability, ability to achieve intended purpose and ascertain possible barriers

• Knowledge Implementation: Local teams will use strategies/tools tailored to knowledge product. – Education, protocols, checklists, order sets, organizational changes and

reminder systems – PDSA cycles to track implementation activities

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Even when motivated to change our behavior, we cannot manage what we do not measure.

Measurement can identify gaps in best practice.

Measurement can illuminate the results of our efforts at implementing best practice.

Measurement can inform future research direction.

Measurement- Why?

Model for Participation • Main benefits of participation

– Access to KT activities/initiatives – Access to KS products – Access to educational events/webinars – Access to a repository of knowledge products, protocols etc. – Opportunity to participate in incubator units – Ability to influence network activities – Benchmarked reports of performance with national peers – A vehicle to drive critical care quality improvement

• ICUs provide periodic data in return

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Current Status

• Baseline Data Collection – Started and ongoing. Site recruitment ongoing.

• Development of barriers/enablers Questionnaires – Completed

• Repository of KT tools/Products – Being populated

• KT activities – Slated for 2014

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Questions/Comments?

Canadian ICU Collaborative Faculty

Paule Bernier, P.Dt., Msc, Présidente, Ordre professionnel des diététistes du Québec; Sir MB David Jewish General Hospital (McGill University), Montreal

Paul Boiteau MD, Department Head, Critical Care Medicine, Alberta Health Services; Professor of Medicine, University of Calgary Mike Cass, BSc, RN, MScN, Advanced Practice Nurse, Trillium Health Centre Leanne Couves, Improvement Advisor, Improvement Associates Ltd. Maryanne D’Arpino, Patient Safety Improvement Lead, CPSI Bruce Harries, Collaborative Director, Improvement Associates Ltd. Denny Laporta MD, Intensivist, Department of Adult Critical Care, Jewish General Hospital; Faculty of Medicine, McGill University Claudio Martin MD,Intensivist, London Health Sciences Centre, Critical Care Trauma Centre; Professor of Medicine and Physiology,

University of Western Ontario; Chair/Chief of Critical Care Western Cathy Mawdsley, RN, MScN, CNCC; Clinical Nurse Specialist – Critical Care, London Health Sciences Centre; John Muscedere MD, Assistant Professor of Medicine, Queens University; Intensivist, Kingston General Hospital Yoanna Skrobik MD, Intensivist, Hôpital Maisonneuve Rosemont, Montréal; Expert Panel for the new Pain, Sedation and Delirium

Guidelines, Society of Critical Care Medline (SCCM)

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Reminders Rappels

Call is recorded Slides and links to

recordings will be available on Safer Healthcare Now! Communities of Practice

Additional resources are available on the SHN Website and Communities of Practice

L'appel est enregistré Les diapositives et liens

vers les enregistrements seront disponibles sur Des soins de santé plus sécuritaires maintenant! Communautés de pratique

Des ressources supplémentaires sont disponibles sur le site Web SSPSM et Communautés de Pratique

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THANK YOU MERCI

This National Call is hosted by:

Supported by:

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