Reducing Sepsis Mortality Richard Crowell, MD Chief Quality Officer UNM Health System Professor,...

Reducing Sepsis MortalityReducing Sepsis Mortality

Richard Crowell, MDRichard Crowell, MDChief Quality OfficerChief Quality OfficerUNM Health SystemUNM Health System

Professor, Dept of Internal MedicineProfessor, Dept of Internal Medicine

ObjectivesObjectives

• History of Early Goal-Directed Therapy History of Early Goal-Directed Therapy at UNM Hospital: SMITeat UNM Hospital: SMITe

• Recent Sepsis informationRecent Sepsis information

• The future is nowThe future is now

Sepsis: A Complex DiseaseSepsis: A Complex Disease

Adapted from: Bone RC et al. Adapted from: Bone RC et al. Chest.Chest. 1992;101:1644- 1992;101:1644-5555..Used with permission, S.Simpson, MD, KU, 2008Used with permission, S.Simpson, MD, KU, 2008

SevereSevereSepsisSepsis

Trauma

Infection

SepsisOther

Pancreatitis

Burns

SIRS

Sepsis: A Deadly ContinuumSepsis: A Deadly Continuum

• A clinical response arising from a nonspecific insult, with 2 of the following:• T >38oC or <36oC• HR >90 beats/min• RR >20/min• WBC >12,000/mm3 or <4,000/mm3

or >10% bands

SIRS with a presumed

or confirmed infectious process

Chest 1992;101:1644.Chest 1992;101:1644.

SepsisSepsisSIRSSIRSSevere Severe

SepsisSepsisShockShock

SepticSeptic

Sepsis with organ

dysfunction

RefractoryHypotension

Related toSepsis

Clinical Alterations in Severe SepsisClinical Alterations in Severe Sepsis

• VasculopathyVasculopathy• Loss of regional autoregulationLoss of regional autoregulation• VasodilationVasodilation• Relative intravascular hypovolemiaRelative intravascular hypovolemia

• CardiopathyCardiopathy• ↓ ↓ contractility, ↑ compliancecontractility, ↑ compliance• ↑ ↑ CO, but ↓ EFCO, but ↓ EF

• Acute organ dysfunctionAcute organ dysfunction• Toxin and cytokine actions on Toxin and cytokine actions on

vascular / tissue barriersvascular / tissue barriers

Inflammatory MediatorsCardiovascular Insufficiency

Global Tissue HypoxiaGlobal Tissue Hypoxia

Increased MetabolicDemands

Hypovolemia VasodilationMyocardial Depression

Microvascular AlterationsOO22 Delivery DeliveryOO22 Demand Demand

After Fink. Crit Care Clin 2002.After Fink. Crit Care Clin 2002.Used with permission, S.Simpson, MD, KU, 2008Used with permission, S.Simpson, MD, KU, 2008

Acute Organ Dysfunction as the Hallmark of Acute Organ Dysfunction as the Hallmark of Severe SepsisSevere Sepsis

TachycardiaTachycardiaHypotensionHypotension

OliguriaOliguriaAnuriaAnuria

CreatinineCreatinine

PlateletsPlatelets PT/APTTPT/APTT Protein CProtein C D-dimerD-dimer

Altered Altered ConsciousnessConsciousness

ConfusionConfusionPsychosisPsychosis

TachypneaTachypneaPaOPaO22 <70 mm Hg <70 mm Hg

SaOSaO22 <90% <90%

PaOPaO22/FiO/FiO22 300 300

JaundiceJaundice EnzymesEnzymes AlbuminAlbumin

PTPT

Lactic acidosisLactic acidosis

Used with permission, S.Simpson, MD, KU, 2008Used with permission, S.Simpson, MD, KU, 2008

Treatment of SepsisTreatment of Sepsis

• Address cause: Treat infectionAddress cause: Treat infection

• Intravascular volume resuscitationIntravascular volume resuscitation

• Cardiovascular supportCardiovascular support

• Support of dysfunctional organ systemsSupport of dysfunctional organ systems

But prior to the new millenium, little improvement in But prior to the new millenium, little improvement in sepsis mortality…sepsis mortality…

• Patients enrolled on entry into EDPatients enrolled on entry into ED

• Evidence of Infection Evidence of Infection

• Met SIRS criteria Met SIRS criteria

• Hypotensive OR Lactic acidosis (>4 mmol/L)Hypotensive OR Lactic acidosis (>4 mmol/L)• 6 hour protocol6 hour protocol

• Cultures and antibioticsCultures and antibiotics

• Fluid resuscitation 20 ml/kgFluid resuscitation 20 ml/kg

• CV support with vasopressors, augmented O2 CV support with vasopressors, augmented O2 deliverydelivery

The Importance of Early Goal-DirectedThe Importance of Early Goal-DirectedTherapy for Sepsis Induced Hypoperfusion Therapy for Sepsis Induced Hypoperfusion

Adapted from Table 3, page 1374, from Rivers E, Nguyen B, Havstad S, et al. Early goal-directed Adapted from Table 3, page 1374, from Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. therapy in the treatment of severe sepsis and septic shock. N Engl J MedN Engl J Med 2001; 345:1368-1377 2001; 345:1368-1377

In-hospital In-hospital mortality mortality

(all (all patients)patients)

00

1010

2020

3030

4040

5050

6060 Standard therapyStandard therapy

EGDTEGDT

28-day 28-day mortalitymortality

60-day 60-day mortality mortality

NNT to prevent 1 event (death) = 6-8NNT to prevent 1 event (death) = 6-8

Mort

ality

(%

)M

ort

ality

(%

)

Early Goal-Direct Therapy (EGDT)Early Goal-Direct Therapy (EGDT)

EGDT is designed to: EGDT is designed to:

Recognize patients with severe sepsis as early as Recognize patients with severe sepsis as early as possible and begin treatment quicklypossible and begin treatment quickly

Assess laboratory and clinical variables for acute Assess laboratory and clinical variables for acute organ dysfunction, hemodynamic instabilityorgan dysfunction, hemodynamic instability

Delineate time targets for delivery of treatment of Delineate time targets for delivery of treatment of patients with sepsispatients with sepsis

Develop hospital-specific bundled protocolsDevelop hospital-specific bundled protocols

Earlier treatment leads to better outcomesEarlier treatment leads to better outcomes

Good Evidence-based Data for EGDTGood Evidence-based Data for EGDT

• Mortality improvement Mortality improvement

• Use of lactate as severity and prognostic indicatorUse of lactate as severity and prognostic indicator

• Bundled protocols improve outcomesBundled protocols improve outcomes• But not all individual bundle elements have been But not all individual bundle elements have been

shown to specifically improve mortalityshown to specifically improve mortality

• Early and appropriate antibioticsEarly and appropriate antibiotics

• Aggressive fluid resuscitation improve outcomesAggressive fluid resuscitation improve outcomes

• But how much fluid?But how much fluid?

• Enough to improve end organ dysfunctionEnough to improve end organ dysfunction

• But not too much…But not too much…

© 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc.

11

Figure 5Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003 to 2007. Lagu, Tara, et.al. Critical Care Medicine. 40(3):754-761, 2012.DOI: 10.1097/CCM.0b013e318232db65

Figure 5 . Discharge disposition among patients with severe sepsis, 2003 to 2007.

Date of download: 7/16/2014Copyright © 2014 American Medical

Association. All rights reserved.

From: Mortality Related to Severe Sepsis and Septic Shock Among Critically Ill Patients in Australia and New Zealand, 2000-2012

JAMA. 2014;311(13):1308-1316. doi:10.1001/jama.2014.2637 Mean Annual Mortality in Patients With Severe SepsisError bars indicate 95% CI.

Best current, generally available measure of Best current, generally available measure of Global Tissue Hypoxia is Global Tissue Hypoxia is LactateLactate

• What is role of lactate ?What is role of lactate ?

• Patient assessmentPatient assessment

• Assigning prognosisAssigning prognosis

• Guiding treatment decisionsGuiding treatment decisions

Serum Lactate as a predictor of mortality in Serum Lactate as a predictor of mortality in patients with infectionpatients with infection

Trzeciak S, et.al. Intensive Care Medicine 33:970-77, 2007

•Retrospective analysis of patients with dx of infection and lactate measured•Did not evaluate +/- shock

© 2009 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 4

Lactate is associated with mortality in Severe Sepsis Independent of organ failure and shock

Prospective cohort study

Critical Care Medicine. 37(5):1670-1677, May 2009.


Figure 3.


Lactate is associated with mortality in Severe Lactate is associated with mortality in Severe Sepsis Independent of organ failure and shockSepsis Independent of organ failure and shock


Lactate is associated with mortality in Severe Sepsis Independent of organ failure and shock 2.


Outcomes of patients undergoing early sepsis resuscitation for cyptic shock compared with overt shock. Puskarich MA, etal. Resuscitation 82:1289, 2011




• Bundled protocols improve outcomesBundled protocols improve outcomes• Even though not all individual bundle elements have Even though not all individual bundle elements have

been shown to specifically improve mortalitybeen shown to specifically improve mortality









• Bundled protocols improve outcomesBundled protocols improve outcomes• Even though all individual bundle elements have not Even though all individual bundle elements have not

been shown to specifically improve mortalitybeen shown to specifically improve mortality






EGDT: Bundled approaches to protocolsEGDT: Bundled approaches to protocols

• Use is evidence-based:Use is evidence-based:

• Combine multiple elementsCombine multiple elements

• Outcome is additive or synergisticOutcome is additive or synergistic

• Framework that leverages changeFramework that leverages change

• Avoids a piecemeal approachAvoids a piecemeal approach

Do Bundles Work?Do Bundles Work?

Gao, et al. Gao, et al. Critical CareCritical Care 2005, 2005, 9:9:R764-R770.R764-R770.With Permission from S. Simpson, MD,, Kansas University, 2008With Permission from S. Simpson, MD,, Kansas University, 2008

Multicenter implementation of a severe sepsisand septic shock treatment bundle. Miller RR, et.al. Am Journal Respir Crit Care Med, 2013; 188, 77-82

A. All subjects with Severe Sepsis/Septic Shock

B. Only subjects with Septic Shock

Timeliness of Antibiotics in Septic Shock

• Kumar, et.al. reviewed medical records of 2731 adults Kumar, et.al. reviewed medical records of 2731 adults with septic shock over 25 years in Manitoba, Canadawith septic shock over 25 years in Manitoba, Canada

• Focused on 2,154 patients who received Ab ONLY Focused on 2,154 patients who received Ab ONLY after onset of hypotensionafter onset of hypotension

• Clinical site infectionsClinical site infections

• 37.2% lung37.2% lung

• 29.3% intraabdominal29.3% intraabdominal

• 10.7% genitourinary10.7% genitourinary

• Documented infection (by cx) in 78% of casesDocumented infection (by cx) in 78% of cases

• Others by definitive xray, surgical, biopsy, or Others by definitive xray, surgical, biopsy, or autopsy evidenceautopsy evidence

• Microbiology: Gram (-) 47.9%, Gram (+) 38.3%Microbiology: Gram (-) 47.9%, Gram (+) 38.3%

Kumar A, et.al. Crit Care Med 34:1589, 2006

Septic Shock: Timing of AntibioticsSeptic Shock: Timing of AntibioticsKumar et al, CCM. 2006:34:1589-96

0.00.0

.20.20

.40.40

.60.60

.80.80

1.001.00

% Survival

% Total receiving antibiotics

0 - .5

.5 – 1.01 - 2 2 - 3 3-4 4 - 5 5 - 6 6 - 9 9 - 1

212 - 2

424 - 3

6> 36

Percent of Percent of total ptstotal pts

Time (hrs) from hypotension onset

14 ICUs; n = 2,731

Only 50% of patients in Septic Shock

received antibiotics w/in 6 hrs.

Timeliness of Antibiotics in Septic Shock

• Antibiotics w/in first hour: 79.9% survivalAntibiotics w/in first hour: 79.9% survival

• Every hour delay decreased survival by 7.6%Every hour delay decreased survival by 7.6%

• OR of in-hospital mortality increased by 12% for OR of in-hospital mortality increased by 12% for each hour delay in administrationeach hour delay in administration

• In Multivariate analysis:In Multivariate analysis:

• Time to antimicrobial therapy most strongly Time to antimicrobial therapy most strongly associated with survivalassociated with survival

• Others: APACHE score, volume of fluid in first Others: APACHE score, volume of fluid in first hour of resuscitationhour of resuscitation

•Kumar A, et.al. Crit Care Med 34:1589, 2006Kumar A, et.al. Crit Care Med 34:1589, 2006

Mor

tali

ty (

%)







• Aggressive fluid resuscitation improves outcomesAggressive fluid resuscitation improves outcomes




Cardiovascular Resuscitation-Based EGDTLin, et.al. 2006

• 241 consecutive patients enrolled, randomized to protocol vs no protocol

• Protocol focused on rapid fluids to:

• 1) attain CVP ≥ 8-12

then

2) MAP ≥ 65 (pressors, steroids as needed)

then

• 2) urine output ≥ 0.5 ml/kg/hr

• All patients got antibiotics per clinician; no differences in groups

Lin SM, et.al. Shock 6:551-7, 2006Lin SM, et.al. Shock 6:551-7, 2006

Cardiovascular Resuscitation-Based EGDT

Outcome Protocol (n=108)

No Protocol (n=116)

p

Hosp Mortality 53.7 % 71.6% 0.006

Shock reversal (hrs) 47 ± 22.8 65.4 ± 32.1 0.006

Resuscitation fluids 136.2 ± 119 88.6 ± 57.7 0.034

Time to pressors 78 22.2 104.4 29 0.001

Length of ICU stay 14.3 ± 11.7 20.3 ± 16.6 0.003

Renal failure 42 (38.9%) 64 (55.2%) 0.015

CNS failure 20 (18.5%) 42 (36.2%) 0.003

Lin SM, et.al. Shock 6:551-7, 2006Lin SM, et.al. Shock 6:551-7, 2006

Successful fluid resuscitation in EGDTSuccessful fluid resuscitation in EGDT

• What are appropriate endpoints for “successful” What are appropriate endpoints for “successful” volume resuscitation?volume resuscitation?

• Depends on “volume responsiveness”Depends on “volume responsiveness”• where is the patient on the Starling curve?where is the patient on the Starling curve?

• CVP: may not be best measure for volume CVP: may not be best measure for volume responsivenessresponsiveness

• Pulse pressure variation, IVC diameter Pulse pressure variation, IVC diameter before/after fluid challengesbefore/after fluid challenges

Study Overview

• In septic shock, the first few hours of care are critical for survival.In septic shock, the first few hours of care are critical for survival.

• In this study, two protocols for the care of patients with septic shock In this study, two protocols for the care of patients with septic shock were compared with usual care with respect to 60-day mortality and were compared with usual care with respect to 60-day mortality and other outcomes.other outcomes.

• There were no significant differences in outcome.There were no significant differences in outcome.

Screening, Randomization, and Follow-up

The ProCESS Investigators. N Engl J Med 2014;370:1683-1693

Cumulative Mortality.

The ProCESS Investigators. N Engl J Med 2014;370:1683-1693

Notes from ProCess StudyNotes from ProCess Study• All patients received mean 2.2L volume resuscitation prior All patients received mean 2.2L volume resuscitation prior

to randomization (180 min)to randomization (180 min)

• Mean of 29 ml/kgMean of 29 ml/kg

• 75% in each group received antibiotics prior to 75% in each group received antibiotics prior to randomizationrandomization

• Unknown distribution of Ab within 1 vs. 2 vs. 3 hrs in Unknown distribution of Ab within 1 vs. 2 vs. 3 hrs in each groupeach group

• All patients in non-EGDT groups cared for by Critical All patients in non-EGDT groups cared for by Critical Care or ED-trained facultyCare or ED-trained faculty

• All institutions had long history of participation in SCC All institutions had long history of participation in SCC EGDT guidelinesEGDT guidelines

• Question of illness severity compared to other studiesQuestion of illness severity compared to other studies

• Did NOT evaluate value of ScVO2 as treatment guidelineDid NOT evaluate value of ScVO2 as treatment guideline

UNM ED -> MICUUNM ED -> MICU

• Plans to evaluate alternative approaches to Plans to evaluate alternative approaches to evaluation of adequacy of fluid resuscitationevaluation of adequacy of fluid resuscitation

• Passive Leg Raise, Pulse Pressure Variation Passive Leg Raise, Pulse Pressure Variation with FloTrackwith FloTrack

• IVC diameter responsiveness to fluidsIVC diameter responsiveness to fluids

• Minimal volume resuscitation of 2-3L within 3 Minimal volume resuscitation of 2-3L within 3 hourshours

Lee S, et.al. Increased fluid administration in the first 3 hours of sepsis resuscitation is associated with reduced mortality: a retrospective cohort study. Chest Online, 2014

Surviving Sepsis Campaign:Surviving Sepsis Campaign:Early Recognition is Crucial!!!Early Recognition is Crucial!!!

• Use of screening tools improves overall Use of screening tools improves overall awareness, educates, and increases awareness, educates, and increases recognitionrecognition

• UNM: UNM: • Wards/MICU: qshift screening by Wards/MICU: qshift screening by

nursing staffnursing staff• ED: Triage nurses, EMS do initial ED: Triage nurses, EMS do initial

evaluationevaluation

Surviving Sepsis Campaign:Surviving Sepsis Campaign:Early Recognition is Crucial!!!Early Recognition is Crucial!!!

• UNM ScreeningUNM Screening

• Temp >38.3C, <36CTemp >38.3C, <36C

• RR >20RR >20

• HR >90HR >90

• WBC >10, <4*WBC >10, <4*

• *ED triage: Mental Status Changes*ED triage: Mental Status Changes

Identification of sepsis severity !!

3 pathways

Green (sepsis)

Yellow (lactate 2-4)

Red (severe sepsis or septic shock)

• Protocol was based on literature and input from all areas involved

• Several revisions before consensus

SEPSIS

RRT

SEPSIS/Critical Care Team

Septic Shock(hypotension)

Occult Septic Shock(lactate > 4,

No hypotension)

Bedside LactateMeasured

SEPSIS(Lactate < 4

No organ dysfunctionNo hypotension)

Severe SEPSIS(organ dysfunction*

lactate < 4No hypotension)

Basic SMITE Bundle1. Lactate q 4 X 2⁰2. Blood culture3. Antibiotics within 1 hr4. Fluids

Re-evaluate as needed

Advanced SMITE BundleBasic Bundle Plus:4. Fluids bolus5. CVP6. Vasopressors

NOTIFY MD Ward Team/Covering Provider

“Intermediate Risk”

Bedside Lactate “High Risk” Bedside

Lactate

*Organ Dysfunction•AMS (Glasgow < 12)•Creat > 1.5•Total Bili > 2.0 •INR > 1.5•Platelets < 100K

• Confirm Sepsis Dx• Determine Sepsis Severity

If NOT Sepsis: Document alternative Dx

OrderSerumLactate

Contact RRT

YES

SIRS CriteriaAssess for 2 or more1.Temp > 38 C or ⁰ < 36 C⁰2.HR > 903.Resp rate > 20 or pa CO₂ < 324.WBC > 12K, < 4K, or > 10% bands

YES NO Evaluate as clinically indicated

Suspected site of

Infection

ICU Admission

NO

Re-asses Q shift

Table 2Table 2

TABLE 2. Severe SepsisTABLE 2. Severe Sepsis

Copyright © 2013 Critical Care Medicine. Published by Lippincott Williams & Wilkins. 48

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

Dellinger, R. Phillip; Levy, Mitchell M.; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; Opal, Steven M.; Sevransky, Jonathan E.; Sprung, Charles L.; Douglas, Ivor S.; Jaeschke, Dellinger, R. Phillip; Levy, Mitchell M.; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; Opal, Steven M.; Sevransky, Jonathan E.; Sprung, Charles L.; Douglas, Ivor S.; Jaeschke, Roman; Osborn, Tiffany M.; Nunnally, Mark E.; Townsend, Sean R.; Reinhart, Konrad; Kleinpell, Ruth M.; Angus, Derek C.; Deutschman, Clifford S.; Machado, Flavia R.; Rubenfeld, Roman; Osborn, Tiffany M.; Nunnally, Mark E.; Townsend, Sean R.; Reinhart, Konrad; Kleinpell, Ruth M.; Angus, Derek C.; Deutschman, Clifford S.; Machado, Flavia R.; Rubenfeld, Gordon D.; Webb, Steven A.; Beale, Richard J.; Vincent, Jean-Louis; Moreno, Rui; and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric SubgroupGordon D.; Webb, Steven A.; Beale, Richard J.; Vincent, Jean-Louis; Moreno, Rui; and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup

Critical Care Medicine. 41(2):580-637, February 2013.Critical Care Medicine. 41(2):580-637, February 2013.

doi: 10.1097/CCM.0b013e31827e83afdoi: 10.1097/CCM.0b013e31827e83af

•

http://journals.lww.com/ccmjournal/Fulltext/2013/02000/Surviving_Sepsis_Campaign___International.24.aspx

IHI Severe Sepsis Collaborative IHI Severe Sepsis Collaborative Expanded SMITe to EDExpanded SMITe to ED

• Fall 2009 Fall 2009 Joined IHI collaborative Joined IHI collaborative• Aims:Aims:

• Improve ED recognition of Improve ED recognition of severe sepsissevere sepsis• Facilitate transfers to the Facilitate transfers to the MICUMICU• Improve communication between both unitsImprove communication between both units

• ED-specific screening tool for triageED-specific screening tool for triage• Concurrent patient trackingConcurrent patient tracking• Still have twice-monthly group meetingStill have twice-monthly group meeting• Patient criteriaPatient criteria

• Septic shockSeptic shock• Lactate >/= 4Lactate >/= 4

UNMH Mortality: Severe SepsisUNMH Mortality: Severe Sepsis2010 – May, 20142010 – May, 2014

Figure 1. Surviving Sepsis Campaign Care Figure 1. Surviving Sepsis Campaign Care Bundles.Bundles.

Copyright © 2013 Critical Care Medicine. Published by Lippincott Williams & Wilkins. 51

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012Dellinger, R. Phillip; Levy, Mitchell M.; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; Opal, Steven M.; Sevransky, Jonathan E.; Sprung, Charles L.; Douglas, Ivor S.; Jaeschke, Roman; Osborn, Tiffany M.; Nunnally, Mark E.; Townsend, Sean R.; Reinhart, Konrad; Kleinpell, Ruth M.; Angus, Dellinger, R. Phillip; Levy, Mitchell M.; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; Opal, Steven M.; Sevransky, Jonathan E.; Sprung, Charles L.; Douglas, Ivor S.; Jaeschke, Roman; Osborn, Tiffany M.; Nunnally, Mark E.; Townsend, Sean R.; Reinhart, Konrad; Kleinpell, Ruth M.; Angus, Derek C.; Deutschman, Clifford S.; Machado, Flavia R.; Rubenfeld, Gordon D.; Webb, Steven A.; Beale, Richard J.; Vincent, Jean-Louis; Moreno, Rui; and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric SubgroupDerek C.; Deutschman, Clifford S.; Machado, Flavia R.; Rubenfeld, Gordon D.; Webb, Steven A.; Beale, Richard J.; Vincent, Jean-Louis; Moreno, Rui; and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric SubgroupCritical Care Medicine. 41(2):580-637, February 2013.Critical Care Medicine. 41(2):580-637, February 2013.doi: 10.1097/CCM.0b013e31827e83afdoi: 10.1097/CCM.0b013e31827e83af

•

http://journals.lww.com/ccmjournal/Fulltext/2013/02000/Surviving_Sepsis_Campaign___International.24.aspx

Is optimization of oxygen delivery/utilization Is optimization of oxygen delivery/utilization necessary for successful EGDT?necessary for successful EGDT?

• Is ScVOIs ScVO22 the appropriate surrogate measure for the appropriate surrogate measure for

optimizing oxygen delivery/utilization in septic optimizing oxygen delivery/utilization in septic shock? shock?

• Role of transfusion, inotropic supportRole of transfusion, inotropic support

• Can lactate clearance be used as a measure of Can lactate clearance be used as a measure of successful EGDT ?successful EGDT ?

Summary of recent data on EGDTSummary of recent data on EGDT

• EGDT bundle completion improves mortalityEGDT bundle completion improves mortality

• Antibiotics within 1 hour saves livesAntibiotics within 1 hour saves lives

• Hospital-derived Sepsis much higher mortality Hospital-derived Sepsis much higher mortality than if present on admissionthan if present on admission

• UH Sepsis mortality NOT POA 2x that if UH Sepsis mortality NOT POA 2x that if Present On Admission (PAO)Present On Admission (PAO)

Non-POA Severe SepsisNon-POA Severe SepsisUNMH: 2/2013 – 3/2014UNMH: 2/2013 – 3/2014

Total Obs Mortality

Medical Mortality Index

Surgical MortalityIndex

Sepsis 8.0 % 12.0 % 1.93 4.0% 0.42

Severe Sepsis

39.25% 50% 2.8 31.5% 2.19

Non-POA Severe Sepsis TeamNon-POA Severe Sepsis Team

• Member of national SCCM CollaborativeMember of national SCCM Collaborative• Focus is on:Focus is on:

• Early and accurate identificationEarly and accurate identification

• Physician responsiveness, assessment, Physician responsiveness, assessment, documentation of decisionsdocumentation of decisions

• Identification and transfer to higher level of Identification and transfer to higher level of care as neededcare as needed

• Adequate fluid resuscitationAdequate fluid resuscitation

• Antibiotics within 1 hourAntibiotics within 1 hour

Brought to you by Brought to you by SMITeSMITe

SSepsisepsis

MMortalityortality

IImprovement mprovement

TeTeamam

at UNMat UNM

Documentation of Disease Severity: Documentation of Disease Severity: Severe Sepsis/Septic ShockSevere Sepsis/Septic Shock

• Severe sepsis w/o MV 96+ hours Severe sepsis w/o MV 96+ hours

with MCCwith MCC• DRG 871 DRG 871 RW: 1.9090RW: 1.9090

Est. Payment: $17,654Est. Payment: $17,654

• Severe sepsis w/o MV 96+ hoursSevere sepsis w/o MV 96+ hours

without MCCwithout MCC• DRG 872 DRG 872 RW 1.1339 RW 1.1339

Est. Payment: $10,486Est. Payment: $10,48657

Severity of Illness and Risk of MortalitySeverity of Illness and Risk of Mortality

Comorbidity and/or Complication (CC)Comorbidity and/or Complication (CC)•Comorbitidy: Comorbitidy: A pre-existing condition/illness A pre-existing condition/illness that will cause an increase in length of stay because that will cause an increase in length of stay because of its presence with the condition that caused the of its presence with the condition that caused the admission.admission.

•ComplicationComplication: A condition that arises during the : A condition that arises during the hospital stay that may prolong the length of stay. hospital stay that may prolong the length of stay.

•Major comordibity/complication (MCC)Major comordibity/complication (MCC)

58

MCCs for Sepsis MCCs for Sepsis

Example of MCCs for SepsisExample of MCCs for Sepsis

•Respiratory Failure due to SepsisRespiratory Failure due to Sepsis• Acute Respiratory FailureAcute Respiratory Failure

• Lung AbcessLung Abcess

• EmpyemaEmpyema

• Ventilator Dependent (can’t use unable to wean)Ventilator Dependent (can’t use unable to wean)

59

Figure 1. Mean hospital mortality (solid line) and 95% confidence interval (dotted lines) based on the magnitude of lactate change within 12 hours compared with index values. Patients with decreased lactate (across percentage strata) are represented toward the right of the figure, whereas those with increased lactate are toward the left. The vertical line demarcates increased and decreased repeat lactate values.

Annals ATS, 2013http://www.atsjournals.org/doi/abs/10.1513/AnnalsATS.201304-099OC

Published in: Vincent Liu; John W. Morehouse; Jay Soule; Alan Whippy; Gabriel J. Escobar; Annals ATS 10, 466-473.DOI: 10.1513/AnnalsATS.201304-099OCCopyright © 2013 by the American Thoracic Society

One PowerPoint slide of each figure may be downloaded and used for educational not promotional purposes by an author for slide presentations only. The ATS citation line must appear in at least 10-point type on all figures in all presentations. Pharmaceutical and Medical Education companies must request permission to download and use slides, and authors and/or publishing companies using the slides for new article creations for books or journals must apply for permission. For permission requests, please contact the Publisher at [email protected] or 212-315-6441.

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