sirs, nice, sofas and cquins: challenges of changing

SIRS, NICE, SOFAs and CQUINs:

Challenges of changing definitions

and guidelines

Dr Sian Coggle

Consultant Acute Medicine and

Infectious Diseases

Objectives

• Context

• Case

• Changing definitions

• Systems for recognition and management

• Evidence behind treatment

• Balances

• CUH work

• Cases/quiz

• 123,000 cases of sepsis occur in England each

year

• Approx. 37,000 deaths annually

• More than breast, bowel and prostate cancers

combined

• Prompt recognition of sepsis and rapid

intervention will help reduce the number of

deaths occurring annually.

63 yr old P.S

• From wife

• Whole family “flu-like illness”

• PS cough for last 3 days

• Headache

• Sweaty, drowsy, not following commands

• DH:

• Mirtazipine

• PMH:

• Measles aged 7 yrs

• Right petrousectomy 2014

25.12.16 19:02 = 0 mins

Minute ED action

0 T 40.4 at home, to resus

1 RR20, SpO2 96% (non rebreath bag), HR

99, BP 158/97, GCS 13, T 38.2 – NEWS 4

3 Sepsis criteria alert triggered

6 Bloods and cultures taken

10 Lactate 2.1, Ceftriaxone, Aciclovir, CT

head, CXR, urine dip, ECG, fluid balance

chart – ordered

34 WCC 16.7, neut 15, lymph 0.78, CRP 116,

Cr 77

35 IV ceftriaxone 2grm given

38 Hartmann’s 1l over 15 mins given

Minute ED action

60-120 Aciclovir given, lact repeated 3.0, Medical

and RRT review, CXR, CT head

340 LP – turbid fluid, OP 17.5 cmH2O

Dexamethasone added 0.15mg/Kg

480 PMN 1060, lymph 0, gluc and prot

pending. Gram stain difficult

Discussed with microbiology and ID SpR

Add Amoxicillin and Vancomycin

720 Concerns about pupils and GCS, repeat CT

head on way to RRT bed on IDA

2001 definition• Systemic inflammatory response syndrome (SIRS) requires 2 or more of the following

• 1. T >38 C or <36 C2. P >90/min3. RR >20/min or PaCO2 <32 mmHg4. WCC >12 or >10% immature band forms

• Sepsis

• Sepsis is SIRS + confirmed or presumed infections

• Severe Sepsis

• Severe Sepsis is sepsis with organ dysfunction

• organ dysfunction includes:

– SBP <90 mmHg or MAP < 65 mmHg or lactate > 2.0 mmol/L (after initial fluid challenge)

– INR >1.5 or a PTT >60 s

– Bilirubin >34 µmol/L

– Urine output <0.5 mL/kg/h for 2 h

– Creatinine >177 µmol/L

– Platelets <100 ×109/L

– SpO2 <90% on room air

• Septic Shock

• Septic shock is defined as sepsis with refractory hypotension

– hypotension is defined as SBP <90 mmHg or MAP <70 mmHg

– refractory means that hypotension persists after 30 mL/kg crystalloid; i.e. vasopressor dependence after adequate volume resuscitation

Definition – Sepsis - 3

• Sepsis “life-threatening organ dysfunction caused by a dysregulated host response to infection”

• Septic shock “a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.”

• Inclusion of organ dysfunction in the definition

of sepsis, the term “severe sepsis” was

eliminated in this new iteration

• European Society of Intensive Care Medicine and Society of Critical

Care Medicine Third International Consensus Task Force

• Singer M et al. JAMA 2016 Feb 23. Seymour CW et al. JAMA 2016 Feb 23.

Shankar-Hari M et al. JAMA 2016 Feb 23. Abraham E. JAMA 2016 Feb 23

• Sepsis is a life-threatening organ dysfunction

due to a dysregulated host response to

infection.

• Suspected sepsis is used to indicate people

who might have sepsis and require face-to-

face assessment and consideration of urgent

intervention.

• NICE guidelines July 2016

Recognising

• Sequential Organ Failure Assessment (SOFA) scores compared with Logistic Organ Dysfunction System (LODS) and SIRS criteria

• Performed same – chose SOFA

• Suspected infection plus a change in baseline SOFA score ≥2 points

• Clinical criteria to diagnose septic shock included vasopressor use to maintain mean arterial pressure >65 mm Hg and lactate level >2 mmol/L despite adequate fluid resuscitation.

qSOFA

• Limitations – starting to be addressed

• Defining sepsis by an increase in SOFA score

provided greater prognostic accuracy for in-

hospital mortality than either SIRS criteria or

qSOFA

• “Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qSOFA Score for

In-Hospital Mortality Among Adults With Suspected Infection Admitted to

the Intensive Care Unit” Raith et al JAMA. 2017;317(3):290-300

• 8% in hospital mortality - qSOFA helped predict who

• 3% for those with qSOFA of 1,

• 24% for those with a qSOFA ≥2

• Adding lactate to the model did not improve the predictions

• Data were incomplete on 14% of patients, limiting the conclusions' strength

• “Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected Infection Presenting to the Emergency Department” Freund et al JAMA. 2017;317(3):301-308.

Sensitive Specific Positive

predictive

value

Negative

predictive

value

SIRS 97% 2.4% 15.9% 80%

qSOFA 48% 90% 42% 92%

• Retrospective review 200 cases presenting to ED six month

period who had a sepsis 6 form completed

• qSOFA is a more specific test to identify patients requiring

critical care input or at risk of death. Although SIRS is more

sensitive, its lack of specificity makes it a much less effective

screening tool for severe sepsis

• “TRIAGE OF SEPSIS PATIENTS: SIRS OR QSOFA – WHICH IS BEST?” Gunn

et al emermed-2016-206402.23

• qSOFA

• sBP <100

• Altered mental status

• RR > 22

• >2 = 10% mortality rate

Management the evidence:

• Early directed goal therapy:

• Randomized trial of 263 patients with suspected

sepsis reported a lower mortality in patients when

ScvO2, CVP, MAP, and urine output were used to

direct therapy compared with those in whom only

CVP, MAP, and urine output were targeted (31 vs 47

%)

• Both groups initiated therapy, including

antibiotics, within six hours of presentation.

There was a heavy emphasis on the use of red

cell transfusion (for a hematocrit >30) and

dobutamine to reach the ScvO2 target in this

trial

• “EARLY GOAL-DIRECTED THERAPY IN THE TREATMENT OF SEVERE SEPSIS

AND SEPTIC SHOCK” Emanuel Rivers et al N Engl J Med, Vol. 345, No. 19

November 8, 2001

• Three subsequent multicenter randomized

trials of patients with septic shock, ProCESS,

ARISE and ProMISE and two meta-analyses all

reported no mortality benefit (20 to 30 %),

associated with an identical protocol

compared with protocols that used some of

these targets or usual care

• A systematic review and meta-analysis of early goal-directed therapy for

septic shock: the ARISE, ProCESS and ProMISe Investigators. Intensive Care

Med 2015; 41:1549. Angus DC, Barnato AE, Bell D, et al

• PRISM Investigators. Early, Goal-Directed Therapy for Septic Shock - A

Patient-Level Meta-Analysis. N Engl J Med 2017

Sepsis 6

Author n Setting Median time

(mins)

Odds Ratio for

death

GaieskiCrit Care Med 2010;

38:1045-53

261 ED, USA

(Shock)

119 0.30(first hour vs all times)

DanielsEmerg Med J 2010;

doi:10.1136

567 Whole hospital,

UK

121 0.62(first hour vs all times)

KumarCrit Care Med 2006;

34(6):1589-1596

2 154 ED, Canada

(Shock)

360 0.59(first hour vs second hour)

AppelboamCritical Care 2010;

14(Suppl 1): 50

375 Whole hospital,

UK

240 0.74(first 3 hours vs delayed)

LevyCrit Care Med 2010; 38

(2): 1-8

15 022 Multi-centre 0.86(first 3 hours vs delayed)

LevyNEJM 2017;

10.1056/NEJMoa1703058

49 331 Multi-centre 57 1.04 per hour( increased odds per

hour delay)

Antibiotics – for every hour delayed 7-8% increase in mortality

• Retrospective cohort study of adult patients who presented to a single emergency department with severe sepsis over an 8-year period

• Approx. 1000 patients from severe sepsis to septic shock

• median time to initial antimicrobial administration was significantly longer for patients who progressed to septic shock than for those who did not progress (3.77 hours vs. 2.76 hours)

• Multivariable logistic regression showed an 8% increase in the odds of progression to septic shock for each 1 hour delay in antimicrobial administration

• “Increased time to initial antimicrobial administration is associated with progression to septic shock in severe sepsis patients.” Whiles BB et al. CritCare Med 2017 Feb 6

Surviving Sepsis Campaign/Society of Critical Care

Medicine/European Society of Intensive Care

Medicine

• IV antibiotics within one hour of presentation

• source control and antibiotic stewardship

• infusion of crystalloid solution at a rate at 30

mL/kg/hour within three hours for early fluid

resuscitation

• movement away from previously recommended

early goal-directed therapy targets (eg, central

venous pressure) to use of dynamic predictors of

fluid responsiveness, when feasible.

Balances• Does the patient have an infection?

• Is it likely to be bacterial/fungal/viral?

• Source control achieved?

• “Start Smart - Then Focus”

CQUIN

Sepsis at CUH

0

10

20

30

40

50

60

70

80

90

100

Jun

-15

Jul-

15

Au

g-1

5

Se

p-1

5

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Fe

b-1

6

Ma

r-1

6

Ap

r-1

6

Ma

y-1

6

Jun

-16

Jul-

16

Au

g-1

6

Se

p-1

6

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

Ap

r-1

7

%

Sepsis Management in CUH ED

% antibiotics within 60 mins

% full sepsis 6 bundle in 60 mins

% antibiotics within 90 mins

% full sepsis 6 bundle in 90 mins

SEPSIS IS A MEDICAL EMERGENCY

ACT FAST, SAVE LIVES

Mortality increases by 8% for every hour of delay in antibiotics

SEPSIS

Does your

patient have a

NEWS >5

and/or look

sick?

ANY HIGH RISK

CRITERIA?� Mottled or blue

� Altered mental state

� Respiratory rate >25/min

� Increasing oxygen

requirement

� Heart rate >130/min

� Systolic BP <90mmHg

� Urine output lower than

0.5ml/kg/hr

� Not passed urine for

>18hrs

URGENT SENIOR

REVIEW NOW

GET HELP

Senior medical

review within

30 mins and/or

RRT if

deteriorating

OPEN SEPSIS

ORDER SET ON

EPIC

GIVE ANTIBIOTICS

WITHIN 60

MINUTES

Think: Could

this be

infection?

Quiz 1

18 yr old man presents to ED on Friday night

with his friends. Been on night out in town and

friends concerned patient is now acutely

confused. Observations:

T37, HR 135, BP 110/70, sats 98% OA, RR 22

What would you do next?

A. Meets high risk criteria start sepsis 6

B. Obtain more history

C. Give some fluids and reassess HR before

considering antibiotics

D. Wait for bloods including a lactate and Cr

before starting any management

Answer 1

• B – obtain more history

• Consider if infection present before assessing

for sepsis

Quiz 2

75 yr old on surgical ward following recent

resection for bowl obstruction. HCA performs

observations as part of routine rounds and

patient mentions some increased redness and

pain in surgical wound. Observations are:

T 38.5, HR 100, BP140/70, RR 20, Sats 98 %

OA

You are the medical SpR covering wards what

would you do next?

A. Phone the surgeons and arrange CT scan

B. Ensure adequate analgesia and fluid

intake, then reassess observations

C. Arrange an urgent set of bloods including

lactate and creatinine

D. Start sepsis 6 immediately

Answer 2

• C – meets criteria for intermediate risk sepsis

and need urgent bloods to ensure not high

risk

Quiz 3

61 yr old lady bed bound from MS, catheter

in situ (changed yesterday) with history of

recurrent UTI’s. Found that morning by her

carer acutely confused and now barely

rousable. Observations in ED:

T 37.5, HR 140, BP 90/60, sats 94%OA, RR 25

What would you do next:

A. This is high risk sepsis start sepsis 6 within

an hour of presentation, target antibiotics

to likely source

B. Arrange full set of bloods and CT head as

confused

C. Further history

D. Hold off sepsis 6 until central line in situ

for monitoring

Answer 3

• A – high risk sepsis, a medical emergency

Quiz 4

84 yr old lady brought into ED by daughter

“not quite right”. Had a fall last night and

maybe slightly confused. Has had a cough over

last few days and GP started on antibiotics.

Observations:

T 36.5, HR 110, BP 150/90, RR 22, Sats 94 %

OA

Bloods back – CRP 250, WCC 22, neut 16, Cr

80, lact 1.5

What would you do:

A. Meets high risk criteria start sepsis 6

B. Measured oxygen, CXR, infection screen

C. Find out baseline creatinine, if stable start

antibiotics in timely manner and reassess

in hour

D. Reassure daughter antibiotics likely to start

working soon and discharge

Answer 4

• C – meets intermediate criteria. Need to

ensure not in AKI and reassess. Does require

treatment for sepsis, but less urgency

Summary

• Context

• Case

• Changing definitions

• Systems for recognition and management

• Evidence behind treatment

• Balances

• CUH work

• Cases/quiz