sepsis in unique populations - njha · l\ukemia accounts for 28% of all cancers diagnosed in...
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Sepsis in Unique PopulationsChrista Schorr, DNP, MSN, RN, FCCM, NEA-BC
Associate Professor of Medicine, CMSRUClinical Nurse Scientist, CUH
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NJHA January 24, 2020
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Disclosures
• No financial disclosures• Member of the Surviving Sepsis Campaign (SSC) Steering Committee• Member of the SSC Guidelines- Group Head for Long term outcomes
and goals of care• Member of SCCM Thrive Committee
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Objectives
Sepsis and Cancer Sepsis and Transplantation Sepsis and Surgery
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Sepsis in People with Cancer
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American Cancer Society https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2019.html 2019 report.
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In 2019, there were an estimated 1,762,450
new cancer cases diagnosed and 606,880
cancer deaths in the United States.
https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2019.html
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https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2019.html 7
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https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2019.html 8
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Hensley MK et al. Crit Care Med 2019; 47:1310–1316
More than one in five sepsis hospitalizations were
cancer related
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10Hensley MK et al. Crit Care Med 2019; 47:1310–1316
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11Hensley MK et al. Crit Care Med 2019; 47:1310–1316
Organ dysfunction
Site of infection
LOS & mortality
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In-Hospital Cancer-Related Sepsis Mortality by Age Group
12Hensley MK et al. Crit Care Med 2019; 47:1310–1316
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Outcomes
• In hospital mortality in cancer related sepsis was 28% compared to 20% in non-cancer related sepsis.
• In-hospital mortality was higher in hematologic and undifferentiated tumor types compared to solid tumors.
• The burden of acute organ dysfunction was similar between the two groups.
• More than one in five sepsis hospitalization was followed by a 30-day readmission.
Hensley MK et al. Crit Care Med 2019; 47:1310–1316 13
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Dimopoulos G et al. 2019 BMC Infectious Diseases15
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Dimopoulos G et al. 2019 BMC Infectious Diseases16
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Clinical Implications in Cancer Patients
• Mortality difference between cancer-related and non–cancer-related sepsis may be declining over time as a result of changes in cancer treatment, immune suppression therapies and growing awareness of sepsis.
• Patients with cancer may present earlier with signs of infection and receive treatment sooner.
• Educate cancer patients and their families about infection and sepsis.• Do they have a thermometer at home?• Do they have a clear plan when they are concerned?• Who should they contact in an emergency?
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https://www.cdc.gov/sepsis/pdfs/cancer-infection-and-sepsis-fact-sheet.pdf 18
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Sepsis and Transplant Recipients
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36,528 transplants
performed in 2018.
About 80/day.62% Male; 38%
female
https://www.organdonor.gov/statistics-stories/statistics.html20
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Schachtner t et al. Transpl Infect Dis. 2017; 19:e12695.
• 112 of 957 kidney transplant recipients (KTRs) with sepsis.• 31 developed severe sepsis or septic shock• 30 KTRs died from sepsis
• Five year survival was 70.3% with sepsis vs 88.2% without (p=0.001)
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Risk factors associated with sepsis
Schachtner t et al. Transpl Infect Dis. 2017; 19:e12695.22
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• This was a matched, case-control propensity-adjusted study. Conditional logistic regression was performed for risk factor analysis, and Cox proportional hazards regression for survival analysis.
• 369 pts (123 cases; 246 controls) 1:2Kalil, A. C. Et al. (2014). Clinical Infectious Diseases, 60(2), 216-222. 23
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No transplant
Transplant
No transplant
Transplant
Compared to nontransplant pts, organ transplant was associated with a 78% lower 28-day mortality (HR=0.22 [95% CI, .09–.54], P=.001
Compared to nontransplant pts, organ transplant was associated with a 57% lower 90-day mortality (HR=0.43 [95% CI, .20–.89], P=.025
Kalil, A. C. Et al. (2014). Clinical Infectious Diseases, 60(2), 216-222. 24
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Risk factors associated with sepsis
• Heart recipients- pre-transplant hospitalization, post-op tracheal intubation for >1 day, high dose steroids, allograft rejection, CMV infection and post-transplant reintubation
• Kidney recipients- anastomotic leaks, contamination of the perfusate or allograft, presence of urinary catheters, ureteral stents, central venous catheters, recent diagnosis of wound infection, and advanced age at the time of transplantation
• Liver recipients- Biliary and enteric contamination, poor baseline medical condition, prolonged length of liver transplantation procedure, and extended ICU stay in the post-operative period
Kalil AC & Opal SM Curr Infect Dis Rep (2015) 17:3226
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Kalil AC & Opal SM Curr Infect Dis Rep (2015) 17:3227
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Principles of therapeutic management for sepsis that apply to all allograft types1. Rapid initiation of intravenous antibiotics 2. Rapid diagnosis 3. Source control4. Aggressive search for pathologies that mimic severe sepsis and lead
to significant morbidity and mortality if missed 5. Reduction of immunosuppressive drugs to levels that allow better
immunological response to fight the infection process, while still preventing graft rejection.
Kalil AC & Opal SM Curr Infect Dis Rep (2015) 17:32 28
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Clinical Implications in Transplantation
• Early identification of sepsis – Assessment of surgical incisions• Adequate source control• Minimize use of urinary catheters and central venous catheters• Adequate control of glucose levels• Consider frequent screening for CMV with adequate treatment• Educate patients and families about the risk of sepsis.
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Sepsis and the Surgical Patient
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Summary of the risk factors associated with post-operative sepsis established through multivariate analysis
Plaeke P et al. Surgery Today 2019. https://doi.org/10.1007/s00595-019-01827-4 32
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Incidence of sepsis according to the type of surgery
Plaeke P et al. Surgery Today 2019. https://doi.org/10.1007/s00595-019-01827-4 33
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• 2,621 patients; Setting of infection: 31.6% community acquired, 25% early onset hospital-acquired, 43.4% late-onset hospital-acquired.
• Overall mortality 29.1%34
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1,594 of 1,982 cultured were culture positiveBlot S et al Intensive Care Med (2019) 45; 1703-1717
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Mortality according to classification of intra-abdominal infection
Blot S et al Intensive Care Med (2019) 45; 1703-171736
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Blot S et al Intensive Care Med (2019) 45; 1703-1717
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Brakenridge SC et al. Ann Surg 2019; 270:(502-510)
• Prospective, longitudinal cohort study of surgical intensive care unit(SICU) patients with sepsis
• 301 SICU patients with sepsis, 30-day mortality 9.6%• Most had rapid recovery (RAP) 189 (63%); 99 (33%)
developed chronic critical illness (CCI).
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Inpatient Clinical Trajectories and Outcomes
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• ACS-NSQIP database from 2005-2016• Compared a sepsis group to non-sepsis group undergoing the
same procedure• 24,257 patients underwent flap reconstruction surgery, due to
cancer, trauma, etc.40
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Sparenberg S. et al. Journal of Plastics and Hand Surgery. 2019. 53(6) 328-334.
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Predictors of sepsis after reconstructive flap surgery
Sparenberg S. et al. Journal of Plastics and Hand Surgery. 2019. 53(6) 328-334.42
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Clinical Implications in Surgical Sepsis
• The decrease in early mortality reflects improvement in sepsis screening.1
• The discordance between low inpatient mortality and poor long term outcomes including development of CCI is important information to discuss with complicated surgical sepsis patients and families.
• Clinicians should take a proactive approach - Risk reduction and prevention
• Be aware of risk factors contributing to the development of sepsis in the surgical patient, allowing for early treatment and intervention.
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Summary
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Thank you for your time
55 days until
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