BUNDLES IN 2013: SURVIVING SEPSIS CAMPAIGN

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1 BUNDLES IN 2013: SURVIVING SEPSIS CAMPAIGN R. Phillip Dellinger MD, MSc, MCCM Professor of Medicine Cooper Medical School of Rowan University Professor of Medicine University Medicine and Dentistry of New Jersey Director Critical Care Medicine Cooper University Hospital Camden NJ USA

2 Potential Conflicts of Interest No potential financial conflict of interest as to any material presented in this presentation Leadership position in Surviving Sepsis Campaign

3 DEBATING (SEPSIS) GUIDELINES Bundles in 2013: Surviving Sepsis - P. Dellinger Surviving Sepsis Guidelines: where they went wrong - J. Kahn Surviving Sepsis Guidelines: what they got right - J-L. Vincent Doubts about Bundles - B. Kavanaugh

4 Phil and the Lion s Den

5 Dellinger s Last Stand

6

7 DEBATING (SEPSIS) GUIDELINES Bundles in 2013: Surviving Sepsis - P. Dellinger Surviving Sepsis Guidelines: where they went wrong - J. Kahn Surviving Sepsis Guidelines: what they got right - J-L. Vincent Doubts about Bundles - B. Kavanaugh

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9 Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012 R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali Annane, Herwig Gerlach, Steven M. Opal, Jonathan E. Sevransky, Charles L. Sprung, Ivor S. Douglas, Roman Jaeschke, Tiffany M. Osborn, Mark E. Nunnally, Sean R. Townsend, Konrad Reinhart, Ruth M. Kleinpell, Derek C. Angus, Clifford S. Deutschman, Flavia R. Machado,Gordon D. Rubenfeld, Steven A. Webb, Richard J. Beale, Jean-Louis Vincent, Rui Moreno, and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Crit Care Med 2013; 41: Intensive Care Medicine 2013; 39:

10 Surviving Sepsis Campaign Currently Funded with a Gordon and Betty Moore Foundation Grant (Intel family).

11 Current Surviving Sepsis Campaign Guideline Sponsors (2010/11 Update) American Association of Critical-Care Nurses American College of Chest Physicians American College of Emergency Physicians Australian and New Zealand Intensive Care Society Asia Pacific Association of Critical Care Medicine American Thoracic Society Brazilian Society of Critical Care(AIMB) Canadian Critical Care Society Chinese Society of Critical Care Medicine Chinese Medical Society Chinese Society of Critical Care Medicine Emirates Intensive Care Society European Respiratory Society European Society of Clinical Microbiology and Infectious Diseases European Society of Intensive Care Medicine European Society of Pediatric and Neonatal Intensive Care Infectious Diseases Society of America Indian Society of Critical Care Medicine International Pan Arab Critical Care Medicine Society Japanese Association for Acute Medicine Japanese Society of Intensive Care Medicine Pediatric Acute Lung Injury and Sepsis Investigators Society Academic Emergency Medicine Society of Critical Care Medicine Society of Hospital Medicine Surgical Infection Society World Federation of Critical Care Nurses World Federation of Pediatric Intensive and Critical Care Societies World Federation of Societies of Intensive and Critical Care Medicine Participation and endorsement: German Sepsis Society Latin American Sepsis Institute

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13 Guidelines Are Not Enough Protocols Performance Improvement Programs Audit and Feedback

14 SSC Performance Improvement Program Partnership with Institute of Healthcare Improvement (IHI) Key elements of guidelines identified Goals established based on those chosen recommendations can be graded easily as yes or no for achievement based on chart review Sepsis Change Bundle(s) and 24 hours and 6 hours

15 Primary Advantage of Bundle Care Structuring of care to promote consistency in the management of clinical conditions (standardization of care)

16 Critics of Bundled Care Cookbook medicine Supplanting clinical judgment Complacency Effect on medical education

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18 Bundles should not negate deviations when particular patient scenario warrants

19 Converting Goals to Measurable Indicators

20 Bundled Care Indicators of care retrievable from chart review

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22

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24 Early Screening and a Performance Improvement Program (1C) Surviving Sepsis Campaign 2013

25 SURVIVING SEPSIS CAMPAIGN BUNDLES TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate 4mmol/L TO BE COMPLETED WITHIN 6 HOURS: 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure [MAP] 65 mm Hg) 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/l (36 mg/dl): - Measure central venous pressure (CVP) - Measure central venous oxygen saturation (ScvO2) 7) Remeasure lactate if initial lactate was elevated

26 Why measure lactate? Diagnose severe sepsis with elevated lactate as a diagnosis of tissue hypoperfusion Trigger for quantitative resuscitation if lactate is 4 mg/dl or more

27 SURVIVING SEPSIS CAMPAIGN BUNDLES TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate 4mmol/L TO BE COMPLETED WITHIN 6 HOURS: 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure [MAP] 65 mm Hg) 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/l (36 mg/dl): - Measure central venous pressure (CVP) - Measure central venous oxygen saturation (ScvO2) 7) Remeasure lactate if initial lactate was elevated

28 Blood Cultures

29 SURVIVING SEPSIS CAMPAIGN BUNDLES TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate 4mmol/L TO BE COMPLETED WITHIN 6 HOURS: 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure [MAP] 65 mm Hg) 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/l (36 mg/dl): - Measure central venous pressure (CVP) - Measure central venous oxygen saturation (ScvO2) 7) Remeasure lactate if initial lactate was elevated

30 Antibiotic Therapy We recommend that intravenous antibiotic therapy be started as early as possible and within the first hour of recognition of septic shock (1B) and severe sepsis without septic shock (1C). Remark: Judged to be best practice but not standard of care

31 Antibiotic Therapy Cover broad initially Reassess antibiotic regimen daily for deescalation

32 SURVIVING SEPSIS CAMPAIGN BUNDLES TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate 4mmol/L TO BE COMPLETED WITHIN 6 HOURS: 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure [MAP] 65 mm Hg) 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/l (36 mg/dl): - Measure central venous pressure (CVP) - Measure central venous oxygen saturation (ScvO2) 7) Remeasure lactate if initial lactate was elevated

33

34 Fluid therapy Initial fluid challenge in sepsis-induced tissue hypoperfusion (hypotension or elevated lactate) with suspicion of hypovolemia to be a minimum of 30ml/kg of crystalloids(a portion of this may be albumin equivalent). More rapid administration and greater amounts of fluid, may be needed in some patients ( 1B) Surviving Sepsis Campaign 2013

35 SURVIVING SEPSIS CAMPAIGN BUNDLES TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate 4mmol/L TO BE COMPLETED WITHIN 6 HOURS: 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure [MAP] 65 mm Hg) 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/l (36 mg/dl): - Measure central venous pressure (CVP) - Measure central venous oxygen saturation (ScvO2) 7) Remeasure lactate if initial lactate was elevated

36 Resuscitation of Sepsis Induced Tissue Hypoperfusion Recommend MAP 65 mm Hg Grade 1C Surviving Sepsis Campaign 2013

37 Potential Conflicts of Interest No potential financial conflict of interest as to any material presented in this presentation Leadership position in Surviving Sepsis Campaign

38 Sepsis Induced Tissue Hypoperfusion Requirement for vasopressors after fluid challenge Lactate 4 mg/dl

39 Protocolized Care Protocolized Quantitative Resuscitation

40 SURVIVING SEPSIS CAMPAIGN BUNDLES TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate 4mmol/L TO BE COMPLETED WITHIN 6 HOURS: 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure [MAP] 65 mm Hg) 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/l (36 mg/dl): - Measure central venous pressure (CVP) - Measure central venous oxygen saturation (ScvO2) 7) Remeasure lactate if initial lactate was elevated

41 Why Measure CVP and ScvO2? Can be accomplished within the critical first 6 hours Are these variables perfect? No Trials ongoing that seek better quantitative resuscitation targets Attempts at pushing newer technologies to the critical first 6 hours Are these variables useful for decision making? Yes, when integrated into total clinical picture

42 Also may choose to use: Systolic pressure variation (if mechanically ventilated) Inferior vena cava ultrasound (if technology and expertise available) Echocardiography(if technology and expertise available) Stroke volume and stroke volume variation (if technology and expertise available)

43 SURVIVING SEPSIS CAMPAIGN BUNDLES TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate 4mmol/L TO BE COMPLETED WITHIN 6 HOURS: 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure [MAP] 65 mm Hg) 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/l (36 mg/dl): - Measure central venous pressure (CVP) - Measure central venous oxygen saturation (ScvO2) 7) Remeasure lactate if initial lactate was elevated*

44 Hospital Mortality and Length of Stay Jones, A. E. et al. JAMA 2010;303:

45 Am J Respir Crit Care Med Sep 15;182(6):

46 In Summary, ICU Bundles: Are not perfect Are still evolving and always will be Attempt to provide the best quality for the typical patient in the ICU with the matched disorder Will never replace clinical decision-making Allow audit, feedback, and behavior change Offer education and team-building capability

47

48 Thank You

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