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Sepsis in the Surgical Patient- Alastair Glossop
 

Sepsis in the Surgical Patient- Alastair Glossop

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A presentation given by Alastair Glossop, Sheffield, at the Dukes' Club AGM 2012

A presentation given by Alastair Glossop, Sheffield, at the Dukes' Club AGM 2012

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    Sepsis in the Surgical Patient- Alastair Glossop Sepsis in the Surgical Patient- Alastair Glossop Presentation Transcript

    • Sepsis in the surgical patient Dr Alastair GlossopConsultant in Anaesthesia and Intensive Care Medicine Sheffield Teaching Hospitals NHS Foundation Trust
    • Why worry about sepsis?• Leading cause of death in general ICUs• Common• Incidence is increasing: • Affects 250 per 100,000 hospital inpatients • 1 million cases of severe sepsis in 2010
    • Is it a problem in surgical patients?• Yes it is• 30% of severe sepsis occurs in surgical patients• Overall mortality 28.6% • Elective surgery – 31% • Emergency surgery – 39%
    • Why are surgeons such a problem?The defence… The prosecution…• Well trained • Work in a dirty environment• Decisive, incisive • Insult and injury• Obsessed with source predispose to sepsis control • Surgery increases risk of• Obsessed with asepsis infection elsewhere• Close relationship with • Patients “go off” on anaesthesia and ICU wards post op
    • What can we do to improve this? Start at the beginning...
    • Surviving sepsis campaign• Committee established in 2003• Tasked with producing evidence based guidelines• Reducing global mortality from sepsis• Produced “care bundles” – targets to be achieved at 6 and 24 hours• Based on 5 “seminal” papers demonstrating mortality benefit in sepsis
    • Six hour goals…• Resuscitation goals• Also specified: • antibiotics and source control within 1 hour • Lactate measurement• Rivers protocol – level B evidence• Antibiotics within 1 hour – level E evidence
    • Twenty four hour goals… Superseeded – no mortality benefit!Superseeded – reduced mortality benefit and increased complications! Xigris withdrawn due to safety concerns! Litigation being brought by families of controls!
    • Despite being based on shaky evidence, bundles seem to workEarly work suggested poor compliance with bundles – 50% at 6 hoursNon compliance grt. 2 fold increase in hospital mortality (p = 0.01) NNT = 4
    • What really is important in reducing mortality from sepsis? Both Grade E recommendations
    • Sepsis and Septic Shock:An ID View Cellular dysfunction/tissue injury Inflammatory response Shock Threshold Toxic burden Microbial load TIME
    • “An Injury Paradigm of Sepsis and Septic Shock” Prof A Kumar, University of ManitobaAntimicrobial therapy Cellular dysfunction/tissue injury Inflammatory response Shock Threshold Toxic burdenMicrobial load TIME
    • “An Injury Paradigm of Sepsis and Septic Shock” Prof A Kumar, University of Manitoba earlierantimicrobial therapy Shock Threshold Cellular dysfunction/tissue injury Inflammatory response Toxic burden Microbial load TIME
    • So just get the antibiotics in early, yeah?
    • “An Injury Paradigm of Sepsis and Septic Shock” Prof A Kumar, University of ManitobaAntimicrobial therapy +Source control Cellular dysfunction/tissue injury Shock Threshold Inflammatory response Toxic burden Microbial load TIME
    • Audit of event timing from EWS 2 to theatre for the deteriorating colorectal patient by stage 9 A: EWS 2 to SpR review 8 B: SpR review to Antibiotics 7 6 C: CT booking to scanhours 5 4 D: CTscan to report 3 E: Scan to theatre booking 2 1 F: Booking to arrival 0 A B C D E F
    • Audit of event timing from EWS 2 to theatre for the deteriorating colorectal patient by outcomes 25 20 15 Total time from 10 trigger to theatre 5 0 Survivors Non- survivors
    • The clock is ticking…• Awareness of the problem• Early antibiotics• Source controlalastair.glossop@sth.nhs.uk
    • With special thanks to… Dr James Wigfull Prof Anand Kumar Eli Lilly