Sepsis in the Surgical Patient- Alastair Glossop

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

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Sepsis in the Surgical Patient- Alastair Glossop

  1. 1. Sepsis in the surgical patient Dr Alastair GlossopConsultant in Anaesthesia and Intensive Care Medicine Sheffield Teaching Hospitals NHS Foundation Trust
  2. 2. 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
  3. 3. 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%
  4. 4. 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
  5. 5. What can we do to improve this? Start at the beginning...
  6. 6. 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
  7. 7. 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
  8. 8. 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 Xigris withdrawn due to safety concerns!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!
  9. 9. 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
  10. 10. What really is important in reducing mortality from sepsis? Both Grade E recommendations
  11. 11. Sepsis and Septic Shock:An ID View Cellular dysfunction/tissue injury Inflammatory response Shock Threshold Toxic burden Microbial load TIME
  12. 12. “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
  13. 13. “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
  14. 14. So just get the antibiotics in early, yeah?
  15. 15. “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
  16. 16. 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
  17. 17. 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
  18. 18. The clock is ticking…• Awareness of the problem• Early antibiotics• Source controlalastair.glossop@sth.nhs.uk
  19. 19. With special thanks to… Dr James Wigfull Prof Anand Kumar Eli Lilly

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