Webinar - Surviving Sepsis: State of the Art

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Intervention:
Sepsis

Date:
Thursday, May 8, 2014

Sponsor:
•Canadian Patient Safety Institute
•Canadian ICU Collaborative
Speakers:
•John C. Marshall, MD FACS, St. Michael’s Hospital, University of Toronto
Purpose of the Call:
Provide update on the Surviving Sepsis Campaign

Published in: Health & Medicine
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Webinar - Surviving Sepsis: State of the Art

  1. 1. SURVIVING SEPSIS: STATE OF THE ART Thursday, May 8 2014 Jeudi 8 mai 2014
  2. 2. Your Hosts & Presenters Vos hôtes et présentateurs Bruce Harries, Moderator Denny Laporta, MD, FRCPC, CSPQ Ardis Eliason, Technical Host John C. Marshall, MD, FRCSC, FACS 208/05/2014
  3. 3. Interacting in WebEx: Today’s Tools Interagir dans Webex : outils à utiliser 3 Be prepared to use: - Pointer - Raise hand - CHAT - Text Tool “writing on the slide” - Shape Tools Have you used WebEx before? Avez-vous déjà utilisé WebEx?  YES / OUI NO / NON  Soyez prêts à utiliser les outils : - le pointeur - lever la main - clavardage - Outil textuel pour « écrire sur la diapo » - Outils de forme08/05/2014 Type your message & click ‘send’ Select ‘send to’
  4. 4. 4 Who’s Online? Qui est en ligne? POINTER 08/05/2014
  5. 5. What professions are represented? Quelles professions sont représentées? Nurse MD Educator / Quality Improvement Professional Infection Control Administrator / Senior Leader Other POINTER Respiratory Therapist Nutritionist 508/05/2014
  6. 6. Dr. John C. Marshall Surviving Sepsis: State of the Art
  7. 7. The Surviving Sepsis Campaign: State of the Art St. Michael’s Hospital University of Toronto John C. Marshall MD FACS Safer Healthcare Now May 8, 2014
  8. 8. Paris, 1997 …
  9. 9. • Definitions • Diagnosis of infection • Antibiotics • Hemodynamic support • Source control • ICU care • Adjunctive therapies • Novel therapies
  10. 10. Phase 1 Barcelona declaration Phase 2 Evidence-based guidelines Phase 3 Implementation and evaluation
  11. 11. A global program to reduce mortality rates in severe sepsis ESICM, ISF and SCCM Partially funded by unrestricted educational grants from Baxter, Edwards, Philips and Lilly
  12. 12. Sponsoring Organizations • American Association of Critical Care Nurses • American College of Chest Physicians • American College of Emergency Physicians • American Thoracic Society • Australian and New Zealand Intensive Care Society • European Society of Clinical Microbiology and Infectious Diseases • European Society of Intensive Care Medicine • European Respiratory Society • International Sepsis Forum • Society of Critical Care Medicine • Surgical Infection Society
  13. 13. Guidelines Meeting London, England June 2003
  14. 14. - Crit Care Med 32:858, 2004
  15. 15. The Sepsis Bundles • Institute for Healthcare Improvement (IHI) • Measurable activities that indicate compliance with guidelines
  16. 16. - N Engl J Med 355:1640, 2006
  17. 17. San Francisco, January 2006
  18. 18. American Association of Critical-Care Nurses American College of Chest Physicians American College of Emergency Physicians American Thoracic Society Canadian Critical Care Society European Society of Clinical Microbiology and Infectious Diseases European Society of Intensive Care Medicine European Respiratory Society International Sepsis Forum Society of Critical Care Medicine Japanese Association for Acute Medicine Japanese Society of Intensive Care Medicine Surgical Infection Society Participation and endorsement by the German Sepsis Society and the Latin American Sepsis Institute. Sponsors 2006
  19. 19. - Crit Care Med 36:296, 2008
  20. 20. Miami 2010
  21. 21. - Crit Care Med 41:580, 2013
  22. 22. Grading of Recommendations Assessment, Development, and Evaluation • Strength of the Evidence • Strength of the Recommendation
  23. 23. Improving Sepsis Care • Recognition • Resuscitation • Diagnosis and treatment of infection • Physiologic support
  24. 24. Improving Sepsis Care • Recognition • Resuscitation • Diagnosis and treatment of infection • Physiologic support
  25. 25. Rates of Sepsis, U.S. 1979 - 2001 - Martin, N Engl J Med 348:1546, 2003
  26. 26. Sepsis in the Emergency Department • Acute change in health status • Unexplained organ dysfunction • Febrile illness • Underlying co-morbidities
  27. 27. Sepsis on the Hospital Ward • Fever, tachycardia • Altered mental status • Fluid retention • New organ dysfunction • Often subtle presentation
  28. 28. Sepsis Think of it!
  29. 29. Improving Sepsis Care • Recognition • Resuscitation • Diagnosis and treatment of infection • Physiologic support
  30. 30. Optimize Oxygen Delivery to Tissues • Restore intravascular volume • Support cardiac function • Provide oxygen • Enhance O2 carrying capacity
  31. 31. Lactate Metabolism Anerobic Aerobic
  32. 32. Resuscitation
  33. 33. Early Goal-directed Therapy for Septic Shock Standard Goal-Directed (N=133) (N=130) MVO2 65.3+11.4 70.4+10.7* APACHE II 15.9+6.4 13.0+6.3* Mortality 46.5% 30.5%* * p<0.02 - Rivers, N Engl J Med 345:1368, 2001
  34. 34. CVP Mean Arterial Pressure > 8 <8 Fluids ScvO2 > 65 <65 Pressors Goals achieved > 70Transfusion, Inotropes
  35. 35. - Angus, N Engl J Med 370:1683, 2014
  36. 36. The SAFE Study Investigators, N Engl J Med 2004;350:2247 Saline and Albumin are Equally Efficacious
  37. 37. Mortality is Increased with Starches - Zarychanski, JAMA 309:678, 2013
  38. 38. - N Engl J Med 370:1583, 2014
  39. 39. - N Engl J Med 370:1583, 2014
  40. 40. Improving Sepsis Care • Recognition • Resuscitation • Diagnosis and treatment of infection • Physiologic support
  41. 41. Diagnosis Antibiotics Source Control
  42. 42. OddsRatioforDeath (95%CI) 1 10 100 Time from Onset of Hypotension (Hours) -Kumar, Crit Care Med 34:1589, 2006 Impact of Delayed Antibiotic Therapy on Clinical Outcome
  43. 43. “Early versus late necrosectomy in severe necrotizing pancreatitis” Number Mortality Early 25 58% Late 11 27% - Mier et al Am.J.Surg 173:71, 1997
  44. 44. Improving Sepsis Care • Recognition • Resuscitation • Diagnosis and treatment of infection • Physiologic support
  45. 45. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome Mortality (%)Controls 39.8 Volume-limited 31.0* ARDSNet; NEJM 342:1301, 2000 *P=0.007
  46. 46. Impact of Fluid Strategy in ARDS Conservative Liberal p. (N=503) (N=497) 60 day mortality 25.5% 28.4% 0.30 Ventilator-free days 14.6±0.5 12.1±0.5 <0.001 ICU-free days 13.4±0.4 11.2±0.4 <0.001 CNS failure FD 18.8±0.5 17.2±0.5 0.03 - ARDSNet, N Engl J Med 354:2564, 2006
  47. 47. Survival in NICE/SUGAR
  48. 48. Drotrecogin alfa was ineffective in low risk patients … Abraham E N Engl J Med 2005;353:1332
  49. 49. Time to Shock Reversal Survival Sprung et al, N Engl J Med 358:111,2008 CORTICUS N=499
  50. 50. Has It Made a Difference?
  51. 51. • Global process change initiative based on “sepsis bundles” • 15,022 patients enrolled • 7% absolute, 5.4% relative mortality reduction (p<0.001) Surviving Sepsis Campaign
  52. 52. Unadjusted Risk-adjusted Bundle target Population N OR p-value OR 95% CI p-value Measure Lactate All 15,022 0.86 <0.0001 0.97 [0.90, 1.05] 0.48 Obtain blood cultures before antibiotics All 15,022 0.70 <0.0001 0.76 [0.70, 0.83] <0.0001 Commence broad-spectrum antibiotics All 15,022 0.78 <0.0001 0.86 [0.79, 0.93] <0.0001 Achieve tight glucose control All 15,022 0.65 <0.0001 0.67 [0.62, 0.71] <0.0001 Administer drotrecogin alfa Multi-organ failure 8,733 0.90 0.26 0.84 [0.69, 1.02] 0.07 Administer drotrecogin alfa Shock despite fluids 7,854 0.91 0.30 0.81 [0.68, 0.96] 0.02 Administer low-dose steroids Shock despite fluids 7,854 1.06 0.18 1.06 [0.96, 1.17] 0.24 Demonstrate CVP ≥ 8 mm Hg Shock despite fluids 7,854 1.08 0.10 1.00 [0.89, 1.12] 0.98 Demonstrate ScvO2 ≥ 70% Shock despite fluids 7,854 0.94 0.24 0.98 [0.86, 1.10] 0.69 Achieve low plateau pressure control Mechanical ventilation 7,860 0.67 <0.0001 0.70 [0.62, 0.78] <0.0001
  53. 53. - Kaukonen et al JAMA 2014 Survival in Sepsis is Improving
  54. 54. Conclusions • The SSC has raised awareness regarding sepsis management and defined optimal approaches to care • This has been associated with improved survival • But the elements responsible for that improvement need further study
  55. 55. Thank You!!
  56. 56. QUESTIONS? RAISE YOUR HAND / LEVEZ LA MAIN OR/OU CHAT TO “ALL PARTICIPANTS”
  57. 57. 62 a Canadian Critical Care Knowledge Translation Network “aC3KTion Net”
  58. 58. 63 aC3KTion Net • Network of ICUs (Networks) from across Canada • Academic • Community • Primary activity will be Knowledge Translation and development of Critical Care Knowledge Synthesis products • Not KT Research • Measurement of uptake/outcomes
  59. 59. 64 Network Activities • Measurement of current practice • Knowledge Synthesis: Development of clinical practice guidelines, evidence syntheses and scoping reviews. • Testing of Knowledge Products: Reviewed and tested before implementation, to ensure acceptability, ability to achieve intended purpose and ascertain possible barriers • Knowledge Implementation: Local teams will use strategies/tools tailored to knowledge product. – Education, protocols, checklists, order sets, organizational changes and reminder systems – PDSA cycles to track implementation activities
  60. 60. 65  Even when motivated to change our behavior, we cannot manage what we do not measure.  Measurement can identify gaps in best practice.  Measurement can illuminate the results of our efforts at implementing best practice.  Measurement can inform future research direction. Measurement- Why?
  61. 61. Model for Participation • Main benefits of participation – Access to KT activities/initiatives – Access to KS products – Access to educational events/webinars – Access to a repository of knowledge products, protocols etc. – Opportunity to participate in incubator units – Ability to influence network activities – Benchmarked reports of performance with national peers – A vehicle to drive critical care quality improvement • ICUs provide periodic data in return 66
  62. 62. Current Status • Baseline Data Collection – Started and ongoing. Site recruitment ongoing. • Development of barriers/enablers Questionnaires – Completed • Repository of KT tools/Products – Being populated • KT activities – Slated for 2014 67
  63. 63. 68 Questions/Comments?
  64. 64. Canadian ICU Collaborative Faculty Paule Bernier, P.Dt., Msc, Présidente, Ordre professionnel des diététistes du Québec; Sir MB David Jewish General Hospital (McGill University), Montreal Paul Boiteau MD, Department Head, Critical Care Medicine, Alberta Health Services; Professor of Medicine, University of Calgary Mike Cass, BSc, RN, MScN, Advanced Practice Nurse, Trillium Health Centre Leanne Couves, Improvement Advisor, Improvement Associates Ltd. Maryanne D’Arpino, Patient Safety Improvement Lead, CPSI Bruce Harries, Collaborative Director, Improvement Associates Ltd. Denny Laporta MD, Intensivist, Department of Adult Critical Care, Jewish General Hospital; Faculty of Medicine, McGill University Claudio Martin MD,Intensivist, London Health Sciences Centre, Critical Care Trauma Centre; Professor of Medicine and Physiology, University of Western Ontario; Chair/Chief of Critical Care Western Cathy Mawdsley, RN, MScN, CNCC; Clinical Nurse Specialist – Critical Care, London Health Sciences Centre; John Muscedere MD, Assistant Professor of Medicine, Queens University; Intensivist, Kingston General Hospital Yoanna Skrobik MD, Intensivist, Hôpital Maisonneuve Rosemont, Montréal; Expert Panel for the new Pain, Sedation and Delirium Guidelines, Society of Critical Care Medline (SCCM) 6908/05/2014
  65. 65. Reminders Rappels  Call is recorded  Slides and links to recordings will be available on Safer Healthcare Now! Communities of Practice  Additional resources are available on the SHN Website and Communities of Practice  L'appel est enregistré  Les diapositives et liens vers les enregistrements seront disponibles sur Des soins de santé plus sécuritaires maintenant! Communautés de pratique  Des ressources supplémentaires sont disponibles sur le site Web SSPSM et Communautés de Pratique 7008/05/2014
  66. 66. THANK YOU MERCI
  67. 67. This National Call is hosted by: Supported by: 72 08/05/2014

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