Current epidemiology of meningococcal disease in the African meningitis belt and new WHO outbreak response guidelines after the Meningitis Vaccine Project
http://www.meningitis.org/conference2015
Emergence of a virulent new meningococcal W sequence type 11 in South America: experience, control measures and impact
http://www.meningitis.org/conference2015
Current epidemiology of meningococcal disease in the African meningitis belt and new WHO outbreak response guidelines after the Meningitis Vaccine Project
http://www.meningitis.org/conference2015
Emergence of a virulent new meningococcal W sequence type 11 in South America: experience, control measures and impact
http://www.meningitis.org/conference2015
Dr Marie-Pierre Preziosi's presentation at Meningitis Research Foundation's 2013 conference, Meningitis & Septicaemia in Children & Adults http://www.meningitis.org/conference2013
Novartis satellite breakfast session at the Meningitis Research Foundation 2013 conference, Meningitis & Septicaemia in Children & Adults presented by Emeritus Professor Richard Moxon, Dr Jamie Findlow and Dr Simon Nadel
Single-dose oral ciprofloxacin prophylaxis as a meningococcal meningitis outbreak response: results of a cluster-randomized trial
https://www.meningitis.org/mrf-conference-2017
Professor Michael Levin's presentation at Meningitis Research Foundation's 2013 conference Meningitis & Septicaemia in Children & Adults www.meningitis.org/conference2013
Prospects for GBS prevention - current candidates & removing barriers to licensure of a GBS vaccine for pregnant women globally
https://www.meningitis.org/mrf-conference-2017
Meningococcal carriage in the African meningitis belt and the impact of MenAfriVac: an overview of the MenAfriCar project
http://www.meningitis.org/conference2015
Dr Marie-Pierre Preziosi's presentation at Meningitis Research Foundation's 2013 conference, Meningitis & Septicaemia in Children & Adults http://www.meningitis.org/conference2013
Novartis satellite breakfast session at the Meningitis Research Foundation 2013 conference, Meningitis & Septicaemia in Children & Adults presented by Emeritus Professor Richard Moxon, Dr Jamie Findlow and Dr Simon Nadel
Single-dose oral ciprofloxacin prophylaxis as a meningococcal meningitis outbreak response: results of a cluster-randomized trial
https://www.meningitis.org/mrf-conference-2017
Professor Michael Levin's presentation at Meningitis Research Foundation's 2013 conference Meningitis & Septicaemia in Children & Adults www.meningitis.org/conference2013
Prospects for GBS prevention - current candidates & removing barriers to licensure of a GBS vaccine for pregnant women globally
https://www.meningitis.org/mrf-conference-2017
Meningococcal carriage in the African meningitis belt and the impact of MenAfriVac: an overview of the MenAfriCar project
http://www.meningitis.org/conference2015
Sepsis Trials - Keeping up with the literatureJesse Spurr
Presentation as part of CRICU Sepsis Workshop. Included evidenced based practice, discussion and critical appraisal of major sepsis trials relevant to our ICU practice.
This talk is a summary of 4 Objectives:
1. What is the ideal MAP in Sepsis (65 vs 85 mmHg)
2. What is the ideal Hb Transfusion Threshold (7 vs 9 g/dL)
3. SIRS Criteria for Screening of Severe Sepsis
4. Summary and Take Home Messages from the ProCESS, ARISE, & ProMISe Trials
Pathology Optimisation in Chronic Blood Disease MonitoringAndrew O'Hara
Richard Croker shows how an innovative approach to service redesign can improve patient outcomes at pace and scale through the safe and effective use of testing at NHS Northern, Eastern and Western Devon CCG.
Enhanced Recovery After Surgery (ERAS®) is the Enhanced Recovery After Surgery (ERAS®) is the implementation of patient-focused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidence-based, interdisciplinary perioperative guidelines.
Learn more about Enhanced Recovery Canada:
http://ow.ly/hR3j30jsnjR
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
Professor Richard Beale @ MRF's Meningitis & Septicaemia in Children & Adults 2015
1. Richard Beale FRCA, FFICM
King’s Health Partners
London, UK
On behalf of the SCCM/ESICM Surviving Sepsis Campaign
Surviving Sepsis 2015
2. Disclosures
• Personal:
– Financial:
• None
• SSC
– Financial:
• None
• No industry support since 2006
• Initial industry support from Eli Lilly & Co, Baxter
Lifesciences and Philips Medical Systems
• Robust COI policy in place
3. Let me remind you…
• In the 1990s – common presentation of severe
sepsis was “sudden” respiratory arrest (or peri-
arrest)
• Recognition, and presentation to ICU, was
frequently physiological decompensation, and final
collapse, with established multi-organ failure
• Mortality was high
• Severe sepsis was an ICU “disease”
4. Let me remind you…
• Attitudes to treatment were nihilistic – all trials were
negative, clinician opinion was the dominant driver
of practice, with much inconsistency
Then, from 2000 onwards, seminal studies
appeared:
• 2000 - Tidal volume control in ARDS
• 2001 - Tight glycaemic control
• 2001 - Early Goal Directed Therapy
5. Origins of the Surviving Sepsis Campaign
• It was against this context that the SSC was
established:
– A desire to address the ongoing and potentially
preventable mortality from sepsis
– The emergence of new therapeutic approaches
that finally held out hope of reducing mortality
– The realisation that processes of care were too
fragmented to deliver these new approaches
reliably
6. Campaign Structure
• And so the Campaign had an unique approach:
1.Build awareness and establish the need for
change – Professor Graham Ramsay
2.Assimilate the evidence in the most authoritative
manner possible – Professor R Phillip Dellinger
3.Design an implementation approach that would
ensure the process change necessary actually to
deliver the new evidence-based practices, and so
improve outcome - Professor Mitchell Levy
7. The sepsis landscape is changing…
• Definitions
• Incidence and outcome
• Recent large studies
• New SSC guidelines
• Health system interest
• But – also still considerable disparities in
performance
• This is therefore a crucial time to build upon what
we have achieved
8. Sepsis Definitions
• New Sepsis Task Force established by SCCM and
ESICM – working currently
• Chairmanship of Professor Cliff Deutschman and
Professor Mervyn Singer
• Definitions will be released soon, but we already
know:
– More data based, i.e tested against large
databases
– Will be simpler
– Term severe sepsis will disappear
9. Comparative Incidence
• The incidence of severe
sepsis is greater than
that of AIDS, colon &
breast cancer, and
Chronic Heart Failure
(CHF) 0
50
100
150
200
250
300
†
National Center for Health Statistics, 2001.
§
American Cancer Society, 2001.
*American Heart Association. 2000.
‡
Angus DC et al. Crit Care Med. 2001.
AIDS†
Colon Breast
Cancer§
CHF* Severe
Sepsis‡
Cases/100,000
11. The Epidemiology of Sepsis: USA 1979-
2000 Martin GS et al. NEJM 2003;
• ICD-9 sepsis codes
• Sample of 500 acute hospitals
• 750 million hospitalisations
• 10,319,418 cases of sepsis / 22 yrs
Incidence Mortality
12.
13.
14.
15.
16.
17.
18. What is the true impact of sepsis?
• What do we need to know to judge the
epidemiological landscape?
– The true incidence
• requires comprehensive data capture and
standard definitions
– Unconfounded outcomes
• Equity of treatment
• We have neither of these things…
19. Message
• There are major methodological issues with
documenting the true incidence and outcomes for
severe sepsis
• Nevertheless, there seems little doubt that the
recognition and incidence are both genuinely going up
• Outcomes also seem to be improving
• Even if the denominator is changing, and access is
improving, these are good rather than bad things
• The Campaign, and the efforts of dedicated clinicians,
have resulted in this dramatic change
22. Mortality of Sites During Campaign
Mortality over 4 year study period
• 36.7% to 27.5%
• ARR: 9.2% and RRR: 25.0%
• p=0.005
23.
24.
25.
26. • We recommend the protocolized, quantitative resuscitation of
patients with sepsis- induced tissue hypoperfusion. During the
first 6 hours of resuscitation, the goals of initial resuscitation
should include all of the following as a part of a treatment
protocol (grade 1C):
a) CVP 8–12 mm Hg
b) MAP ≥ 65 mm Hg
c) Urine output ≥ 0.5 mL/kg/hr
d) Scvo2 ≥ 70%.
28. Background of Resuscitation Bundle
• Landmark trial by Rivers in
2001
• Single-centre design RCT
• N=263
• Randomized EGDT vs. usual
care
• 16% Absolute Mortality
reduction
29. Rivers Protocol
Potential for RBC
and Inotropes
Potential for RBC
and Inotropes
Therapy
titrated to
CVP, MAP
and ScvO2
Therapy
titrated to
CVP, MAP
and ScvO2
Early insertion of
ScvO2 catheter
Early insertion of
ScvO2 catheter
30. Questions still to be answered from Rivers..
• Is the difference due to protocolized care?
• Is it necessary to use all elements of the protocol?
– Controversial aspects include:
• Early CVP line insertion
• ScvO2 monitoring, which drives RBC and inotropes
• Are the results generalizable?
– In 2015 where we have SSC +
• With current practices
• In a multi-centric design
31. Why continue with CVP and ScvO2?
• Evidence base
– Including (crucially) the success of the first
phase of the Campaign itself
• Belief that patients with severe sepsis and septic
shock should have a central line
• Limitations of all postulated alternative approaches
• Inability to generalise other technologies
– Only a CVC/blood gas analyser combination is
available (nearly) everywhere
32. In the last 12 months there have been 3
RCTs published in the NEJM repeating this
work.
• ProCESS / ARISE / PROMISE
• Each of these essentially repeats the Rivers work,
but
– In a multi-centric design
– In a group of patients with a better outcome
• None of them have been able to repeat the
findings of improved outcomes with this
protocolised methodology
33. Caveats / Limitations of ProCESS, ARISE
& PROMISE
• Usual care was usual care when shock was recognized
– It did not test:
• Early versus late recognition
• Prompt versus late treatment
• Therefore these studies do not undermine efforts to
– Promote sepsis awareness, early diagnosis and prompt
treatment.
• These studies were not a repeat of the Rivers study
– Single versus multi-centered
– Late 1990s versus 2008-13
34. Original Article
A Randomized Trial of Protocol-Based Care for
Early Septic Shock
The ProCESS Investigators
N Engl J Med
Volume 370(18):1683-1693
May 1, 2014
35. Study Overview
• In septic shock, the first few hours of care are critical for survival.
• In this study, two protocols for the care of patients with septic shock were
compared with usual care with respect to 60-day mortality and other
outcomes.
• There were no significant differences in outcome.
39. Conclusions
• In a multicenter trial conducted in the tertiary care setting, protocol-based
resuscitation of patients in whom septic shock was diagnosed in the
emergency department did not improve outcomes.
45. November 7th
2013
62 Countries from all continents
1794 Patients
Top Countries
1.USA
2.United Kingdom
3.Malaysia
4.Spain
5.India
6.Italy
7.China
8.Brazil
9.Greece
10.Belgium
The IMPRESS-SSC Study
An International Multi-Centre Prevalence Study of Sepsis
46. IMPRESS Study
• SSC point prevalence study
• November 7th
2013
• Aim was to inform current performance in real life
setting compared with study populations
50. Variable
Hospital mortality
odds ratio1
95% CI p-value
Full 3 hour bundle 0.70 0.51 – 0.96 0.026
Full 6 hour bundle 0.75 0.58 – 0.96 0.020
Relationship Between Bundle
Compliance and Outcome.
1
Adjusted for ICU admission, sepsis status (severe vs. shock), location
(ED, ward, ICU, OR, unknown), and APACHE II
GEE population-averaged logistic regression model adjusted
hospital mortality odds ratios
51. Lessons from SSC Database (s)
Participation alone is
associated with improvement.
Continued participation is
associated with further
benefits.
• For every quarter, mortality
reduced by 1%
Higher compliance was
associated with:
• Even greater mortality reductions
• Reduced use of resources
52. Summary
• Resuscitation of patients with sepsis should be initiated as soon as
hypoperfusion is recognized and should not be delayed pending ICU
admission.
• The goal of resuscitation is to restore tissue perfusion within the first 6
hours (Best Practice Statement), reasonable goals may include:
– CVP 8–12 mm Hg (if available),
– MAP ≥ 65 mm Hg,
– urine output ≥ 0.5 mL/kg/hr,
– and resolution of clinical signs of hypoperfusion (including altered
mental status, mottled skin, and oliguria).
53. Summary
• Frequent assessment of the patients’ volume status is crucial
throughout the resuscitation period.
• We suggest targeting resuscitation to normalize lactate in patients with
elevated lactate levels as a marker of tissue hypoperfusion (grade 2C).
• We do not suggest routine measurement of ScvO2 or SvO2 to guide
therapy during resuscitation of patients with sepsis and hypoperfusion
(grade 2B).
54.
55.
56.
57.
58. What are the consequences of this?
• Mandated sepsis protocols in New York State
• Sepsis bundle approach being incorporated into
the US National Quality Framework
• Increasingly, a “must-do” mentality
• Often beneficial, but always risk on unintended
consequence
• Considerable concerns about medico-legal
implications, and issues of physician autonomy
60. NQF BUNDLE: Sepsis 0500
TO BE COMPLETED WITHIN 3 HOURS OF TIME OF
PRESENTATION† :
1.Measure lactate level
2.Obtain blood cultures prior to administration of antibiotics
3.Administer broad spectrum antibiotics
4.Administer 30ml/kg crystalloid for hypotension or lactate
≥4mmol/L
† “time of presentation” is defined as the time of triage in the
Emergency Department or, if presenting from another care
venue, from the earliest chart annotation consistent with all
elements severe sepsis or septic shock ascertained through
chart review.
61. TO BE COMPLETED WITHIN 6 HOURS OF TIME OF
PRESENTATION:
5. Apply vasopressors (for hypotension that does not respond
to initial fluid resuscitation) to maintain a mean arterial
pressure (MAP) ≥65mmHg
6. In the event of persistent hypotension after initial fluid
administration (MAP < 65 mm Hg) or if initial lactate was ≥4
mmol/L, re-assess volume status and tissue perfusion and
document findings according to table 1.
7. Re-measure lactate if initial lactate elevated.
NQF BUNDLE: Sepsis 0500
62. DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE
PERFUSION WITH:EITHER• Repeat focused exam (after initial fluid
resuscitation) including vital signs, cardiopulmonary, capillary refill, pulse, and
skin findings.OR TWO OF THE FOLLOWING:• Measure CVP• Measure
ScvO2 • Bedside cardiovascular ultrasound• Dynamic assessment of fluid
responsiveness with passive leg raise or fluid challenge
NQF BUNDLE: Sepsis 0500
63.
64.
65.
66.
67. What are the next challenges?
• Allow me to use the current process in the UK as
an illustration:
• NICE
– National Institute for Health and Care
Excellence
– Responsible for clinical guidance in the NHS
– Now considering sepsis
68. NICE Sepsis Guideline
• Scope:
– All populations
– All healthcare settings
– Recognition and early assessment
– Diagnosis and prognosis
– Initial treatment
– Escalating treatment
– Identifying the source of infection
– Early monitoring
– Information for patients and carers
– Training and education
69. NICE Sepsis Guideline
• Outcomes:
– Mortality
– Progression to sepsis
– Duration of hospital stay
– Duration of ICU stay
– Number of organs supported
– Change in physical signs and symptoms
– Adverse events
– Health-related quality of life
– Psychological outcomes
– Outcomes indicating long-term disability/rehabilitation
needs
70. NICE Sepsis Guideline
• Economic analysis:
– Recommendations have to be cost-effective
– Maximum cost per QALY of £30,000
• Exclusions:
– Managing sepsis in neonates, children and adults in the
ICU
– Procalcitonin
– Treatment and care of secondary effects on other
organs
– Preventing sepsis
– Premature neonates and infants
71. What does this approach reveal?
• Breadth of problems
• Wide number of stakeholders
• Sepsis is no longer just, or even primarily, an ICU
“disease”
• Education and recognition requires meaningful
definition
• Community and pre-hospital care highly relevant
• Both emphasise need for better diagnostics with
point-of-care utility
72. Where are we with these problems?
• First, require political engagement
– Access to the levers of the health system,
including mandating elements of care
– Needs patient and public involvement
– Requires responsible professional engagement
73. Where are we with these problems?
• Second, require better definitions
• For research and for clinical use
• Recent exemplar of Belin definition for ARDS
• Joint ESICM/SCCM working group currently
producing new sepsis definition
74. Where are we with these problems?
• Third, need for education and intervention in/from
healthcare professional not previously engaged
– Many challenges here
– Most practitioners will see very few individual
patients
– But, increasing work as a result of SSC
– Many generic examples from other fields
– Developing pre-hospital care intervention,
building on experience with trauma, AMI and
stroke
78. Conclusion
• Much progress has been made
• Indeed – sepsis management is already a major
success story, in advanced health systems
• But, still much more to do
• Treatment standards are now becoming a
mainstream health system activity
• In less advanced environments, though, we have
barely started, and will need quite different
solutions
Angus et al studied the incidence, cost, and outcome of severe sepsis in the United States. In a study based on 1995 state hospital discharge records from 7 large states with population and hospital data from the US Census, Centers for Disease Control, HCFA, and the American Hospital Association, the investigators generated national sepsis data. In this study, they report that the incidence of severe sepsis is 300 cases/100,000 population. As shown on the slide, this is significantly greater than the incidence of other well recognized diseases as reported by the American Heart Association.
Similarly, Angus et al reported that the annual mortality of severe sepsis in 1995 was 215,000. According to the American Heart Association, this is virtually identical to the number of people in the US who die suddenly of coronary heart disease without being hospitalized.
American Cancer Society. 2000 Statistics. Available at: www.cancer.org on 3/19/01.
American Heart Association. 2001 Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association, 2000.
Angus DC, Linde-Zwirble WT, Lidicker J, et al. Incidence, cost, outcome of severe sepsis in the United States. Crit Care Med. 2001 (In Press).
National Center for Health Statistics. Fast Stats (AIDS/HIV). Available at: www.cdc.gov/nchs/fastats/aids-hiv.htm on 3/19/01.
Figure 2 Cumulative Mortality. Panel A shows cumulative in-hospital mortality, truncated at 60 days, and Panel B cumulative mortality up to 1 year after randomization.
Table 1 Characteristics of the Patients at Baseline.