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Sepsis in the Surgical Patient- Alastair Glossop
- 1. Sepsis in the surgical patient Dr Alastair Glossop Consultant in Anaesthesia and Intensive Care Medicine Sheffield Teaching Hospitals NHS Foundation Trust
- 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. 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. 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. What can we do to improve this? Start at the beginning...
- 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
- 8. 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
- 9. 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 Xigris withdrawn due to safety concerns!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!
- 10. Despite being based on shaky evidence, bundles seem to work Early work suggested poor compliance with bundles – 50% at 6 hours Non compliance grt. 2 fold increase in hospital mortality (p = 0.01) NNT = 4
- 11. What really is important in reducing mortality from sepsis? Both Grade E recommendations
- 13. Sepsis and Septic Shock: An ID View Cellular dysfunction/tissue injury Inflammatory response Shock Threshold Toxic burden Microbial load TIME
- 14. “An Injury Paradigm of Sepsis and Septic Shock” Prof A Kumar, University of Manitoba Antimicrobial therapy Cellular dysfunction/tissue injury Inflammatory response Shock Threshold Toxic burden Microbial load TIME
- 15. “An Injury Paradigm of Sepsis and Septic Shock” Prof A Kumar, University of Manitoba earlier antimicrobial therapy Shock Threshold Cellular dysfunction/tissue injury Inflammatory response Toxic burden Microbial load TIME
- 16. So just get the antibiotics in early, yeah?
- 17. “An Injury Paradigm of Sepsis and Septic Shock” Prof A Kumar, University of Manitoba Antimicrobial therapy + Source control Cellular dysfunction/tissue injury Shock Threshold Inflammatory response Toxic burden Microbial load TIME
- 18. 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 scan hours 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
- 19. 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
- 21. The clock is ticking… • Awareness of the problem • Early antibiotics • Source control alastair.glossop@sth.nhs.uk
- 22. With special thanks to… Dr James Wigfull Prof Anand Kumar Eli Lilly