What is Sepsis? New and Old Definitions, How Do They Match Reality?

Transkript

1 What is Sepsis? New and Old Definitions, How Do They Match Reality? Magnus Brink M.D. Ph.D. Departement of Infectious Diseases Sahlgrenska University Hospital Gothenburg, Sweden

2 Vad har sepsis och fotboll gemensamt?

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4 σ ηψιζ Hippokrates ( f.kr.) rot, foul smell

5 A local lesion, heated by humor afflux, makes the whole body become feverish. One can die because of this, especially on odd numbered days Hippocrates

6 Germ theory Louis Pasteur ( ) Robert Koch ( )

7 penicillin 1928 Alexander Flemming ( )

8 39 The time has come to close the book on infectious diseases. We have basically wiped out infection in the United States. the Surgeon General of the United States of America, William Stewart, 1967 ANTI- BIOTIC multiorgan failure

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12 39 HOST THEORY multiorgan failure

13 Exterminate the Beast

14 Dr. Roger C. Bone, Specialist in Pulmonary Medicine Published some 1,000 scientific articles and wrote or edited 56 books.

15 bacteremia sepsis International Classification of Diseases positive bloodculture sepsis

16 Sepsis SEPTIC SHOCK SEVERE SEPSIS SEPSIS Severe sepsis with hypotension despite adequate fluid resuscitation Sepsis with organ dysfunction, hypoperfusion (lactacidosis, oliguria, altered mental status), or hypotension (SBP < 90 mmhg or SBP >40 mmhg below baseline) Infection + SIRS SIRS Systemic Inflammatory Response Syndrome 2 of BT > 38 or < 36 WBC > 12 or < 4 HR > 90 RR > 20 or PaCO 2 < 4 kpa

17 Sepsis SEPTIC SHOCK Severe sepsis with hypotension (SBT < 90 mmhg or MAP < 60 mmhg or > 40 mmhg below baseline despite adequate fluid resuscitation) SEVERE SEPSIS SEPSIS SIRS Systemic Inflammatory Response Syndrome Sepsis with organ dysfunction PIRO Because of the limitations of SIRS discussed above, we included a list of possible signs (predisposition, of systemic inflammation in response to infection (Table 1). infection, response, organ dysfunction) 2 of BT > 38 or < 36 WBC > 12 or < 4 HR > 90 RR > 20 or PaCO 2 < 4 kpa

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19 Hypotension= SBT<90 MAP<70 Hypoperfusion= P-laktat > 3 mmol el. BE <-5 mmol/l Organdysfunktion= oliguri <0,5 ml/kg/tim el. krea >45 mmol/l PaO 2 /FiO 2 <33 (27) SaO 2 86% (78%) TPK <100, INR >1,5 Bil >70 RLS SEPSIS misstänkt el. verifierad infektion SIRS= Systemic Inflammatory Response Syndrome >2 av: Temp > 38 el. <36 LPK >12 el. <4 HF >90/min SEPTISK CHOCK SVÅR SEPSIS SEPSIS + endera hypotension/ hypoperfusion/organdysfunktion + SIRS Septisk hypotension som inte svarar på adekvat mängd vätska AF >20/min el. PaCO 2 <4kPa tillsammans med hypoperfusion o/el. organdysfunktion

20 Of all patients with SIRS in ED only 38 % had infection Liao 2014 > 2 av: Temp > 38 el. <36 LPK >12 el. <4 HF >90/min AF >20/min el. PaCO 2 <4kPa 12 % of patients in ICU with infection and organ failure did not have SIRS Kaukonen 2015

21 GÅR DET ATT FÅ ORDNING PÅ ELÄNDET?

22 SEPSIS-3

23 Sepsis 3: tre nivåer DEFINITIONER ANGER VAD VI UTIFRÅN VÅR NUVARANDE KUNSKAPSHORISONT ANSER ATT SEPSIS ÄR SVAR PÅ FRÅGAN: VAD ÄR SEPSIS? DIAGNOSTISKA KRITERIER ANGER KRITERIER FÖR ATT FASTSTÄLLA SEPSISDIAGNOS HOS ENSKILDA PATIENTER SVAR PÅ FRÅGAN: VEM HAR (HAFT) SEPSIS? SCREENING VERKTYG FÖR TIDIG KLINISK IDENTIFIERING AV PATIENTER SOM KAN HA SEPSIS SVAR PÅ FRÅGAN: VEM KAN HA SEPSIS?

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25 Sepsis SEPTIC SHOCK SEVERE SEPSIS SEPSIS SIRS

26 definition SEPSIS life-threatening organ dysfunction caused by a dysregulated host response to infection. INFEKTION DYSREGULATED HOST RESPONSE ORGAN DYSFUNCTION LIFE- THREATENING

27 Sepsis is life threatening organ dysfunction caused by a dysregulated host response to infection. Ok, Plato I get your point, but is this guy septic? This is Sepsis!

28 DIAGNOSTIC CRITERIA for SEPSIS INFECTION DYSREGULATED HOST RESPONSE ORGAN DYSFUNCTION LIFE- THREATENING

29 DIAGNOSTIC CRITERIA for SEPSIS INFECTION DYSREGULATED HOST RESPONSE ORGAN DYSFUNCTION LIFE- THREATENING

30 0-24

31 Diagnostic criteriera for SEPSIS infection + an acuet increase of 2 SOFA-points

32 definition SEPTIC SHOCK a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality

33 Diagnostic criteriera for SEPTIC SHOCK Persisting hypotension requiring vasopressors to maintain MAP 65 mmhg and having a serum lactate level >2 mmol/l (18mg/dL) despite adequate volume resuscitation

34 Diagnostic criteria for SEPSIS 1 milion patients with infection Singer 2016

35 Diagnostic criteria for SEPTIC SHOCK mortality rates 42,3% 30,1% Singer 2016

36 SEPSIS-3 mortality risk alla with INFECTION 5% SEPSIS 10% SEPTIC SHOCK 40%

37 quick SOFA RR > 22 SBP < 100 GSC < 15 confirmed/suspected infection + qsofa > 2 WARNING! It can be sepsis!

38 Nya koder R65.2 Sepsis R65.21 Septic chock

39 How Do They Match Reality? SEPSIS-1 SEPSIS-2 SEPSIS-3

40 Sepsis 2 vs. 3 in the ICU Shankar-Hari, BJA, 2017

41 Sepsis 2 vs. 3 in the ICU Shock Sepsis-2 Shock Sepsis-3 Shankar-Hari, BJA, 2017

42 What shall we expect in the ICU when changing from Sepsis-2 to Sepsis-3 1. Same number of patients the ICU with sepsis as previously with severe sepsis, unchanged case fatality rate 2. Fewer patients in the ICU with septic chock criteria, but higher case fatality rate

43 SEPSIS-2 SEPSIS-3 SEPSIS SEPTIC SHOCK Sepsis: same incidence, same CFR Septic shock: lower incidence, higher CFR

44 BUT, HOW ARE WE CODING? SEPSIS OR SEPTIC SHOCK SEPTIC SEPSIS SHOCK SEPTIC SHOCK SEPTIC SEPSIS SHOCK: Lower incidence, higher CFR SEPSIS: Higher incidence, higher CFR

45 Sepsis på Svenska IVA Svenska intensivvårdsregistret

46 ICU hospital wards

47 Sepsis in one Swedish Centre Ljungström 2017

48 Men hur skall vi ha det? SILF Magnus Brink Jonas Cronqvist SWESEM Lisa Kurland Mantas Okas SFAI Anneli Fagerberg Miklos Lipcsey SIR Johan Petersson Pär Lindgren

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50 SEPSIS-3 i Sverige Definition: Livshotande organdysfunktion som orsakas av ett stört systemiskt svar på infektion Diagnostiska kriterier: infektionsutlöst akut ökning 2 SOFA-poäng Screening utanför IVA: infektion med 2 qsofa SEPSIS SEPTISK CHOCK Definition: En undergrupp av sepsis där bakomliggande cirkulatoriska och cellulära / metabola störningar är tillräckligt uttalade för att avsevärt öka dödligheten Diagnostiska kriterier: Kvarstående hypotension som kräver vasopressor för att upprätthålla MAP 65 mmhg tillsammans med laktat >2 mmol/l trots adekvat vätskerescusitering ICD-10: R65.2 ICD-10: R65.21

51 National Early Warning Score 2 (NEWS-2)

52 Koder De föreslagna koderna (R65.2, R65.21) kan bara användas I USA Lösning: Återanvändning av de gamla sepsiskoderna: R65.1 Sepsis R57.2 Septisk chock

53 Inga fastställda tidsgränser Maximalt tidsintervall för SOFA-poäng? Vårt beslut: max 36 timmar

54 The main SOFA-problem outside ICU Grading of respiratory dysfunction PaO 2 /FiO 2 PaO 2 : partial pressure of O 2 i arterial blood FiO 2 : O 2 -fraction i inspired gas (0,21-1,0)

55 Simplification Aproximation Breathing room air (FiO 2 =0,21) SpO % 1 SOFA-point SpO 2 < 92% 2 SOFA-points

56 Sepsis Criteria What Reality Shall They Match? Clinical care Research basic clinical Epidemiology and surveillance Quality improvement and audit an exercise in pragmatism

57 How has Sepsis-3 been received?

58 Parts of SEPSIS-3 that were not so good Process Some key specialities (e.g. Emergency Medicine) were not involved Underrepresentation from resource poor settings Content Suggested codes (R 65.2, R 65.21) not universally accept by WHO No timeframe for SOFA-scoring SOFA is not an optimal tool for grading of organ failure outside ICU The calibration of SOFA ( 2 for sepsis) can be questioned

59 EXTRA Sepsis-3 Nu även i Sverige Va ska det vara bra för? Hmm ganska bra tror jag