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SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical School of Rowan University Medical Director Adult Health Institute Senior Critical Care Attending Cooper University Hospital Camden NJ USA

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Page 1: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

SURVIVING SEPSIS IN THE

ERA OF NEW DEFINITIONS

R. Phillip Dellinger MD, MSc, MCCMProfessor and Chair of MedicineCooper Medical School of Rowan UniversityMedical Director Adult Health InstituteSenior Critical Care AttendingCooper University HospitalCamden NJ USA

Page 2: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

POTENTIAL CONFLICTS OF INTEREST

• No potential financial COI

• Potential intellectual COI• Surviving Sepsis Campaign Guidelines Committee

• Guidelines lead for 2004, 2008 and 2012 SSC

guidelines

• Executive Committee SSC 2002-2014

Page 3: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

New Sepsis

Definitions

Evolution of Sepsis

Performance

Improvement

New Definitions and

Sepsis Performance

Improvement

Page 4: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

Evolution of Sepsis

Performance

Improvement

Page 5: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

•Phase 1 • Barcelona Declaration

2002

•Phase 2 • Guidelines

•Phase 3 • Mortality 25%

Page 6: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

2004 GUIDELINES

Page 7: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

GUIDELINES TO BUNDLES - 2004

6 hour

24 hour

Page 8: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

2008 GUIDELINES

Page 9: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical
Page 10: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical
Page 11: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

SSC Mortality

Crit Care Med. 2015 Jan;43(1):3-12.

Page 12: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

February 2013

https://www.google.com/url?url=https://unbound.co.uk/books?states%3DPublished&rct=j&frm=1&q=&esrc=s&sa=U&ved=0CB4QwW4wBGoVChMIopvWxt2XxwIVDBY-Ch3cywVl&usg=AFQjCNE0p78MJTUlvIOQeF1SHHpFXNUN0A
Page 13: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

2012 NQF: 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

Page 14: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

2012 NQF: Sepsis 0500

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 arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36mg/dl):

- Measure central venous pressure (CVP) - Measure central venous oxygen saturation

(ScvO2)

7. Remeasure lactate if elevated.

Page 15: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

N Engl J Med. 2014 May 1;370(18):1683-93.

N Engl J Med. 2014 Oct 16;371(16):1496-506.

1600 Patients

Over 1500 Patients

Page 16: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

SEPSIS BUNDLE PROJECT (SEP)

NATIONAL HOSPITAL INPATIENT QUALITY

MEASURES

SEP-1 EARLY MANAGEMENT BUNDLE,

SEVERE SEPSIS/SEPTIC SHOCK

Discharges 10-01-2015 (4Q15)

through 06-30-16 (2Q16)

Page 17: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

SEP-1 Two Clocks

3

hour

Severe Sepsis Septic Shock

Page 18: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

SEPTIC SHOCK REASSESSMENT FOR

INTRAVASCULAR VOLUME STATUS AND

TISSUE PERFUSION

Physical Exam (ALL)

• Vital Signs (T, HR, RR, BP)

• Cardiopulmonary exam

• Capillary refill evaluation

• Peripheral Pulse evaluation

• Skin evaluation

Hemodynamics (2 of 4)

• CVP

• SVO2

• Bedside cardiovascular ultrasound

• Passive leg raise / fluid challenge

Remaining hypotensive after fluid bolus or initial lactate ≥4

After fluid bolus

Page 19: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

Sepsis Definitions

Page 20: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

“Sepsis Syndrome”

Page 21: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical
Page 22: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical
Page 23: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

SEPSIS DEFINITIONS 1992

Systemic Inflammatory Response Syndrome (SIRS)

Septic ShockSevere sepsis +

hypotension despite adequate fluid resuscitation

Severe SepsisSepsis + organ failure

Sepsis

SIRS + infection

CHEST 1992

Page 24: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

HISTORICAL PERSPECTIVE

CHEST 1992

SIRS Criteria ( > 2)• Temperature > 38 C < 36 C• Heart rate > 90 bpm• Respiratory rate > 20 /min or a

PaCO2 < 32 mmHg• White blood cell count > 12,000 / cu

mm or < 4,000 / cu mm, or > 10 bands

Page 25: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical
Page 26: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

Slide Title

Crit Care Med 2003

Page 27: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

Slide Title

JAMA 2016

Page 28: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

INFECTION

SEPSIS

SEVERE SEPSIS

SEPSIS

INFECTION

INFECTION

SEPTICSHOCK

SEPTIC* SHOCK

* Elevated lactate

Page 29: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

Recommended de-emphasis of SIRS

Page 30: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

SIRS

Page 31: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

TOO SENSITIVE OR NOT SENSITIVE?

New Eng J Med 2015

Page 32: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

1/8th

Empty

Or7/8Full

Page 33: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

SEQUENTIAL [SEPSIS-RELATED] ORGAN FAILURE ASSESSMENT SCORE (SOFA)

Acute change in total SOFA score > 2 identifiesmortality risk of approximately 10%

Page 34: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

Quick SOFA or qSOFA

> 22/ min SBP ≤100mmHg

In patients with infection a qSOFAscore > 2 is associated with higher mortality and prolonged ICU stay.

Page 35: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

New Definitions andSepsis Performance

Improvement

Page 36: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

One commonlanguage for infectedpatients at risk formorbidity/mortality

2016 Definitions

. .Data Driven

Page 37: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

SHOULD WE BE USING THE PROPOSED NEW DEFINITIONS?

ICD-10

Page 38: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

38

Orders within the

alert

Can we really forget about SIRS and “simple” sepsis?

Page 39: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical
Page 40: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

SEPSIS BUNDLE PROJECT (SEP)NATIONAL HOSPITAL INPATIENT QUALITY MEASURES

SEP-1 EARLY MANAGEMENT BUNDLE, SEVERE SEPSIS/SEPTIC SHOCK

Discharges 10-01-2015 (4Q15) through 06-30-16 (2Q16)

Page 41: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

Infection induced organ dysfunction and/or tissue hypoperfusion

(IIODTH)

IIODTH(e-oh-duth)

Page 42: SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS · SURVIVING SEPSIS IN THE ERA OF NEW DEFINITIONS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical

ThankYou


Disclosures CODE SEPSIS: Surviving Severe Sepsis and

Surviving Sepsis Campaign Guidelines 2012

Special Article Surviving Sepsis Campaign: International … · 2018-03-21 · clinical management guidelines, “Surviving Sepsis Campaign Guidelines for Man-agement of Severe Sepsis

Special Article Surviving Sepsis Campaign: International ... · Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 ... absence

Surviving Sepsis Campaign The Pathophysiology of · PDF file1 Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis/Septic Shock An Overview The Pathophysiology of Sepsis

Surviving Sepsis Guidelines 2016

Surviving Sepsis Campaign: international guidelines for ... · PDF fileSpecial Article Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic

Surviving Sepsis Campaign

Bundles in 2013 Surviving Sepsis

Management of sepsis Surviving sepsis campaign guidelines

Surviving Sepsis

Surviving Sepsis Campaign Give 5.14.04

Surviving Sepsis Guidelines 2012

Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 For the International Surviving Sepsis Campaign

Surviving sepsis guidelines

Surviving Sepsis Campaign_2008

The Surviving Sepsis Campaign: The Sepsis Epidemic: How to Win

Surviving Sepsis Talk

surviving Sepsis 2016

A Users’ Guide to the 2016 Surviving Sepsis Guidelines · PDF filehe 2016 Surviving Sepsis Guidelines have arrived, a ... A Users’ Guide to the 2016 Surviving Sepsis ... The flow

Surviving Sepsis Guidelines Updated

The Surviving Sepsis Campaign: The Sepsis Epidemic: How to Win

Surviving Pediatric Sepsis: What’s Next?

Surviving Sepsis Campaign 2012 Methodology

Update on Surviving Sepsis 2008

Surviving Sepsis Campaign - Guideline 2012

Surviving sepsis campaign highlights 2016

Surviving Sepsis Campaign 2012 Critical Care Medicine (SOBREVIVIENDO A SEPSIS)

Surviving Sepsis Campaign3

The Surviving Sepsis Campaign Guidelines 2012: Update for ...dickyricky.com/Medicine/Papers/2014_01 AnnEM Surviving Sepsis 20… · The Surviving Sepsis Campaign Guidelines 2012:

Surviving Sepsis Campaign: International Guidelines for ...files.dia-mundial-de-la-sepsis-pemex.webnode.mx/200000073-c0970c1934... · an update to the ‘‘Surviving Sepsis Campaign

SSC Surviving Sepsis Guidelines 2008

Surviving Sepsis Campaign Guidelines

Surviving Sepsis Slides

Surviving Sepsis Campaign: International …...Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 COI Disclosures •Evans –Nothing