Sepsis-en oppdatering og bakgrunn for tiltakspakken!

Presentasjon om: "Sepsis-en oppdatering og bakgrunn for tiltakspakken!"— Utskrift av presentasjonen:

1 Sepsis-en oppdatering og bakgrunn for tiltakspakken!
Pasientsikkerhetsprogrammet 8 mars 2017 Hans Flaatten KSK/Intensiv Bergen 5,2 / 1000 innleggelser, eller 1,4 / 1000 innbygger (per år)

2 Hvorfor?

3 Sepsis: et komplisert forløp
Initial håndtering Diagnostikk Start behandling: Respirasjons og sirkulasjonssvikt Kildekontroll Antibiotika Fjerne fokus Intensivbehandling Organsvikt Rehabilitering

4 Tidligere definisjoner
Sitert i 7427 andre artikler! Chest 1992 MODS & SIRS

5 SIRS kriteriene ?

6 Dårlig presisjon N Engl J Med 2015;372:1629-38
Abstract Objective: Evaluation of the usefulness of criteria for sys- temic inflammatory response syn- drome (SIRS) compared with the final diagnosis of infection in pa- tients admitted to the emergency room of two university-based hospi- tals. Design: Longitudinal cohort study. Setting: Hospital Universitario San Vicente de Paul and Hospital General de Medellín, Medellín, Colombia. Patients: Seven hundred thirty-four patients with suspected infection as main diagnosis for ad- mittance into the emergency room. Measurements and results: Sensitivi- ty, specificity, predictive values and likelihood ratios (LR) of SIRS crite- ria at admission were determined us- ing, as gold standards, the diagnosis at the time of discharge based on clinical history and evolution, and microbiological confirmation of in- fection. SIRS criteria were met by 503 patients (68.5%); the discharge diagnosis of infection was found in 657 (89.4%) and 276 (37%) had mi- crobiological confirmation. SIRS criteria exhibited a sensitivity of 69%, specificity of 35%, positive predictive value (PPV) of 90%, neg- ative predictive value (NPV) of 12% and positive LR of There were no differences between the two gold standards. Conclusions: The finding of two or more SIRS criteria was of little usefulness for diagnosis of in- fection. It is necessary to work with new criteria and probably with bio- logical markers, in order to obtain a simple, precise and operative defini- tion of the sepsis phenomenon.

7 JAMA 23 februar 2016

8 Prosess Arbeidsgruppe etablert av ESICM og SCCM (17 personer)
Etter ferdig arbeide har forslaget vært på “høring” i en rekke foreninger som har gitt støtte til definisjonene: Academy of Medical Royal Colleges (UK); American Association of Critical Care Nurses; American Thoracic Society (endorsed August 25, 2015); Australian–New Zealand Intensive Care Society (ANZICS); Asia Pacific Association of Critical Care Medicine; Brasilian Society of Critical Care; Central American and Caribbean Intensive Therapy Consortium; Chinese Society of Critical Care Medicine; Chinese Society of Critical Care Medicine–China Medical Association; Critical Care Society of South Africa; Emirates Intensive Care Society; European Respiratory Society; European Resuscitation Council; European Society of Clinical Microbiology and Infectious Diseases and its Study Group of Bloodstream Infections and Sepsis; European Society of Emergency Medicine; European Society of Intensive Care Medicine; European Society of Paediatric and Neonatal Intensive Care; German Sepsis Society; Indian Society of Critical Care Medicine; International Pan Arabian Critical Care Medicine Society; Japanese Association for Acute Medicine; Japanese Society of Intensive Care Medicine; Pan American/Pan Iberian Congress of Intensive Care; Red Intensiva (Sociedad Chilena de Medicina Crítica y Urgencias); Sociedad Peruana de Medicina Critica; Shock Society; Sociedad Argentina de Terapia Intensiva; Society of Critical Care Medicine; Surgical Infection Society; World Federation of Pediatric Intensive and Critical Care Societies; World Federation of Critical Care Nurses; World Federation of Societies of Intensive and Critical Care Medicine.

9 Hvordan skal vi forstå sepsis?
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis is a syndrome shaped by pathogen factors and host factors (eg, sex, race and other genetic determinants, age, comorbidities, environment) with characteristics that evolve over time. What differentiates sepsis from infection is an aberrant or dysregulated host response and the presence of organ dysfunction.

10 Organdysfunksjon ved sepsis
Sepsis-induced organ dysfunction may be occult; therefore, its presence should be considered in any patient presenting with infection. Conversely, unrecognized infection may be the cause of new-onset organ dysfunction. Any unexplained organ dysfunction should thus raise the possibility of underlying infection.

11 Den nye terminologien Infeksjon Sepsis Septisk sjokk Sepsis inkluderer nå varierende grader av organdysfunksjon, og alvorlig sepsis forsvinner derfor som begrep

12 Kliniske kriterier: Sepsis hos kritiske syke
Bruk av SOFA skår Organ dysfunction can be identified as an acute change in total SOFA score ≥ 2 points consequent to the infection. A SOFA score = 2 reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection

13 Kliniske kriterier: pasienter med akutte infeksjoner
qSOFA (quick SOFA) Patients with suspected infection who are likely to have a prolonged ICU stay or to die in the hospital can be promptly identified at the bedside with qSOFA, ie, alteration in mental status systolic blood pressure ≤ 100 mm Hg, or respiratory rate ≥ 22/min. A parsimonious clinical model developed with multivariable logistic regression identified that any 2 of 3 clinical variables— Glasgow Coma Scale score of 13 or less, systolic blood pressure of 100 mm Hg or less, and respiratory rate 22/min or greater—offered predictive validity (AUROC = 0.81; 95% CI, ) similar to that of the full SOFA score outside the ICU

14 Kliniske kriterier: Septisk sjokk
Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality. Patients with septic shock can be identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain MAP 65 mm Hg AND having a serum lactate level >2 mmol/L (18 mg/dL) despite adequate volume resuscitation. With these criteria, hospital mortality is in excess of 40%.

15 Pasientsikkerhetsprogrammet 2017

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17 Tiltakene

18 ABCDE Mål: MAP ≥ 65 mmHg Sikre vitale funksjoner: Respirasjon
Sirkulasjon Bevissthet Mål: MAP ≥ 65 mmHg

19 Tiltakene

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21 SOFA skår Grad Sirkulasjon* Respirasjon# Nyrefunksjon CNS Koagulasjon
Lever MAP og bruk av vasopressor PaO2/FiO2 ratio (kPa) Kreatinin/DU μmol/l & ml GCS TPK x 103/μl Bilirubin μmol/l MAP ≥ 70 >53 <110 15 > 150 <20 1 MAP < 70 39,9-53 13-14 < 150 20-32 2 DA ≤ 5; Dobutamin 26,6 – 39,8 10-12 < 100 33-101 3 DA > 5; NA/A ≤ 0,1 13,3 – 26,5 < 500 ml/24t 6-9 < 50 4 NA/A > 0,1 < 13,3 >440 < 200 ml/24t <6 < 20 >204 *alle doser gitt i µg/kg/min, DA= Dopamin, NA=Noradrenalin, A=Adrenalin # 3 eller 4 poeng bare for pasienter på respirator (NIV+IPPV)

22 Tiltakene

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25 JAMA. 2017;317(3):

26 Copyright © 2017 American Medical Association. All rights reserved.
From: Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected Infection Presenting to the Emergency Department JAMA. 2017;317(3): doi: /jama Figure Legend: Flow Diagram of Study to Validate qSOFA ScoringqSOFA indicates quick Sequential Organ Failure Assessment. Date of download: 2/2/2017 Copyright © 2017 American Medical Association. All rights reserved.

27 Copyright © 2017 American Medical Association. All rights reserved.
From: Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected Infection Presenting to the Emergency Department JAMA. 2017;317(3): doi: /jama Figure Legend: Receiver Operating Characteristic Curves for In-Hospital MortalityqSOFA indicates quick Sequential Organ Failure Assessment; SIRS, systemic inflammatory response syndrome; and SOFA, Sequential [Sepsis-related] Organ Failure Assessment. The area under the receiver operating characteristic curves for qSOFA is 0.80 (95% CI, ); SOFA, 0.77 (95% CI, ); SIRS, 0.65 (95% CI, ); and severe sepsis, 0.65 (95% CI, ). Date of download: 2/2/2017 Copyright © 2017 American Medical Association. All rights reserved.

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29 In conclusion, qSOFA scores were associated with inhospital mortality, hospital admission, ICU admission, and hospital length of stay in adult ED patients likely to be admitted both with and without suspected infection. qSOFA is an easy tool that can be used in the ED to predict outcomes. Further prospective validation of the qSOFA is required before widespread use.

30 ICD-10 koder for sepsis, endringer 2017
 Endringsdokument for norsk utgave av ICD   Direktoratet for e-helse  

31 Forslag I tillegg tilandre sepsiskoder (eks A40 og A41) og infeksjonskoder foreslår vi at det også brukes koden: R65.1 ved sepsis (ny definisjon) hvor det foreligger dokumentasjon av organsvikt, eks ved SOFA skår økning ≥ 2 poeng R57.2 ved septisk sjokk (ny definisjon) Da vil en lettere både på egen institusjon samt fra NPR enkelt kunne hente ut informasjon om omfanget av sepsis ved norske sykehus!

32 According to family spokesman Bob Gunnell, was "septic shock due to unspecified natural causes."