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Surviving Sepsis CampaignSummary and Concepts

นพ.รฐภม ชามพนท

แผนกอายรกรรม

หนวยโรคระบบหายใจและเวชบาบดวกฤต

รพ.พทธชนราช พษณโลก

www.sepsiseasy.com

Surviving Sepsis Guidelines Updated 2012

Crit Care Med. 2013;41:580-637

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Oh! Look so good

ความจรงของธรรมชาตเปนอยางไร

• การมความร (Knowledge)• การมความเขาใจ (Comprehension)

มนษยจะเอาอยางไร

• การนาไปประยกตใช (Application)• การวเคราะห (Analysis)• การสงเคราะห (Synthesis)• การประเมนได (Evaluation)

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3 phases

• Phase IIntroduction of the Campaign

Following the announcement of the target in 2002, awareness of the incidence and prevalence of the condition became heightened • Phase II

Publication of the GuidelinesThe Surviving Sepsis Campaign Guidelines have become the gold standard for sepsis care asthey are incorporated into hospital protocols and regulatory mandates internationally

Development of Sepsis Survival Campaign (SSC)

In 2002the European Society of Intensive Care Medicine (ESICM), the International Sepsis Forum (ISF), and the Society of Critical Care Medicine (SCCM) Developed the Surviving Sepsis Campaign (SSC or ‘‘the Campaign’’). (Evidence-based guidelines)

In 2004 The initial guidelines were published (endorsed by 11 professional societies)

In 2008 an updated version was published (involving 18 organizations comprising professional societies and organized networks of hospitals).

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Surviving Sepsis Campaign guidelines for

management of severe sepsis and septic shock2004

R. Phillip Dellinger, MD; Jean M. Carlet, MD; Henry Masur, MD; Herwig Gerlach, MD, PhD;Thierry Calandra, MD; Jonathan Cohen, MD; Juan Gea-Banacloche, MD, PhD; Didier Keh, MD; John C. Marshall, MD; Margaret M. Parker, MD; Graham

Ramsay, MD; Janice L. Zimmerman, MD;Jean-Louis Vincent, MD, PhD; Mitchell M. Levy, MD;

for the Surviving Sepsis Campaign ManagementGuidelines Committee

Crit Care Med 2004, 32:858-87316 หนา

44 หนา

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• Phase IIIGuideline Implementation, Data Collection, and Behavior ChangeDrawing on the expertise in quality improvement gained through partnering with the Institute for Healthcare Improvement, we constructed the Surviving Sepsis Campaign Care Bundles from key guideline recommendations. Subsequent development and distribution of a data collection tool along with a website, online discussion forum, implementation manual, newsletter, and a series of educational meetings enabled local and regional networks of hospitals worldwide to document and improve performance.

What is that?bundle

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6-hr resuscitation bundle

SSC 2008

24-hr management bundle

SSC 2008

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Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and

mortality in septic shock patients: Results of a three-year follow-up

quasi-experimental study

Crit Care Med 2010; 38:1036–1043

Compliance (yes/no) for each sepsis bundle

24-hr resuscitation bundleCompleted 4 tasks = 5/480 patients

( 0 in the control VS 5 in the intervention )

Completed 1-2 tasks were common

6-hr resuscitation bundleCompleted 7 tasks = 44/480 patients

( 1 in the control VS 43 in the intervention )

Completed 4-6 tasks were common

9.2%

1.04 % 1.04 %

Crit Care Med 2010; 38:1036–1043

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SSC 2012

Surviving Sepsis Guidelines Updated 2012

Crit Care Med. 2013;41:580-637

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58 pagesCrit Care Med. 2013;41:580-637

Crit Care Med. 2013;41:583

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Crit Care Med. 2013;41:583

METHODOLOGY• Definitions• History of the Guidelines• Selection and Organization of Committee

Members• Search Techniques• Grading of Recommendations• Conflict of Interest Policy

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Crit Care Med. 2013;41:580-637

MANAGEMENT OF SEVERE SEPSIS

Initial Resuscitation and Infection IssuesA. Initial ResuscitationB. Screening for Sepsis and Performance ImprovementC. DiagnosisD. Antimicrobial TherapyE. Source ControlF. Infection Prevention

Crit Care Med. 2013;41:580-637

MANAGEMENT OF SEVERE SEPSIS

Hemodynamic Support and Adjunctive TherapyG. Fluid Therapy of Severe SepsisH. VasopressorsI. Inotropic TherapyJ. Corticosteroids

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Crit Care Med. 2013;41:580-637

MANAGEMENT OF SEVERE SEPSIS

SUPPORTIVE THERAPY OF SEVERE SEPSIS (1)K. blood Product AdministrationL. ImmunoglobulinsM. SeleniumN. History of Recommendations Regarding Use of

Recombinant Activated Protein C (rhAPC)O. Mechanical Ventilation of Sepsis-Induced Acute

Respiratory Distress Syndrome (ARDS)

Crit Care Med. 2013;41:580-637

MANAGEMENT OF SEVERE SEPSIS

SUPPORTIVE THERAPY OF SEVERE SEPSIS (2)P. Sedation, Analgesia, and Neuromuscular

blockade in SepsisQ. Glucose ControlR. Renal Replacement TherapyS. bicarbonate Therapy

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Crit Care Med. 2013;41:580-637

MANAGEMENT OF SEVERE SEPSIS

SUPPORTIVE THERAPY OF SEVERE SEPSIS (3)T. Deep Vein Thrombosis ProphylaxisU. Stress Ulcer ProphylaxisV. NutritionW. Setting Goals of Care

Crit Care Med. 2013;41:580-637

PEDIATRICCONSIDERATIONS IN

SEVERE SEPSIS

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Crit Care Med. 2013;41:580-637

Special Considerations in Pediatrics

A. Initial ResuscitationB. Antibiotics and Source ControlC. Fluid ResuscitationD. Inotropes/Vasopressors/VasodilatorsE. Extracorporeal Membrane Oxygenation (ECMO)F. CorticosteroidsG. Protein C and Activated Protein Concentrate

Crit Care Med. 2013;41:580-637

Special Considerations in Pediatrics

H. blood Products and Plasma TherapiesI. Mechanical VentilationJ. Sedation/Analgesia/Drug ToxicitiesK. Glycemic ControlL. Diuretics and Renal Replacement TherapyM. Deep Vein Thrombosis (DVT) ProphylaxisN. Stress Ulcer(SU) ProphylaxisO. Nutrition

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METHODOLOGY• Definitions• History of the Guidelines• Selection and Organization of Committee

Members• Search Techniques• Grading of Recommendations• Conflict of Interest Policy

Crit Care Med. 2013;41:580-637

Guide to Recommendations’ Strengths and Supporting Evidence

1 = strong recommendation2 = weak recommendation or suggestion

A (high) RCTs B (moderate) Downgraded RCTs or upgraded

observational studies C (low) Well-done observational studies with control

RCTs D (very low) Downgraded controlled studies or expert

opinion based on other evidence

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BMJ 2004; 329(7480): 1473–1474

Easy ways to resist change in medicine

UG = ungraded

In the opinion of the committee……..These recommendations were not conductive for the GRADE process

Evidence Base Medicine

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• Imaging studies performed promptly to confirm a potential source of infection (UG)

• Fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG)

• Hospital–based performance improvement efforts in severe sepsis (UG)

• Antimicrobial agents should not be used in patients with severe inflammatory states determined to be of noninfectious cause (UG)

UG SSC 2012

Crit Care Med. 2013;41:580-637

• If intravascular access devices are a possible source of severe sepsis or septic shock, they should be removed promptly after other vascular access has been established (UG)

• When source control in a severely septic patient is required, the effective intervention associated with the least physiologic insult should be used (eg, percutaneous rather than surgical drainage of an abscess) (UG)

• …………………………………

UG SSC 2012

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Evidence Base Medicine

= UngradedUG

หลกกาลามสตร

เกสปตตสตร

หลกกาลามสตร

(เกสปตตสตร)

“ ................. เมอใด ทานทงหลายพงรดวยตนเองวา

ธรรมเหลานเปนกศลธรรมเหลานไมมโทษ ธรรม

เหลานทานผรสรรเสรญ ธรรมเหลานใครสมาทาน

ใหบรบรณแลว เปนไปเพอประโยชนเกอกล เพอ

ความสข เมอนนทานทงหลายควรเขาถงธรรม

เหลานนอย .........”

หลกกาลามสตรหลกกาลามสตร

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Evidence Base Medicine Grade ?

Ungraded

But we can create evidence !!

SUMMARY AND FUTURE DIRECTIONS

Crit Care Med. 2013;41:619

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“This initiative can work only if clinicians implement these tools in their institutions, begin to measure their results"

Mitchell Levy, MD, FCCM, A member of the executive committee of Surviving Sepsis Campaign and SCCM Past President

Put the Right patient to the Right place, Right time

and Right therapy

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ดวยความขอบคณโรงพยาบาลชมชนทกแหงในจงหวดพษณโลก

แผนกอบตเหตและฉกเฉน

และแผนกอายรกรรมโรงพยาบาลพทธชนราช

ทรวมกนดแลผปวย Sepsis ใหมประสทธภาพมากยงขน

www.sepsiseasy.com