Sepsis Update 2017

A Year in Review Revised SSC Guidelines A Beacon of Light?

April 10, 2017

James D. Leo, MD, FACP, FCCP

Medical Director of Best Practice and Clinical Outcomes

Chair, Sepsis Best Practice Team MemorialCare Health System

Sepsis: What Happened in 2016?

JAMA, Feb. 23, 2016: Sepsis-3, New criteria for defining sepsis

Sepsis is redefined as : “life-threatening organ dysfunction caused by a dysregulated host response to infection.”

Sepsis: What Happened in 2016? Sepsis-3

Organ Dysfunction: Rise in SOFA of ≥ 2 points

Image result for trash can Sepsis: What Happened in 2016? Sepsis-3

Severe Sepsis: No longer used
Sepsis:
- Suspected or documented infection and
- Acute increase of ≥2 SOFA points (a proxy for organ dysfunction)
Septic Shock:
- Sepsis and
- Vasopressor therapy needed to elevate MAP ≥65 mm Hg and
- Lactate >2 mmol/L (18 mg/dL) despite adequate fluid resuscitation

Sepsis: What Happened in 2016? Sepsis-3

qSOFA Score: A means of rapidly identifying ED and hospital ward (non- ICU) patients with suspected infection at increased risk

At least 2 of 3 criteria:
- RR ≥ 22/min
- Altered mentation
- SBP ≤ 100 mmHg

Sepsis: What Happened in 2016? Sepsis-3

The U.S. response to the new definition:

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Sepsis: What Happened in 2016? Sepsis-3

U.S. professional societies didn’t adopt Sepsis-3 (ACEP, ACCP)

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Chest May 2016

CMS had already released SEP-1 Core Measure criteria based on Sepsis-2 definitions

How Good is SOFA?

JAMA 1/17/17

Conclusion: in the ICU, SOFA is better than SIRS or qSOFA

JAMA | Original Investigation | CARING F-OR THE CRITICALLY ILL PATIENT

Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected Infection Presenting to the Emergency Department

Yonathan Freund, MD. PhD. Najla LemaÖiatti, MD. Evguenia Krastinova, MD, PhD: Marie Van Laer, MD. Yann-EnckClaessens, MD, PhD, Aurélie Avondo, MD; Céline Occelli, MD; Anne-Laure Ferai-Pierssens, MD;

Jennifer Tmchot. MD: Mar Drtega, MD. Bruno Carneiro, MD. Julie Pernet. MD: Rerre-Géraud Claret. MD. PhD;

Fabriœ Dami, MD. Ben Bloom, MD. Bmro Riou. MD, PhD: Sébastien Beaune. MD. PhD. farthe French Sooery of Ernergency Medicine Collaborators Group

Table Z. Diagnostic Performances forthe Pred’ætiori of In-Hospital Death

JAMA 1/17/17

For Prediction of Oeath		qS0FA	SDFA	SIRS
Sensitivi\y, % (95a CI)		70 (59-8d)	73 (61•82)	92 (85-98)	47(36 59}
Specific ivy, % (95% CI)		79 (76-82)	70 (67 -72)	27 (24- J 1)	82(80-B5)
Prcdictive value,	(95% CI)
Posit ise		24 (1 830)	18 (14-22)	11 (8- IJ)	20([4-27)
h egat il e		97 (95-98)	97 /9s-98)	98 (95-99)	94(92-96)
L ike ihood ratio (95s CI)
Posit ise		J.40 (2.80-4.17)	2.40 (2.00-2.90)	1.2 9 (1.17 – L. 3 7)	2.70 (2.00- 2.52)
hegat ise		0.J7 (0.3 6-g.52)	o.39 /o.›7-o.s6j	d.25 (0.1 1 -0.58)	0.64 (g.51-0.79)
AüROC. (9 5% CI)		0.80 (0.74-0.85)	0.7 7 (0.71-0.82)	g.65 (0.59-0.70)	o.6s /o.s9-o.7oj

How Good is qSOFA?

Retrospective review of ED and ward patients with suspected infection
Compared SIRS, qSOFA, MEWS, and NEWS
Primary endpoint: in-hospital mortality, and combined endpoint of mortality or ICU admission

Select cutoNs to predict mortality or ICU transfer

	en ï	i	Specificity
SIR5 z 2 q5OFA 2 2	9:t’¥•		67%
NEWS L 7	7796		53&
NSWS z 8 NEWS 2 9	67& 5A96		66% 78B

How Good is qSOFA?

Conclusions:

qSOFA has a poor sensitivity
qSOFA is a late indicator of deterioration
qSOFA is inferior to the NEWS score (despite the NEWS score being based on data which is equally easy to obtain at the bedside)

Sepsis: What Happened in 2016? VANISH Trial

Factorial 2 x 2 Design, DBRCT

Vasopressin + Placebo

+/- Norepinephrine PRN

Norepinephrine + Placebo

+/- Vasopressin PRN

Vasopressin + Hydrocortisone

+/- Norepinephrine PRN

Norepinephrine + Hydrocortisone

+/- Vasopressin PRN

Outcome: No difference in renal failure-free days.

No difference in mortality

Statins in Sepsis

Follow-up of patients from Statins for Acutely Injured Lungs from Sepsis (SAILS) Trial
Compared rosuvastatin vs. placebo in patients with sepsis-induced ARDS
Evaluated SF-36 physical function and mental health domains at 6 months
Findings:
- No difference in 6-month survival
- No difference in physical function
- No difference in mental health
- No difference in 6-minute walk test
- “…survivors [demonstrated] substantial impairments in physical function and mental health.”

Statins in Sepsis

Another subgroup study from the SAILS Trial
Evaluated impact of rosuvastatin on delirium
Findings:
- Most patients had delirium

– no between-group difference

- About 1/3 patients had cognitive impairment at 6 months

Thiamine for Sepsis

Thiamine 200 mg IV q12h vs. placebo x 7 days
Endpoint: Lactate levels, time to shock reversal, SOI, mortality
Findings:
- No difference in overall groups
- In patients with baseline thiamine deficiency (35% of total):
  - Lower lactate
  - Decreased mortality

EGDT and AKI

Am J Respir Crit Care Med 2/1/16

Ancillary study to PROCESS Trial
Evaluated impact of protocolized EGDT vs. standard care
Finding: No difference in incidence/severity of AKI

Out with the Old, In with the New