Professional Documents
Culture Documents
World Sepsis Day 2021 Webinar Slides
World Sepsis Day 2021 Webinar Slides
Dr Martina Healy
Clinical Lead
12.55– 13.05 Adult Sepsis Management HSeLanD e-learning Update & Introduction to
Updated Adult Sepsis Form
Mary Bedding, RCSI Hospitals Sepsis ADON
12.55– 13.05 Adult Sepsis Management HSeLanD e-learning Update & Introduction to
Updated Adult Sepsis Form
Mary Bedding, RCSI Hospitals Sepsis ADON
12
Sepsis management NCG No 26 (previously No. 6)
Purpose
• to implement the Surviving Sepsis Campaign Guideline (SSCG)
(2016) (updated 2018) in the management of the adult
patient in the acute hospital sector in Ireland in a format that
applies to the structures and functions of the Irish Acute
Health Care Sector.
• The wording of the recommendations have not been changed
from the SSCG publication with the exception of units of
measurement applicable to the Irish context
The NSP is very grateful to the SSC for their kind permission to
adopt the SSCG as the Irish National Clinical Guideline on
Sepsis Management
13
Clinical Judgement
• National Clinical Guidelines are designed to guide
clinical judgement but not replace it.
• In individual cases a healthcare professional may,
after careful consideration, decide not to follow
guideline recommendations if it is deemed to be in
the best interests of the patient and is in line with
best practice.
• Clinical decisions and therapeutic options should be
discussed with a senior clinician on a case-by-case
basis as necessary and documented in the clinical
notes.
14
NCG No 26 applies to:
15
Target Users
• All healthcare professionals involved in the care of
adult and maternity patients with sepsis and
suspicion of sepsis, working in the acute hospital
sector in the Republic of Ireland.
• DoH - to support the implementation and audit of
this National Clinical Guideline.
• HSE - to provide appropriate structured support and
adequate resources for the governance,
operationalisation, and audit of sepsis management.
16
Target Users
• Hospital Group Leadership Teams, Hospital
Management and Clinical Directors - to:
• support sepsis QI
• facilitate implementation and audit
• facilitate and monitor required change arising from
outlier intervention.
• Pre-Hospital Emergency Care Council - to inform
their clinical practice guidelines across ambulance
services.
• The public - as an information resource.
17
National Implementation Points
• Recognising that much of the research that informed
the SSCG occurred in the critical care setting, the
NCG provides Implementation Points after the SSCG
recommendations to aid the implementation of
these recommendations within the Irish healthcare
system.
• Implementation Points and are primarily aimed
at the pre- and post-critical care setting.
18
Guideline Development Group
19
Sepsis – Definition (Sepsis 3)
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Sepsis 2 vs Sepsis 3
• The rationale behind the shift away from the SIRS-
based definition of sepsis (Sepsis 2) is primarily
three-fold:
1. The over-sensitivity of the previous definition that
included a cohort of patients who did not have a
life threatening illness and whose clinical course
would not be impacted by escalated care (Churpek
et al., 2015), (Comstedt et al., 2009).
21
Sepsis 2 vs Sepsis 3
2. Its failure to recognise patients with a life-
threatening acute organ dysfunction due to
infection that would benefit from escalated care
but who did not present with a SIRS response
(Comstedt et al., 2009), (Kaukonen et al., 2015).
3. The lack of specificity of the SIRS response that
can be triggered by many non-infective insults
(Thoeni, 2012).
• Whilst the presence of a systemic inflammatory
response (SIRS) is helpful in diagnosing infection, it is
no longer a requirement for the diagnosis of sepsis,
(Singer et al., 2016).
22
Septic Shock
• Septic shock is a subset of sepsis with circulatory and
cellular/metabolic dysfunction associated with a higher risk of
mortality (Singer et al., 2016).
• The sepsis definition taskforce has defined this as the
requirement for vasopressors/ inotropes to achieve a mean
arterial pressure of ≥ 65mmHg AND a lactate > 2mmols/l
despite adequate fluid resuscitation (Singer et al., 2016).
• The rationale behind this definition is to identify the cohort of
patients with a mortality risk of > 40% for the purposes of
international comparison.
• Note: Patients with a vasopressor requirement and normal lactate
post resuscitation have a mortality risk of > 30% (Singer et al.,
2016).
23
Septic Shock
• For the purposes of facilitating clinical care in Ireland and
recognising that lactate measurement is not always available,
this NCG uses the persistent requirement for
vasopressors/inotropes post adequate fluid resuscitation as
its definition of septic shock, because patients who require
vasopressors or inotropes to maintain adequate perfusion
pressure post fluid resuscitation require critical care whether
their lactate is raised or not.
• This is a pragmatic approach and acknowledges that the
sepsis definition taskforce allowed for this interpretation:
• ‘In settings in which lactate measurement is not available, the use of
a working diagnosis of septic shock using hypotension and other
criteria consistent with tissue hypoperfusion (e.g. delayed capillary
refill) may be necessary’ (Singer et al., 2016).
24
Sepsis 6
Sepsis 6 is the name given to a bundle of medical
therapies designed to reduce mortality in patients
with sepsis (Take 3 and Give 3).
• Sepsis 6 was developed by The UK Sepsis Trust
(Daniels et al., 2011) as a practical tool to help
healthcare professionals deliver the SSCG 1 hour
bundle.
• Sepsis 6 + 1 is the same as Sepsis 6 but + 1 refers to
Fetal wellbeing. Resuscitating the mother will
resuscitate the baby, however, it is important to
assess fetal wellbeing and formulate a plan for
delivery if required.
25
SSCG 2018 Update
• SSCG 2018 Update: The 3-h and 6-h bundles have been
combined into a single “hour-1 bundle” with the explicit
intention of beginning resuscitation and management
immediately:
• For patients who present with clinically apparent
sepsis/septic shock on presentation, it is recommended that
the Sepsis 6 bundle be administered within 1 hour of
presentation (Levy et al., 2018).
• If infection is included in the differential diagnosis, and the
patient is in one of the at-risk groups then for these patients,
1 hour is allowed for screening and medical review and once
completed this is considered TIME ZERO. All elements of the
Sepsis 6 bundle are then to be initiated within 1 hour of TIME
ZERO.
26
Operationalising the NCG
• The NSP provides Clinical decision
support tools (CDSTs) and Sepsis
eLearning education to promote
standardised clinical practice and
support implementation of the
NCG.
• The CDSTs have been updated in
line with the updated NCG and
include:
• Adult Sepsis Form In-patient and www.hse.ie/sepsis
Emergency Department use
• Sepsis Predisposition & Recognition www.hseland.ie
– Maternity patients
• Fluid resuscitation algorithm for
adults with sepsis
27
28
HSeLand Introduction to Sepsis Management
for Adults including Maternity
29
Why the update?
30
Audience & Aim
• Audience - all staff involved in the recognition management
and escalation of treatment for sepsis in adults in the acute
hospital setting – includes nurses/midwives, doctors and
HSCP
31
Scope
Includes:
• Non-pregnant & pregnant adult patients over the age of 16
yrs
• Pregnant adults include from conception up to 42 days post
birth (including miscarriage or abortion)
32
Learning Outcomes
At the end of the programme should be able to:
• Recognise patients that require sepsis screening – high risk
groups, deterioration due to infection & those with signs of
sepsis
• Know when & how to use the Sepsis Form to aid recognition
and treatment
• Identify when to escalate for a medical review
• Manage patients with 1 hr sepsis bundle (Sepsis 6 (+1))
• Review and respond to patient’s response to treatment
• Define sepsis & septic shock and document same
• Know when escalation to critical care is required
33
Maternity Content
• Maternity specific
information highlighted
using purple text.
• Content is optional
• REMEMBER pregnant or
post birth women can be
in any acute care setting
outside of maternity
34
Design
35
Topics
36
Topic 5 Scenarios
37
Scenarios
38
Scenarios
39
Summary & Learning
• Summarises whole programme
• Directs participants to where to find sepsis resources
• ‘Extend my Learning’
40
How to complete
• Will take approx. 1 hr to complete
• Can be completed in multiple sittings
• Must visit at least 80% slides to complete
• Must complete the high risk patient scenario (maternity is
optional)
• Certificate found in ‘My Certificates’ section on HSeLanD
• Awarded 1.5 NMBI CEUs or 2 RCSI CPD
• Programme is valid for 3 years
41
Updated Sepsis Forms – Clinical Decision Tools
42
Adult Sepsis Form
43
Adult Sepsis Form – Page 1
44
Adult Sepsis Form – Page 1
45
Adult Sepsis Form – Page 1
46
Adult Sepsis Form – Page 1
47
Adult Sepsis Form – Page 2
48
Maternity Sepsis Form
49
Paediatric Sepsis Form
50
Thanks & Feedback
• Thanks to Clinical Design & Innovation for providing the
funding for the e-learning update.
51
Paediatric Sepsis
Guidelines
An introduction and
guide to implementation
Dr Martina Healy
National Sepsis Programme
Clinical Lead
52
International Paediatric Guidelines
53
SSCGC
Surviving sepsis campaign international guidelines for the management of septic shock
and sepsis-associated organ dysfunction in children
February 2020, Volume 46, Supplement 1, pp 10–67
Intensive Care Medicine
Scott L. Weiss, MD, MSCE, FCCM (Co-Vice Chair)1; Mark J. Peters, MD, PhD (Co-Vice Chair)2; Waleed Alhazzani, MD, MSc,
FRCPC (Methodology Chair)3; Michael S. D. Agus, MD, FCCM, FAAP4; Heidi R. Flori, MD, FAAP5; David P. Inwald, MB, BChir,
FRCPCH, FFICM, PhD6; Simon Nadel, MBBS, MRCP, FRCP6; Luregn J. Schlapbach, FCICM, FMH-ICU, FMH-Paeds, FMH-
Neonatology7; Robert C. Tasker, MB BS, MA, AM, MD, FRCPHC, FRCP4; Andrew C. Argent, MB BCh, MMed, MD
(Paediatrics)8; Joe Brierley, MD, MA9; Joseph Carcillo, MD10; Enitan D. Carrol, MB ChB, MD, FRCPCH, DTMH11; Christopher L.
Carroll, MD, MS, FCCM, FAAP12; Ira M. Cheifetz, MD, FCCM13; Karen Choong, MB, BCh, FRCP(C) (methodologist)3; Jeffry J.
Cies, PharmD, MPH, BCPS-AQ ID, BCPPS, FCCP, FCCM, FPPAG14; Andrea T. Cruz, MD, MPH, FAAP15; Daniele De Luca MD,
PhD16,43; Akash Deep, MB BS, MD, FRCPCH17; Saul N. Faust, MA, MB BS, FRCPCH, PhD, FHEA18; Claudio Flauzino De Oliveira,
MD, PhD19; Mark W. Hall, MD, FCCM, FAAP20; Paul Ishimine, MD, FAAP21; Etienne Javouhey, MD, PhD22; Koen F. M. Joosten,
PhD23 ; Poonam Joshi, PhD24; Oliver Karam, MD, PhD25; Martin C. J. Kneyber, MD, PhD, FCCM26; Joris Lemson, MD, PhD27;
Graeme MacLaren, MD, MSc, FCCM28; Nilesh M. Mehta, MD4; Morten Hylander Møller, MD, PhD29; Christopher J. L. Newth,
MD, ChB, FRCPC, FRACP30; Trung C. Nguyen, MD, FAAP15; Akira Nishisaki, MD, MSCE, FAAP1; Mark E. Nunnally, MD, FCCM
(methodologist)31; Margaret M. Parker, MD, MCCM, FAAP32; Raina M. Paul, MD, FAAP33; Adrienne G. Randolph, MD, MS,
FCCM, FAAP4; Suchitra Ranjit, MD, FCCM34; Lewis H. Romer, MD35; Halden F. Scott, MD, MSCS, FAAP, FACEP36; Lyvonne N.
Tume, BS, MSN, PhD, RN37; Judy T. Verger, RN, PhD, CPNP-AC, FCCM, FAAN1, 44; Eric A. Williams, MD, MS, MMM, FAAP15;
Joshua Wolf, MBBS, PhD, FRACP38; Hector R. Wong, MD39; Jerry J. Zimmerman, MD, PhD, FCCM40; Niranjan Kissoon, MB BS,
MCCM, FRCP(C), FAAP, FACPE (Co-Chair)41; Pierre Tissieres, MD, DSc (Co-Chair)16,42
54
SSCGC
55
SSCGC – the big ticket items
57
SSCGC – the big ticket items
Fluids in Paediatric sepsis
• Bolus if intensive care available, if not then don’t
unless documented hypotension
• In units with access to intensive care, 40-60ml/kg bolus
fluid (10-20ml/kg per bolus) over the first hour is
recommended. With no intensive care, and in the
absence of hypotension, then avoiding bolus and just
commencing maintenance is recommended. It is not
clear how long access to intensive care has to be to
switch from fluid liberal to restrictive.
58
SSCGC – the big ticket items
59
SSCGC – the big ticket items
60
SSCGC – the big ticket items
61
SSCGC – the big ticket items
62
SSCGC – the big ticket items
• Intensive care vasoactive and ventilation management is
given but acknowledged as weak recommendations
• There is a list of suggestions regarding vasoactive infusion
and ventilatory strategies that are very specific to intensive
care management. While a number of recommendations
are given (epinephrine rather than dopamine for septic
shock for example) these are generally based on the panels
summation of weak evidence.
• There are further suggestions on corticosteroid
management, nutrition, and blood products which will be
of interest to those in intensive care and anaesthetic
settings.
•
63
Initial Resuscitation Algorithm for
Children
64
Fluid and vasoactive-inotrope
management algorithm for Children
65
National Implementation Plan (NIP)
67
Sepsis Form
Front page is the recognition and Back page is the treatment,
screening for Sepsis reassessment and referral
68
National Implementation Plan (NIP)
69
Next Steps……..
70
Implementation of the SSCGC recommendations
71
Public awareness campaign
• Posters
• Leaflets
• Video/social media
https://vimeo.com/462650865
/610bbcef55
72
Current programme activity and achievements
74