The Important Role of Sepsis

Bundle in Improving Patients

Outcomes in Critical Care Units
Ronggo Prakoso
Profile
 What is a Bundle?

• Specifically selected care elements

• From evidence based guidelines
• Implemented together provide improved
outcomes compared to individual
elements alone

• Why SEPSIS need a Bundle?

 How Does Severe Sepsis
Compare to Your Current Care Priorities?

Quality US Incidence Number of Mortality Rate

Projects Deaths
AMI1 895,000 171,000 19%
Stroke1 700,000 157,800 23%
Pneumonia2 1,300,000 61,800 4.8%
Severe Sepsis3 751,000 215,000 29%

Why do you think that severe sepsis has not received

the same focus as these other common disease states?

1. American Heart Association. Heart Disease and Stroke Statistics 2006 Update.

2. National Center for Health Statistics. Available at: www.cdc.gov/nchs/fastats/pneumonia.htm. Accessed February 4, 2005.

3. Angus DC, et al. Crit Care Med 2001;29(7):1303-1310.

 Rhode Island Hospital EGDT Data

Time from Entering ED Time from Entering ED

to Receiving Antibiotics to Catheter Insertion Time from Entering ED
to Transfer to MICU
Reduced by 60%
Reduced by 42% Reduced by 51%
200 350
185 500

180
ry
to
300 450

160
148
is
H
400

nd
140 250

a
350

120 11
106 200

es s 300

cc
100 95
90
o
250

80
150

P r
a
200

60

gh 100 150

ou
hr
40 100

T
50
50
20

0
0 0
1 2 3 4 5 6
1 2 3 4 5 6 Month
1 2 3 4 5 6
Month
History; What we learned from them?
Bone RC et al. Chest. 1992;101:1644-55.
 Clinical Inertia: Low Levels of
Compliance at Research Centers

“If those who generated the evidence are slow to

translate it into practice, it is unlikely that passive
forms of dissemination can improve the quality of
care. To accelerate adoption of new evidence, we
need to understand factors other than knowledge
and awareness that influence practice”.

Majumdar SR, et al. Am J Med 2002;113:140-5

No detail on how to give this 30 ml/kg fluid? How fast ?
Must give all 30 ml/kg?
Each hour of delay is associated
with a 7.6% increased death rate
Kumar A et al. Crit Care Med 2006; 34:1589–96
DIAGNOSIS SEPSIS; ORGAN DYSFUNCTION OR
PRESENCE OF INFECTION?
SKENARIO PASIEN SEPSIS:
Pada umumnya pasien mengalami sepsis tidak menunjukkan gejala infeksi yaitu tanda2 SIRS
(demam, lekositosis dan ada sumber infeksi) terlebih dahulu melainkan langsung disfungsi organ
seperti hipoksia sehingga memerlukan tambahan oksigen atau langsung hipotensi sehingga perlu
vasopressor.

Ideal but rare cases Most common cases

 Definitions for sepsis
and septic shock

• Life threatening organ disfunction caused by a dysregulated host

response to infection
• Infection : the invasion of normally sterile tissue by organisms resulting in
infectious pathology
• Organ dysfunction : increase of 2 or more points in sofa score (sepsis
related/ sequential organ failure assessment)
Sofa score

Mortality SOFA score

<10% 0-6 Mortality Score Trend (First 48 hrs)
15-20% 7-9 >50% Increasing
40-50% 10-12
27-35% Unchanged
50-60% 13-14
>80% 15 <27% Decreasing
>90% 15-24
 Quick SOFA
(qSOFA):

1. Respiration

2. Blood Pressure

3. Consciousness

A lesson learned; less is more

Simplifying sofa and sepsis 3
 The most important change in the revision of the
SSC bundles is that 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

DO NOT WAIT until patient arrive in ICU or deteriorate

 HOUR-1 SURVIVING SEPSIS CAMPAIGN
BUNDLE OF CARE
The elements included in the revised bundle are taken from the Surviving Sepsis Campaign
Guidelines, and the level of evidence in support of each element can be seen below
Eradikasi Infeksi tidak hanya sekedar
Menyuntikan AntiBiotik:
• Terkait Konsentrasi AntiBiotik di
Jaringan yang terinfeksi
• Deliveri obat aktif dari lokasi
penyuntikan ke jaringan terinfeksi
(Hemodinamik)
• Volume Distribusi Antibiotik
Terkait dengan dosis dan
konsentrasi obat di jaringan yang
terinfeksi. Terkait juga dengan
fungsi glikokaliks, plasma leakage
dan balance kumulatif cairan.
HOUR-1 BUNDLE: INITIAL RESUSCITATION FOR
SEPSIS AND SEPTIC SHOCK:
1) Measure lactate level.*
2) Obtain blood cultures before administering antibiotics.
3) Administer broad-spectrum antibiotics.
4) Begin rapid administration of 30mL/kg crystalloid for
hypotension or lactate ≥4 mmol/L.
5) Apply vasopressors if hypotensive during or after fluid
resuscitation to maintain a mean arterial pressure ≥ 65 mm
Hg.

*Remeasure lactate if initial lactate elevated (> 2 mmol/L).

1. *Act quickly upon sepsis & septic shock recognition

2. Minimize time to treatment - sepsis & septic shock are
medical emergencies
3. Monitor closely for response to interventions
4. Communicate sepsis status in hand-offs
*All elements of the Hour-1 bundle may or may not be
completed in the first hour after sepsis recognition
 Delayed source control and outcome
Observational, prospective, multicentre study, 2009-2010 Denmark
2803 patients emergency laparotomy or laparoscopy within 48 hours of admission

Over the first 24 hours after hospital admission, each hour of surgical delay beyond hospital
admission was associated with a median (IQR) decrease in 90-day survival of 2.2% (1.9–3.3%)
Vester-Andersen M et al. Scand J Gastroenterol 2016;51:121-8
How does the Evidence?

Interestingly, the mortality

benefit of bundle adherent care
was concentrated in ICU
patients; and not observed any
benefit to bundle-adherent care
for patients with sepsis in the
ED or in those who declared on
the hospital ward.

Peter K. Milano et al
Western Journal of Emergency Medicine
Volume 19, no 5: September 2018
Proportion of patients with severe sepsis and septic shock who died and who had completed bundle
measures during the study period.

doi:10.1371/journal.pone.0026790.g001
Teles et al. Journal of Intensive Care (2017) 5:45 DOI
10.1186/s40560-017-0231-2
 CONCLUSION
SEPSIS, NEEDS DOCTORS WITHOUT BORDERS
• A commonly used is that there are:
“ DOCTORS WITHOUT BORDERS”
• Similarly, there should be ICU physicians without borders, (ICU without Walls)
• There is a belief among many physicians that a patient only becomes an ICU
patient on arrival at the Unit, yet there are many critically ill patients in non ICU
settings.
•Implementation of evidence based medicine conducted by adherence in
bundle/protocols not only improving outcomes, but also extent data collection
and evaluation
DISEASE DEFINITIONS NEED TO BE BROADENED TO SUCH AN EXTENT THAT THEY
ARE NO LONGER BY LOCATION
Terima Kasih

Dedicated to all Health Workers in Pandemic