Ron Daniels

Surviving the first hours in sepsis: getting the basics right (an intensivist's perspective)

Severe sepsis is a major cause of morbidity and mortality, claiming between 36u200a000 and 64u200a000 lives annually in the UK, with a mortality rate of 35%. International guidelines for the management of severe sepsis were published in 2004 by the Surviving Sepsis Campaign and condensed into two Care Bundles. In 2010, the Campaign published results from its improvement programme showing that, although an absolute mortality reduction of 5.4% was seen over a 2 year period in line with increasing compliance with the Bundles, reliability was not achieved and Bundle compliance reached only 31%. This article explores current challenges in sepsis care and opportunities for further improvements. Basic care tasks [microbiological sampling and antibiotic delivery within 1 h, fluid resuscitation, and risk stratification using serum lactate (or alternative)] are likely to benefit patients most, yet are unreliably performed. Barriers include lack of awareness and robust process, the lack of supporting controlled trials, and complex diagnostic criteria leading to recognition delays. Reliable, timely delivery of more complex life-saving tasks (such as early goal-directed therapy) demands greater awareness, faster recognition and initiation of basic care, and more effective collaboration between clinicians and nurses on the front line, in critical care and in specialist support services, such as microbiology and infectious diseases. Organizations such as Survive Sepsis, the Surviving Sepsis Campaign and the Global Sepsis Alliance are working to raise awareness and promote further improvement initiatives. Future developments will focus on sepsis biomarkers and microarray techniques to rapidly screen for pathogens, risk stratification using genetic profiling, and the development of novel therapeutic agents targeting immunomodulation.

The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study

Background Severe sepsis is likely to account for around 37u2008000 deaths annually in the UK. Five years after the international Surviving Sepsis Campaign (SSC) care bundles were published, care standards in the management of patients with severe sepsis are achieved in fewer than one in seven patients. Methods This was a prospective observational cohort study across a 500-bed acute general hospital, to assess the delivery and impact of two interventions: the SSC resuscitation bundle and a new intervention designed to facilitate delivery, the sepsis six. Process measures included compliance with the bundle and the sepsis six; the outcome measure was mortality at hospital discharge. Results Data from 567 patients were suitable for analysis. Compliance with the bundle increased from baseline. 84.6% of those receiving the sepsis six (n=220) achieved the resuscitation bundle compared with only 5.8% of others. Delivery of the interventions had an association with reduced mortality: for the sepsis six (n=220), 20.0% compared with 44.1% (p<0.001); for the resuscitation bundle (n=204), 5.9% compared with 51% (p<0.001). Those receiving the sepsis six were much more likely to receive the full bundle. Those seen by the sepsis team had improved compliance with bundles and reduced mortality. Conclusions This study supports the SSC resuscitation bundle, and is suggestive of an association with reduced mortality although does not demonstrate causation. It demonstrates that simplified pathways, such as the sepsis six, and education programmes such as survive sepsis can contribute to improving the rate of delivery of these life-saving interventions.

Recognizing Sepsis as a Global Health Priority — A WHO Resolution

The World Health Organization has adopted a resolution on improving the prevention, diagnosis, and management of sepsis. Millions of lives can be saved if politicians, policymakers, health care administrators, researchers, and clinicians take coordinated actions.

Sepsis: a need for prehospital intervention?

Prehospital staff have made a significant contribution in recent years to improving care for patients with acute coronary syndrome, multiple trauma and stroke. There is, however, another group of patients that is not currently being targeted, with a similar time-critical condition. This group of patients is those with severe sepsis and septic shock and they could also benefit greatly from timely prehospital care. This article will consider how prehospital staff can improve the outcome of patients with severe sepsis, and in particular how they can aid emergency departments in identifying and initiating treatment in patients with severe sepsis.

Recognizing and managing sepsis: what needs to be done?

Sepsis is associated with significant morbidity and mortality if not promptly recognized and treated. Since the development of early goal-directed therapy, mortality rates have decreased, but sepsis remains a major cause of death in patients arriving at the emergency department or staying in hospital. In this forum article, we asked clinicians and researchers with expertise in sepsis care to discuss the importance of rapid detection and treatment of the condition, as well as special considerations in different patient groups.

The burden of sepsis: a call to action in support of World Sepsis Day 2013

Worldwide, sepsis is one of the most common deadly diseases. It is one of the few conditions to strike with equal ferocity in resource-poor areas and in the developed world. Globally, 20 to 30 million patients are estimated to be afflicted every year. Every hour, about 1,000 people and each day around 24,000 people die from sepsis worldwide. Despite accounting for over 8 million lives lost annually, sepsis it is one of the least well known diseases. In the developing world, sepsis accounts for 60-80% of lost lives in childhood, with more than 6 million neonates and children affected by sepsis annually. Sepsis is responsible for >100,000 cases of maternal sepsis each year, and in some countries is now a greater threat in pregnancy than bleeding or thromboembolism.(1) In high income countries sepsis is increasing at an alarming annual rate of 8-13%.(2) Reasons are diverse, and include the aging population, increasing use of high-risk interventions in all age groups, and the development of drug-resistant and more virulent varieties of pathogens. In the developing world, malnutrition, poverty, and lack of access to vaccines and timely treatment all contribute to death. A considerable percentage of sepsis cases could be prevented through the widespread adoption of practices in good general hygiene and hand washing, cleaner obstetric deliveries, and through improvements in sanitation and nutrition (especially among children under 5 years of age), provision of clean water in resource poor areas(3) and vaccination programs for at risk patient populations.(4,5) Sepsis mortality can be reduced considerably through the adoption of early recognition systems and standardized emergency treatment.(6-8) However, these interventions are currently delivered to fewer than 1 in 7 patients in a timely fashion.(7,9,10) Sepsis is often diagnosed too late. Patients and health care professionals do not suspect sepsis, and the clinical symptoms and laboratory signs that are currently used for the diagnosis, such as raised temperature, increased pulse, breathing rate, or white blood cell count, are not specific for sepsis. Low awareness of sepsis as a discrete clinical entity among health professionals is compounded by a lack of reliable systems to aid identification and speed delivery of care. Recognition in neonates and children is even more problematic because the signs and symptoms may be non-specific and subtle but deterioration is usually rapid. The variation in normal physiological parameters with age is a further contributor to difficulties in identifying acute illness early.(11) Despite the fact that a patient with sepsis is around five times more likely to die than a patient who has suffered a heart attack or stroke, the Konrad Reinhart1, Ron Daniels1, Flavia Ribeiro Machado1 “on behalf of the World Sepsis Day Steering Committee and the Global Sepsis Alliance Executive Board”

Sepsis 3 from the perspective of clinicians and quality improvement initiatives

www.global-sepsis-alliance.org Equity House, 4-6 School Road, Tilehurst, Reading, Berkshire, RG31 5AL. UK The GSA is a charity registered in England and Wales number 1142803 and a company limited by guarantee, registered in England and Wales number 7476120 Barclays Bank, Hampshire, UK Account number: 832 901 07; IBAN: GB18 BARC 2005 0083 2901 07 SWIFTBIC: BARCGB22 VAT No. GB165 7475 74 Chairman Konrad Reinhart

Sepsis-The Final Common Pathway to Death From Multiple Organ Failure in Infection.

To the Editor: Most critical care practitioners will agree that sepsis is an organ dysfunction consequent to an infection (1). In contrast to an epidemiologic definition, this definition is used to identify patients, carries therapeutic and prognostic implications, and is pragmatic and straightforward (2). Thus, we find that the failure of the study by Sueblinvong et al (3), published in a recent issue of Critical Care Medicine, to identify Ebola viral infection associated with multiple organ dysfunction as sepsis is an important oversight. The authors conclude that “Ebola viral disease (EVD) may be related to a combination of direct effects of the virus on organ systems and to a severe sepsis probably from a secondary bacterial infection.” However, according to the leading authorities, EVD immune suppression and systemic inflammatory response cause impairment of the vascular, coagulation, and immune systems, leading to multiple organ failure and shock and, thus, in many ways resemble septic shock (4, 5). Sepsis occurs not only due to bacterial pathogens but also may be due to viral, fungal, and other organisms, and failure to acknowledge this is misleading and has potential to damage international efforts to highlight sepsis as a major silent killer (2). Furthermore, this oversight has therapeutic implications. Many aspects of best sepsis care, including that due to EVD, are not specific to a particular pathogen, but rather focus on resuscitation, vital organ support, and addressing other elements of the host response. EVD in Africa offers an example of poor sepsis outcomes in nonresilient healthcare systems. In resource-limited environments, the disease burden is high and multiple pathogens may contribute to sepsis. Early intervention offers hope for a favorable outcome and may prevent multiple organ failure, the treatment of which demands resources such as ventilators or dialysis machines that are not available. Limited laboratory support also means that the most important interventions to reduce sepsis morbidity and mortality must be made before the specific causative pathogen is identified. Skilled healthcare workers are also in short supply, and hence, the syndromic sepsis approach with simple generic protocols for recognition and treatment must be taught and implemented to achieve the greatest good. The critical importance of labeling infections associated with organ failure including EVD as sepsis cannot be underestimated especially because sepsis is largely ignored as a major public health catastrophe. Only a few countries in the world can boast reliable sepsis care. Thus globally, the focus on sepsis recognition and access to basic medical care is a priority. The focus on EVD is an opportunity to advocate for better sepsis care worldwide. The Global Sepsis Alliance (http://globalsepsisalliance.com/) and its partners are raising awareness about the burden of sepsis and calling for initiatives to decrease the sepsis burden and improve outcomes. Dr. Daniels consulted for UK Sepsis Trust (daily rate for consultancy work in systems design over and above pro bono work as Chief Executive Officer where such work impacts on personal finance or time) and Kimal PLC (manufacturers of central venous catheters), received royalties from BMJ Publishing (two books authored/edited: ABC of Sepsis and ABC of Practical Procedures), received royalties from Peters Fraser Dunlop (all royalties from proceeds of novel “3 and a half heartbeats” by Amanda Prowse), received support for the development of educational presentations from Health Education England (£19,000 received toward development of e-learning applications), and received support for travel from UK Sepsis Trust (travel and accommodation expenses covered for work with U.K. government and delivery of education sessions/lectures). His institution received grant support from Whitewater Trust (£48,000 to support project planning of sepsis registry) and Hospital Saturday Fund (£10,000 to support development of survivors’ support networks). Dr. Reinhart consulted for Adrenomed. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Sepsis in Children: Global Implications of the World Health Assembly Resolution on Sepsis

Background: Sepsis, worldwide the leading cause of death in children, has now been recognized as the global health emergency it is. On May 26, 2017, the World Health Assembly, the decision-making body of the World Health Organization, adopted a resolution proposed by the Global Sepsis Alliance to improve the prevention, diagnosis, and management of sepsis. Objective: To discuss the implications of this resolution for children worldwide. Conclusions: The resolution highlights sepsis as a global threat and urges the 194 United Nations member states to take specific actions and implement appropriate measures to reduce its human and health economic burden. The resolution is a major step toward achieving the targets outlined by the Sustainable Developmental Goals for decreasing mortality in infants and children, but implementing it will require a concerted global effort.

What we learned from the first World Sepsis Day.

On September 13th, 2012, the first World Sepsis Day (WSD) was held, with events in many countries all over the world. The intent was to raise awareness of sepsis, a common but underrecognized threat, despite a mortality rate of between 30% and 50%. As of September 15th, more than 900 health care organizations representing more than 1250 hospitals support the World Sepsis Declaration. In addition, more than 70 organizations and professional societies, comprising all relevant medical fields, and more than 1000 health care workers and individuals from 93 countries of all continents registered on the WSD Web site www.world-sepsis-day.org. The global resonance of a WSD points to the increasing recognition of the challenge that the burden of sepsis lays on citizens everywhere. Sepsis causes more deaths worldwide per year than prostate cancer, breast cancer, and HIV/AIDS combined; and sepsis is the main cause of death in most intensive care units. Worldwide, a person dies from sepsis every few seconds. In the United States, sepsis rates have been increasing by 8% to 13% a year over the last decade; and hospitalizations for sepsis have overtaken those for myocardial infarction in adults [1]. Reasons are diverse, but include the aging population, increasing use of high-risk interventions in all age groups, and the development of drugresistant and more virulent varieties of infections. In the developing world, malnutrition, poverty, and lack of access to vaccines and timely treatment all contribute to death. A patient with sepsis is 5 times more likely to die than a patient who has suffered a myocardial infarction or stroke. Globally, 20 to 30 million patients are estimated to be afflicted every year, with more than 6 million cases of neonatal and early childhood sepsis and more than 100000 cases of maternal sepsis [2]. Indeed, approximately 70% of deaths of children younger than 5 years are a result of infectious causes. Other medical fields like oncology, cardiology, and AIDS/HIV have shown the importance of concerted public and political awareness campaigns to achieve improvements. In the case of cancer, “... it needed icons, mascots, images, slogans, the strategies of advertising as much as the tools of science. For any illness to rise to political prominence, it needed marketing.... A disease needed to be transformed politically before it could be transformed scientifically.”(S Mukherjee) [3]. Inspired by the successes of these fields, the