Sepsis in NY: The first 15K patients by Weingart

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This document describes the results of a trial involving over 15,000 severe sepsis patients across 60 hospitals. It shows that implementing interventions for early recognition and treatment of severe sepsis, including lactate screening, antibiotics, fluids, vasopressors and source control, led to a significant decrease in in-patient mortality rates from 41% to 19% over time. While some interventions like early goal-directed therapy have been debated, the key is focusing initial treatment on the basics of recognizing severe sepsis early, treating infections with antibiotics, and supporting circulation with fluids and vasopressors when needed.

Gesundheit & Medizin

0%

10%

20%

30%

40%

50%

Jan-‐11
Feb-‐11
Mar-‐11
Apr-‐11
May-‐11
Jun-‐11
Jul-‐11
Aug-‐11
Sep-‐11
Oct-‐11
Nov-‐11
Dec-‐11
Jan-‐12
Feb-‐12
Mar-‐12
Apr-‐12
May-‐12
Jun-‐12
Jul-‐12
Aug-‐12
Sep-‐12

*
N
=
9,133

January
2011

41%

September2012

19%

January
2012

27%

22% ARR of In-Patient Mortality

How do Severe
Sepsis Patients Die?
Time
Stability

Pneumonia 14%
Severe Sepsis 40%
Pre-Lactate Screen

Pneumonia 8%
Severe Sepsis 30%
Post-Lactate Screen

Early Abx
Source Control
Don’t box ‘em with the tube
A Wee bit of Fluid
Pressors

Early
Antibiotics
Kumar et al.& Gaieski et al.

How not to kill
septic patients
while
intubating

Gain from Sepsis Interventions
Easy Crap
Mental Masturbation
95%
5%

Balanced
Crystalloid
Ann Surg. 2012 May;255(5):821-9
JAMA. 2012 Oct 17;308(15):1566-72)

Critical Care 2007,11(Suppl 2):P37
Crit Care Med 2011;39(4):689-94
Critical Care 2010,14:R142
Crit Care Med. 2012;40(12):3146-3153
Crit Care Med.2013 Jan;41(1):143-50

Peripheral
Pressor
Administration
Crit Care Med.2013 Sep;41(9):2108-15

First 24 hrs:
Think you Need
Additional
Fluid?

After
First 24 hrs:
Better have a think
about it

MAP > 65
CI > 2.2 (2.5)
Microcirc Goals?

Lack of Prognostic Value of Lactate
Clearance in a Center with a Severe
Sepsis Protocol

199 patients received aggressive monitored
severe sepsis care.
39 patients expired during their hospital course
(18% mortality)
The mean arrival lactate was 4.8 (± 3.0) in the
survivors compared to 7.3 (± 4.4) in those patients
who died (p<0.0001).
Lactates ≥4 were significantly associated with
increased mortality (p<0.05).
However, the patients who achieved lactate
clearance did not have significantly improved
survival when compared to those patients in
whom clearance was not achieved (p=.60).
In addition, patients with rebound in lactate ≥4,
after initial clearance, showed a 10-fold increase
in mortality (p<.05).

If you are already doing the
good stuff, clearance doesn’t
matter--unless they rebound…

May not be applicable to
places without a team that
wants to care about these
patients

Sepsis in NY: The first 15K patients by Weingart

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