A session blog from Day 1 of State of the Art, London December 2015. See the full list.
Blogger Jack Wong
Chair: Gary Masterson
How many are we missing? Lessons from the All-Wales size of sepsis study
Tamas Szakmany, Aneurin Bevan University Health Board Cardiff University
Summary: How many are we missing? Loads.
- 2015 feasibility pilot in 4 hospital – Sepsis screening and delivery was lacking
- You can’t drive improvement if you don’t know the size of the problem!
- CURES NHS Cardiff University
- 1 day point prevalence study for 24 hours
- Changed the data collection to electronic. Open source revolution
- Medical student as data collector
- Tablets for screening tool, guidelines, educational resources
- Online and face to face training of data collectors
- Real time monitoring of device and troubleshooting via Whatsapp groups
- Standardised data, almost immediately available for analysis using E-CRF
- 14 out of 16 hosptal
- Adult patients with NEWS > 3 in A&E and general wards
- 184 data collectors with 56 devices
- 24 hours – 1198 data collection forms
- Focus on severe sepsis patient group – 101 patients on the wards
- Only 42 severely septic patient trigger NEWS out of 101
- 212 patients with sepsis (4%)
- 101 severe sepsis
- >50% have NEWS <6
- Less than 20% of sepsis patients were screend
- Sepsis Six completion was 15%
- Change of sepsis definition is coming
- Life threatening organ dysfunction due to a dysregulated host response to infection
- Future work:
- To test if the new criteria is applicable to the wards
- To see if any change in incidence in a years time
- To see if detection is better and Sepsis 6 is more universally applied
- We will give you an independent reality check
Take home message
- 1 in 25 patients on the ward can have sepsis
- ¼ unwell have sepsis
- Only 20% got picked up
- If you don’t spot it, you can’t treat it
- Be prepare to find out something you might not like
Early warning and decision-support in Birmingham
Nandan Gautam, Queen Elizabeth Birmingham
Summary: To BEWS or not to BEWS?
A solution for previous topic?
- NICE July 2007 – Acutely ill patient – Physiological track and trigger system is required
- Should include at least: HR, RR, SBP, GCS, Sats, T with graded response strategy
- Problem with prediction scores – If you are well, it is not very discriminatory, if you are very unwell, you don’t need it!
- Ideal score should be valid, objective, reproducible, low inter-rater variability, low intra-rater variability
- Scores are just a crude descriptor of current physiological state, doesn’t predict the following – Mortality, Morbidity, LOS, identify cardiac arrest, anticipated organ failure.
- Does MEWS mean anything at all? Does it only trigger but does it track?
There are many scoring systems
- Over 30 scores identified, subtle variation in weighting, different thresholds, different settings, questionable validation, impossible comparisons
- NEWS – good at predicting death within 24 hours and up to 48 hours
- Doesn’t predict morbidity / critical illness
- Good at predicting cardiac arrest – NEWS AUROC 0.86
- Cardiac arrest – Reduction of calls
- LOS – No difference
- Need for organ support – No different in using critical care services / reduced length of stay
What are they good for?
- Makes organisations think about safer system,
- Empowers staff to call for assistance
- Set a threshold at which an intervention is considered
- Makes you think about futility
QIP Project in Queen Elizabeth Hospital
- Review use of SEWS score
- Improve care and timeliness of intervention
- Improve specificity
- Resource allocation
- 100k pt per year
- 30k emergency
- 1100 beds
- 65 level 3 critical care
- 24×7 outreach
- 3 cardiac arrest zones
- 500-650 cardiac arrest calls
- <200 true loss of cardiac output
- 700 inpatient emergency admissions to critical care.
- SEWS = 50% specificity, not valid for patient group, no reproducible
A bespoke score
- Unique but comparable, dynamic, learning, relevant to the resources available locally, reflects changing health care
- Birmingham Predictive Scores (BEWS / BIPS)
- Electronic observation charts
- Labs database that can be interrogated
- Demographics database
- Recorded outcomes
- Large patient records
- Emergency and elective patient cohort
Outcome and comparison
It is a better predictor – So what?
- Linear so it means something
- Dynamic and responsive
- Better pick up rate (vs NEWS)
- Resource allocation – No increased resources but BIPS showed better pick up before patient deteriorate hence resources can be allocated more meaningfully.
Predicting poor outcome
- Change therapy or recognise futility.
The truth about lactate
Rinaldo Bellomo, ANZIC RC Melbourne, Australia
Summary: Lactate = stress ≠ tissue hypoxia
- Hyperlactataemia predicts death.
- Dynamic lactate indices as predictor of outcome in critically ill patient.
- Lactate level predicts mortality as compared to glucose
- At ED presentation, raised lactate signifies increased risk. – ARISE trial
- Bigger predictor than refractory hypotension – but why?
- Belief = lactate is biomarker of tissue hypoxia and anaerobic glycolysis.
The golden rules of biomarkers
- The biomarker link to the condition must be biologically plausible and independent
- Must be tested in the population of interest
- Accuracy of the biomarker must be assessed with AUROC eg. BNP, NGAL
Is lactate plausible?
- Lactate level changes with training – but tissue hypoxia is tissue hypoxia, how can training change it?
- Relatively unchanged lactate level with low PaO2 level in Mount Everest climber.
- Lactate shuttle between organs and cells as shown in magnetic resonance spectroscopy data in animal model and laser microscopy.
- Lactate as a hormone to mitochondria and nucleus
- Renal lactate uptake in endotoxic shock
- Lactate is released in lung in relation to CO2 production
- Lactate increase in adrenergic state, adrenaline infusion, liver failure, hyperdynamic state WITH NO EVIDENCE OF CO-EXISTING TISSUE HYPOXIA.
AUCROC for tissue hypoxia / anaerobic glycolysis
- No such analysis ever done
- The reason is that no one can confirm or refute tissue hypoxia – of what? the whole body? the organ? specific cells?
- Lactate is not an accurate or reliable or robust marker of hypoxia
- Its link with hypoxia is biologically flawed
- More likely to be marker of physiological stress
- It is now clear that lactate is a major mitochondrial fuel
- Rapidly utilized in cell to cell and intracell shuttles
- Taken up by mitochondria to optimize bioenergetics
- It acts like a hormone with powerful effects on protein synthesis
- It is associated with increased mortality, so is fever and hypotension
- Our scientific journey toward real understanding of lactate has only just begun.