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.

1. F*Ckin’
Process
trial

2. Our first
15,000
Severe Sepsis
Patients

3. The old days…

5. 60
Hospitals

6. Recognition
Treatment

7. 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

8. How’d We
Do It?

9. We really
didn’t do

10. Ok there was
some of
stuff…

11. Administrative
Buy-In

12. Recognition
Treatment

13. Recognition
Treatment

14. They’re Not
Looking!

15. Occult or
Cryptogenic
Severe Sepsis

17. Triage
Screen

18. Lactate

19. Lactate
or
Persistent
Hypotension

20. Turnaround <
30 Minutes

21. Panic Value if
≥ 4

22. Why are more
lactates a good
thing?

23. How do Severe
Sepsis Patients Die?
Time
Stability

24. Denominator
Shift
Crit Care 2010;14:R77

25. Pneumonia 14%
Severe Sepsis 40%
Pre-Lactate Screen

26. Pneumonia 8%
Severe Sepsis 30%
Post-Lactate Screen

27. What did they
do after they
found them?

28. Recognition
Treatment

29. Treat the Source
Perfuse the Tissues

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

32. Early
Antibiotics
Kumar et al.& Gaieski et al.

33. Individual
Hospital
Empiric
Guidelines

34. Immediate
Availability

36. Source Control

37. “He’s too sick to
intervene”

38. Arterial Oxygen
Saturation

39. How not to kill
septic patients
while
intubating

40. Responsiveness
Volume?

41. Empirically
Gave 2-3
Liters

43. SWEAR ON
YOUR
PATIENT’S
LIFE

45. 2nd Lactate?

46. Recognition
Treatment

47. 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

48. ARISE
ProCESS
ProMISe

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

50. 5%

51. FOAMcc

52. Fluids
Vasopressors
Endpoints

53. Hemodynamics

54. Plumber’s
Approach

55. Hemodynamic
Resuscitation

56. EGDT

58. Fluids

59. Debate

60. Give everyone
two liters of…

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

62. HIP

64. Give 1
(or max 2)
liter(s) more

65. Tense the Tank

67. 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

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

69. First 24 hrs:
Think you Need
Additional
Fluid?

70. Volume
Loading
by SV

71. After
First 24 hrs:
Better have a think
about it

72. Microcirculatory
Resuscitation?

74. Glycocalyx
?

75. Goals

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

77. ScvO2

78. 2nd
Lactate?

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

80. 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).

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

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

83. emcrit.org/smacc

84. The old days…

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

86. 5%

87. Stop
Sepsis
Deaths

88. You don’t
need to do a
whole lot of

89. You just need
to give a