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Welcome Suspecting and Treating Sepsis in Maternal Medicine

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Stephen L. Davidow, MBA-HCM, APR Manager, Quality Implementation Programs Society of Critical Care Medicine Mount Prospect, IL

Today’s webcast is funded by a generous grant from the Gordon and Betty Moore Foundation

Save the Date! The Next Surviving Sepsis Campaign Webcast September 19, 2013 Topic: Pediatric Guidelines from the Surviving Sepsis Campaign: Considerations for Care Faculty: Margaret M. Parker, MD, FCCM Professor of Pediatrics, Anesthesia, and Medicine, Stony Brook University Learning objectives: • • •

Apply the key recommendations of the Surviving Sepsis Campaign to the care of the pediatric sepsis patient Describe the special considerations in the guidelines for care of pediatric sepsis patients and the differences from adult patients Utilize data from central-line placement to benefit the patient’s care

Jeanne Sheffield, MD Maternal Fetal Medicine University of Texas Southwestern Medical School Dallas, TX

Brenda Downs, MSN, RN, ACNS-BC Program Director, Clinical Performance Improvement Dignity Health Gilbert, AZ

Septic Shock in the Obstetric Patient

Jeanne S. Sheffield, M.D. Maternal Fetal Medicine University of Texas Southwestern 2013

I have no conflict of interest related to the content of this presentation.

The microorganisms that seem to have it in for us..turn out..to be rather more like bystanders..it is our response to their presence that makes the disease Lewis Thomas NEJM 1972

Concept of Septic Shock in 2013 • Early in sepsis there is an increase in inflammatory mediators - then SHIFTS • Mid- to late sepsis consistent with immunosuppression – loss of delayed hypersensitivity – inability to clear infection – predisposition to nosocomial infections

Why immune suppression which increases mortality? • Shift to anti-inflammatory cytokines CD4 CD4TTcells cells ? Pathogen Bacterial inoculum Th1 cells

Th2 cells

Inflammatory cytokines TNF-a IFN-g IL-2

Anti-inflammatory cytokines IL-4 IL-10

Why immune suppression which increases mortality?

• Anergy

– Non-responsiveness to antigen – T cells fail to proliferate and secrete cytokines in response to antigen

• Death of immune cells – Apoptosis (suicide or programmed cell death) – Decrease in B cells, CD4 T cells and follicular dendritic cells

• The normal stress response is activation of anti-inflammatory mechanisms which predominate in sites outside of the affected systems – Not the previously believed uncontrolled hyperinflammatory response

• Survival among patients correlates with recovery of inflammatory responses

Definitions • Shock: When the functional intravascular blood volume is below that of the capacity of the body’s vascular bed – Hypovolemic

– Hemorrhagic – Cardiogenic ( pump failure) – Neurogenic ( loss of sympathetic control of resistance vessels)

Definitions • Systemic Inflammatory Response Syndrome (SIRS) – Inflammatory process that can be generated by infection or by non-infectious causes (burns, trauma) – Non-pregnant: 2 or more of the following • Temperature >38 C or 90 beats/min • RR >20 breaths/min or PaO2 12,000/mm3, < 4,000/mm3 or >10% bands

Definitions • Sepsis : the systemic inflammatory response syndrome that occurs during infection (Society Critical Care Medicine 2001 consensus statement) • Septic shock: vascular collapse secondary to an infectious process – Usually components of hypovolemic and cardiogenic shock

National Guidelines for the NonPregnant Individual • There are several “scoring systems” and national guidelines to help determine admission to the ICU, treatment regimens and predict morbidity and mortality. – Modified Early Warning System – SIRS Criteria – APACHE – Unfortunately not validated for the pregnant and non-pregnant woman

Maternal Sepsis: Incidence • Septic shock: 0.002-0.01% of all deliveries • 0.3-0.6% of all septic patients are pregnant • Has increased over the last decade – Older maternal age at delivery • Obesity, diabetes, CHTN, placental abruption and placenta accreta • ART and multi-fetal gestation

– Obesity • HTN, DM, Cesarean, cardiopulmonary complications Burton and Sibai 2012

Maternal Sepsis Mortality and Morbidity During Hospitalization for Delivery • Bauer et al Anesth Analg 2013 – Population based epidemiologic study in the United States • Nationwide Inpatient Sample (NIS) 1988-2008 • Hospitalizations for delivery • American College of Chest Physician and Society of Critical care medicine Definitions – Severe sepsis: sepsis with acute organ dysfunction, hypotension or hypoperfusion

• Identified independent associations of severe sepsis

Maternal Sepsis Mortality and Morbidity During Hospitalization for Delivery • Bauer et al Anesth Analg 2013 – 44,999,260 hospitalizations for delivery • Sepsis complicated 1:3333 deliveries • Severe sepsis 1:10,823 deliveries • Sepsis related death 1:105,384 deliveries

– Overall frequency of sepsis stayed the same during the study period • Severe sepsis and death odds increased 10% per year

Maternal Sepsis Mortality and Morbidity During Hospitalization for Delivery • Bauer et al Anesth Analg 2013 – Independent risk factors for severe sepsis Age >35 AA Race Medicaid Retained POCs PROM CHF

Chronic renal failure HIV infection SLE Multiple gestation Cerclage Chronic liver failure

Pathophysiology of Septic Shock

Decreased functional intravascular blood volum

Decreased BP and tissue perfusion

Cellular acidosis and hypoxia

End-organ tissue dysfunction and death

Bacterial Infections in Obstetrics • Postpartum endometritis – Cesarean delivery – Vaginal delivery • Lower tract UTI • Septic abortion • Pyelonephritis • Chorioamnionitis • Necrotizing fasciitis • Toxic shock syndrome

15-87 % 1-4 % 1-4 % 1-2 % 1-2 % 0.5 - 1 % general variables  # of patients with severe sepsis

Known Sepsis/ Infection Group 35 2.6/pt 30 (86%) 17 (57%) 13 (43%)

Total # times patients screened  Heart rate > 110  Heart rate > 120  Fetal heart rate > 160  Respiratory rate > 20  Altered temperature (> 38.3° or 15K

90 16 11 9 5* 11 15

91 1 1 0 2 1 4

*10 screenings with no RR taken

25 3.6/pt 3 (12%) 0 0

Changes (& Resources) Along the Way… • Barton & Sibai publication, Sept 2012, Severe sepsis and septic shock in pregnancy (Obstet Gynecol, 2012;120:689-706) – Validated our screening parameter selections – Guided our HR parameter decision

• Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012, 3rd Ed publication (CCM, 2013; 41(2):580-637) – Guidelines updated: added altered mental status; deleted chills/rigors; changed BG to 140

Final Screening Tool • Is there a suspected or confirmed infection? • Are there 2 or more altered general variables? – – – – –

Temp > 38 C or < 36 C FHR > 160 bpm (gestational age >20wks) Maternal HR >110 bpm RR > 24 bpm WBC >15,000 or 10% bands with normal WBC – AMS – BG > 140 (in absence of DM)

Final Screening Tool • Is at least one of the following acute organ dysfunctions present? – – – – – – – – –

Decreased Cap refill/mottling skin Lactic acid above normal values Bilirubin >2mg/dL Urine output < 0.5ml/kg/hr x2 hrs Serum creatinine > 1.5 mg/dL or increase >0.5mg/dL from baseline INR >1.5 or PTT >60 w/o meds SBP decrease >40mmHg from baseline MAP