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Sponsor Innovation Webinar
Nora O’Buck, RN-BSN, CCRNProgram Manager, Professional EducationEdwards Lifesciences
Blood culture incubation can be anywhere from 6-18hrs depending on lab and delivery into incubators
8-24hrs depending on lab
Time to ID/AST Results: 48-96 hours
Delayed Antibiotic Sensitivity Tests (AST) - #1
1Kumar et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical
determinant of survival in human septic shock. Crit Care Med. 2006 Jun; 34 (6 ):1589-96.
n = 2,731
Every hour of delay to optimal antimicrobial therapy for patients with severe sepsis decreases the chances of survival by 7.6%1
82%
77%
70%
61%
57%
50%
43%
32%
26%
19%
9%
5%
Ch
ance
of
surv
ival
Time to Appropriate Antimicrobial Rx following Onset of Hypotension
Clinical Urgency: Surviving Sepsis
>36hrs is when most blood
culture antibiotic sensitivity test
results are available from
standard lab procedures:
1) Delayed appropriate
treatment
2) Longer empiric antibiotic use
3) Delayed isolation for MDROs
Effect of Delayed Antibiotic Sensitivity Results in Healthcare
Antimicrobial Resistance - #2 Overuse of Antibiotics
“The CDC estimates that the direct costs of antimicrobial resistance on the U.S. economy is $20 billion annually. When you factor in the economic consequences of lost productivity, it adds an additional $35 billion in costs”
Resistance is Spreading Across CountriesA real global crisis – for
example:
December 2015
Pan-Resistant Enterobacteriaceae seen in
19 countries
mcr-1 >> Colistin resistant
• Plasmid mediated
• Easily passed between organisms
(E. coli/Klebsiella)
• Pan Resistance = No drugs work
https://www.cdc.gov/drugresistance/
CDC - Pathogen Distribution and Antimicrobial Resistance 2011-2014
infection control & hospital epidemiology January 2018, vol. 39, no. 1
C. difficile from Antibiotics - #3
17
Antibiotic Classes and Risk for C. difficile Infection
• Two meta-analyses found risk to be greatest with clindamycin, fluoroquinolones or cephalosporins
• 465 studies and included 5 published between 1994 and 2011 (total, 26,435 patients) in their meta-analysis1
• Risk for CDI to be more than tripled after any antibiotic exposure (odds ratio, 3.55).
• Treatment with clindamycin showed the strongest association with subsequent CDI (OR, 16.80)
• 910 studies and included 8 published between 2005 and 2011 (total, 30,184 patients)2
• Risk for CDI to be increased nearly sevenfold after antibiotic treatment (OR, 6.91)
• Risk was greatest with clindamycin (OR, 20.43), followed by fluoroquinolones (OR, 5.65), cephalosporins (OR, 4.47)
1. Brown KA et al. Meta-analysis of antibiotics and the risk of community-associated Clostridium difficile infection. Antimicrob Agents Chemother 2013 May; 57:23262. Deshpande A et al. Community-associated Clostridium difficile infection and antibiotics: A meta-analysis. J Antimicrob Chemother 2013 Apr 25
Emerging Technology:
Fast Antibiotic Sensitivity Tests (AST) to Reduce Empiric Use of Antibiotics
Fast Results• Identification in under 90 minutes using
Incubation depends on the organism’s growth – typically from 6-18 hours
Place patients with MDROs
on isolation precautions at
~7hours
De-escalate or Escalate
empiric antibiotic
therapy
Benefits of the Accelerate PhenoTM System
• Standardizes laboratory procedures for BCs
• Allows clinicians to evaluate empiric antibiotic therapy faster and de-escalate or escalate therapy
• Reduces pharmacy costs for unnecessary antibiotics
• Improves care of patients with sepsis
• Reduces length of stay and days of antibiotic therapy
• Expedites isolation/precautions for multiple drug resistant organisms
• Decreases risk of C. difficile and MDROs
• Decreases use of antibiotics - prevents adverse side effects (ototoxicity, nephrotoxicity and acute renal injury, skin conditions, neurological effects
Is there Clinical Evidence???
Use of the Accelerate Pheno™ system, compared to SOC of VITEK® MS and VITEK® 2, resulted in:
• A statistically significant 3.0 day reduction in hospital (total) LOS
• A statistically significant 2.0 day reduction in antibiotic DOT (days on therapy)
• A statistically significant 36 hour reduction in TTOT
Accelerate PhenoTest™ BC Kit
Fast AST Results Improve Clinical OutcomesUniversity of Arkansas for Medical Sciences (UAMS)
Dare et al. Impact of Accelerate PhenoTM Rapid Blood Culture Detection System on Laboratory and Clinical
Outcomes in Bacteremic Patients. Presented as oral presentation at IDWeek 2018.
Clinical
Outcomes
Standard of Care
N=79
Intervention
N=75
p-value
LOS (days) 12.1 (11.9) 9.1 (7.6) 0.03
TTOT (hours) 73.5 (50.2) 37.5 (32.7) <0.001
Total Antibiotic DOT
(days) 9.0 (7.5) 7.0 (4.6) 0.05
Meropenem DOT
(days) 6.6 (3.7) 3.7 (2.1) 0.03
• The UAMS study demonstrated a 3-day LOS reduction following clinical implementation of the Accelerate Pheno™ system
• This suggests a mean cost savings of $6,565.50 per patient with bacteremia
Decreased LOS Improves Economic OutcomesImplications of UAMS’ 2018 Clinical Outcomes Study
“Hospital Adjusted Expenses per Inpatient Day by Ownership”. Henry J Kaiser Family Foundation. 2016. https://www.kff.org/health-costs/state-indicator/expenses-per-inpatient-day-by-ownership
1 inpatient day cost
3 inpatient days cost
Non-profit
hospitals $2,488 $7,464
For-profit hospitals $1,889 $5,667
A Kaiser Family Foundation report summarizes inpatient U.S. hospital costs in
2016 and indicates that the average cost was ~$2,200/day ($1,889 - $2,488).
7 publications
>30 posters/abstracts
31
Improving Operationsthrough simplified workflow for ID & AST results
Individualized Resuscitation: A new chapter for optimizing tissue perfusion
Nora O’Buck RN-BSN, CCRN
Disclosure
▪ Nora O’Buck is a paid employee of Edwards Lifesciences
Objectives
▪ Early resuscitation in sepsis
▪ Current guideline recommendations
▪ Goals of hemodynamic monitoring in sepsis
▪ Introduction of novel, non-invasive monitoring technology
38
Normal circulation vs septic shock patient
Images: Spronk et al. Nitroglycerin in Septic Shock After Intravascular Fluid Resuscitation. The Lancet. 2002.
Imaging of sublingual circulation
Early fluid resuscitation is associated with improved sepsis outcomes
39
Leisman D, et al. Association of fluid resuscitation initiation within 30 minutes of severe sepsis and septic shock: Recognition with reduced mortality and length of stay. Annals of Emergency Medicine 2016.
IV fluid resuscitation initiated within 30 minutes
decreased length of stay and improved mortality
CMS Sepsis Bundle Guides Treatment of Sepsis
Within 3 hours
1.) Measure lactate level
2.) Obtain blood cultures prior to administration of antibiotics
3.) Administer broad spectrum antibiotics
4.) Only if septic shock is present, administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L
Sepsis CMS Core Quality Measure (NQF #0500)
Hospitals reporting on sepsis treatment for FY17 payment determination
Within 6 hours
1.) Apply vasopressors
2.) Re-measure lactate if initial lactate elevated
3.) Re-assess volume status and tissue perfusion
In the event of persistent
hypotension that does not
respond to initial fluid
resuscitation
Severe Sepsis
CMS data collection begins
▪ Vital signs AND
▪ Cardiopulmonary exam AND
▪ Peripheral pulse evaluation AND
▪ Skin examination
All
▪ CVP
▪ ScvO2
▪ Bedside cardiovascular ultrasound
▪ Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge
Two of four
OR
NQF #500 Severe Sepsis and Septic Shock. National Quality Forum. Center for Medicare and Medicaid Services. 2015.
BMJ 2018/360:k703
Right Fluid for the Right Patient
❑ Prioritize immediate fluid resuscitation.20
❑ Recommended fluid volume in first hour: 30mL/kg.21
❑ A history of heart failure, liver failure, or renal failure
is not a contraindication to fluid resuscitation.22
Under and over-resuscitation of fluid is an
important concern in fluid management.23
ACEP DART Tool Recommendations
How do you know if you have given the right amount of fluid for your patient?
Bellamy Curve24
IVF in sepsis patients with heart failure or kidney disease
43
Liu V, et al. Multicenter Implementation of a Treatment Bundle for Patients with Sepsis and Intermediate Lactate Values. American Journal of Respiratory and Critical Care Medicine. 2016.
“Multi-center implementation of a
treatment bundle for sepsis patients
with intermediate lactate values
improved bundle compliance and
was associated with decreased
hospital mortality.
These decreases were mediated by
improved mortality and increased
fluid administration among patients
with a history of heart failure or
chronic kidney disease.”
Goal of Hemodynamic Monitoring in Sepsis
▪ Identify hemodynamic instability and its cause
▪ Monitor response to therapy
▪ Encourage timely clinical intervention to prevent and correct hypoperfusion
▪ Optimizing delivery and consumption of oxygen
44
Blood pressure alone does not reflect perfusion
45
1. Schwaitzberg, et al. A pediatric trauma model of continuous hemorrhage. J Ped Surg 1988
2. Hamilton, et al. Comparison of commonly used clinical indicators of hypovolaemia with gastrointestinal tonometry. Intensive Care Med 1997
3. Rackow, et al. Pathophysiology and Treatment of Septic Shock. JAMA 1991
4. Giglio, et al. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. BJA 2009
25-30%1,2,3
By the time hypotension occurs,
perfusion is compromised3,4
Determinants of blood pressure
46
MAP CO
HR
Preload Contractility Afterload
SV
SVR= X
X
Cannesson & Pearse. Perioperative Hemodynamic Monitoring and Goal Directed Therapy. 1st Edition Cambridge U Press 2014.
Darovic, G. Hemodynamic Monitoring: Invasive and noninvasive clinical application. Third Edition. Chapter 11, page 245.
Fluid Challenge
Fundamentally, the only reason to give a patient a fluid challenge is to increase SV. As preload increases, left ventricular SV increases until optimal preload is achieved, at which point SV remains relatively constant.32
Measure SV
Deliver fluid (200 - 250mL)
SV increase > 10% ?
YES
NO
Monitor SV
for clinical signs of fluid loss
SV change < 10% ? YES
NO
Initiate Bundle
Frank Starling Curve: Michard F. Changes in Arterial Pressure During Mechanical Ventilation. Anesthesiology. 2005.
Fluid Challenge: Johnson, Alexander. Stroke Volume Optimization: The New Hemodynamic Algorithm. American Association of Critical Care Nurses. 2015.
Assess Fluid Responsiveness Post Initial BolusStroke Volume (SV) helps to guide optimal fluid volume administration decisions for septic patient.
*Clinicians can use continuous monitoring to test fluid responsiveness with two challenges:
Smart. Innovation.
Over 40 years of helping you make more informed decisions to advance patient care
49
Introducing the ClearSight System
The ClearSight system is a simple noninvasive technology that provides continuous real-time
advanced hemodynamic information for critically ill patients.
Continuously Monitor
Advanced Parameters:
SV | SVV | SVR | CO | BP
The ClearSight System
connects quickly to the patientThe ClearSight system
provides real-time
hemodynamic information
Know More with Continuous Noninvasive Monitoring
Sepsis patients may present with widely diverse hemodynamic profiles. Knowing an individual
patient’s presenting hemodynamic measurements may provide targets for fluid resuscitation,
an important component of sepsis treatment.1
Reference
1. Nowak, Richard M,. Noninvasive Hemodynamic Monitoring in Emergency Patients with Suspected Heart Failure, Sepsis and Stroke:
• Review types of shock and the incidence of distributive shock
• Discuss recommendation of a mean arterial pressure (MAP) target of 65 mm Hg
• Introduce the Renin Angiotensin-Aldosterone System as a treatment pathway for distributive shock
• Review ATHOS-3 study and introduce GIAPREZA, a novel vasopressor
Session Objectives
Objectives
56
MAP
Types of Circulatory Shock
Distributive shock leads to organ dysfunction and death due to hypotension
and insufficient tissue perfusion1
It is associated with high mortality2,3
1.2 million shock patients annually in the US4
MAP=mean arterial pressure.
1. Cecconi M et al. Intensive Care Med. 2014;40(12):1795-1815; 2. Singer M et al. JAMA. 2016;315(8):801-810; 3. Vincent J et al. N Engl J Med. 2013;369(18):1726-1734; 4. Vincent J et al. N Engl J Med. 2013;369(18):1726-1734 and Decision Resources Group market research
Adapted from
Vincent J-L et al.
New Engl J Med.
2013;369:1726-
1734.
Distributive shock(94% septic shock1)
Vasodilation
Cardiogenic shock
Ventricular
failure
Hypovolemic shock
Loss of plasma
or bloodvolume
66% 16%
16%
2%
Obstructive shock
Obstruction
Pericardialtamponade
57
Guidelines for Initial Resuscitation in Patients with Sepsis or Septic Shock
1. Rhodes A et al. Intensive Care Med. 2017;43:304-377.
Initial resuscitation guidelines
• At least 30 mL/kg of IV crystalloid fluid recommended within the first 3 hours
• An initial target MAP of at least 65 mm Hg in patients with septic shock requiring vasopressors
58
Catecholaminesa: sympathetic nervous
Vasopressin: arginine-vasopressin
Angiotensin II:
renin angiotensin-aldosterone
A Multimodal Approach to Increasing MAP
aCatecholamines include NE, epinephrine, dopamine, phenylephrine, ephedrine.
Adapted from Hendry C et al. Nurs Stand. 2012;27(11):35-40.
Renin secreted by
kidneys, converts
angiotensinogen
to angiotensin I
ACE secreted by
lungs, converts
angiotensin I to
angiotensin II
Secreted by liver and
successively processed
into angiotensin II
Drop in blood pressure
Aldosterone
increases Na+ and
H20 reabsorption by
kidneys
Angiotensinogen Angiotensin I Angiotensin II
• Direct action on blood
vessels promoting
vasoconstriction
• Stimulates aldosterone
release from adrenal gland
Angiotensin II
raises blood pressure
60
GIAPREZA Indication
GIAPREZATM (angiotensin II) [package insert]. San Diego, CA: La Jolla Pharmaceutical Company; 2017.
GIAPREZA is a vasoconstrictor to increase blood pressure in adults with septic or other
distributive shock
61
GIAPREZA Studied in the ATHOS-3 Trial
Khanna A et al. New Engl J Med. 2017;377:419-430
• An international, multicenter, double-blind, placebo-controlled study with 344 randomized patients
ATHOS-3
Angiotensin II for the Treatment of High-Output Shock
62
ATHOS-3 Trial Design
aGIAPREZA and placebo were studied in conjunction with norepinephrine, epinephrine, dopamine, phenylephrine, and vasopressin.1
bTreatment allowed up to Day 7. Day 28 (± 2 days) follow-up determined safety events that occurred between Day 7 and Day 28.3,4
1. GIAPREZATM (angiotensin II) [package insert]. San Diego, CA: La Jolla Pharmaceutical Company; 2017; 2. Chawla LS. Crit Care Resusc. 2017;19:43-49; 3. Khanna A et al. New Engl J Med. 2017;377:419-430; 4. Khanna A et al. New Engl J Med. 2017;377:419-430 [Trial Protocol]
Adults with septic or other distributive shock who remained hypotensive despite fluid resuscitation
and standard of care vasopressor therapy were randomized to GIAPREZA or placebo1,2,a
ATHOS-3 trial design
1:1 double-blind
randomization
(N=321)1
GIAPREZA
and 1 or more standard of
care vasopressorsa
(n=163)1,2
Placebo
and 1 or more standard
or care vasopressorsa
(n=158)1,2
Primary endpoint1
MAP ≥75 mmHg or a ≥10 mmHg
increase, without an increase in baseline
vasopressor therapy at hour 3
Hour 3b
63
70% of GIAPREZA Patients Achieved Primary Endpoint1
aMAP response defined as an increase from baseline of ≥10 mm Hg or an increase to ≥75 mm Hg, without an increase in the dose of background vasopressors.
Modified intention-to-treat (mITT) population.
1. Adapted from Khanna A et al. New Engl J Med. 2017;377:419-430. 2. GIAPREZATM (angiotensin II) [package insert]. San Diego, CA: La Jolla Pharmaceutical Company; 2017.
114163
37158
In the GIAPREZA-treated group, the median time to reach the target MAP endpoint
was 5 minutes2,a
GIAPREZA Placebo
Higher incidence of thrombotic and thromboembolic events in patients who
received GIAPREZA2
64
GIAPREZA: Adverse Reactions
GIAPREZATM (angiotensin II) [package insert]. San Diego, CA: La Jolla Pharmaceutical Company; 2017.
Patients with event, n (%)
GIAPREZA
N=163
Placebo
N=158
Thromboembolic eventsa 21 (12.9%) 8 (5.1%)
Deep vein thrombosis 7 (4.3%) 0 (0.0%)
Thrombocytopenia16 (9.8%) 11 (7.0%)
Tachycardia14 (8.6%) 9 (5.7%)
Fungal infection10 (6.1%) 2 (1.3%)
Delirium9 (5.5%) 1 (0.6%)
Acidosis9 (5.5%) 1 (0.6%)
Hyperglycemia7 (4.3%) 4 (2.5%)
Peripheral ischemia7 (4.3%) 4 (2.5%)
Adverse reactions occurring in ≥4% of patients treated with
GIAPREZA and ≥1.5% more often than in placebo-treated patients
aIncluding arterial and venous thrombotic events.
65
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
-2 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
Days from randomization
Placebo
GIAPREZA
Treatment Day 28 est. (95% CI) Hazard ratio (95% CI) p value
GIAPREZATM (angiotensin II) [package insert]. San Diego, CA: La Jolla Pharmaceutical Company; 2017.
• Concomitant use of ACE inhibitors may increase response to GIAPREZA
• Concomitant use of ARBs may decrease the response to GIAPREZA
Drug Interactions
• None Contraindications
68
GIAPREZA Summary
GIAPREZATM (angiotensin II) [package insert]. San Diego, CA: La Jolla Pharmaceutical Company; 2017.
• GIAPREZA is the only available vasopressor
that utilizes the Renin-Angiotensin-Aldosterone
System (RAAS)
• 70% of patients treated with GIAPREZA
achieved target MAP at hour 3 versus 23% of
patients treated with placebo
• Concomitant use of ACE inhibitors may
increase the response to GIAPREZA
Concomitant use of ARBs may decrease the
response to GIAPREZA
• In the GIAPREZA-treated group, the median
time to reach target MAP endpoint was 5
minutesa
aMAP response defined as an increase from baseline of ≥10 mm Hg or an increase to ≥75 mm Hg, without an increase in the dose of background vasopressors.
Modified intention-to-treat (mITT) population
Sepsis Case StudiesNovember 27 at 2 pm ET
Webinar seriesSepsis: Across the Continuum of Care
This webinar series is made possible with support from bioMérieux, Inc.
Sepsis in Older AdultsDecember 18 at 2 pm ET
Sharon Hansen, MN, RN, CCRN Critical Care Nurse Educator MultiCare Health System
Lori Olvera, DNP, RNC-OB, EFM-CPerinatal Educator Sutter Medical Center