THINK SEPSIS
Lessons from the Confidential
Enquiries 2009-12
David Churchill
Classification
83 deaths in total were attributed to sepsis
20 = Direct (Genital Tract)
63 = Indirect (other infections inc 36 influenza)
12 = Late deaths (after 42 days)
(Also included in the chapter are deaths from the Republic of
Ireland)
The confidential enquiry also included a review of 34
women with septic shock from the UKOSS study
Characteristics of Women who Died
• Age
• Median age 30 years (range 17- 45)
• 35% (n=7) of women who died from Genital Tract Sepsis
were > 35 years, whereas for the influenza and other groups
the figure was 22% & 26%
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Primiparous = 33%
Minority ethnic groups = 33%
Born outside the UK = 24%
Died in the postnatal period = 82%
Smoked = 24%
– the majority of women who smoked (13 out of 20) died from a
respiratory cause
• Obese = 22%
Characteristics of women who survived
septic shock
Survivors of septic shock (n = 69)
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Primiparous = 36% (n=25)
Minority ethnic groups = 36% (n=25)
Smoked = 30% (n=21)
Pre-existing Medical Problem = 26% (n=18)
Obese = 13% (n=9)
A sample of 34 of these women were included in the
confidential enquiry
Acosta CD, Kurinczuk JJ, Lucas DN, Tuffnell DJ, et al. (2014) Severe Maternal Sepsis in
the UK, 2011–2012: A National Case-Control Study. PLoS Med 11(7): e1001672.
Comparison between women who
died and women who survived
Classification of care
received
Percentage of
women who died
Percentage of
women who
survived
Good care
23%
26%
Improvements to care
which would have
made no difference to
outcome
Improvements to care
which may have made
a difference to
outcome
14%
53%
63%
21%
Themes
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Delay in diagnosis
Incomplete assessment
Immediate management
Antibiotics
Lactate
Fluid management
Assessment & deterioration
Care setting
Communication
Governance
Theme:
Delay in Diagnosis
Vignette (precis) page 30
• A woman was unwell and hypoxic 2 hours after delivery. After
inadequate assessment she was diagnosed with hypovolaemic
shock. After failing to respond to fluids she was taken to theatre for a
hysterectomy. However she had a cardiac arrest and died. The
autopsy found overwhelming group A streptococcus sepsis.
Recommendation
• “Think Sepsis”
at an early stage when presented with an unwell pregnant or recently
pregnant woman, take the appropriate observations and act on them.
Theme:
Delay in Diagnosis
• The key actions for diagnosis and management
of sepsis are:
• Timely recognition
• Fast administration of intravenous antibiotics
• Quick involvement of experts - senior review is
essential
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NHS England Patient Safety Alert NHS/PSA/R/2014/015 (NHS England 2014)
Theme:
Incomplete
Assessment
Vignette (precis) page 32
• Three hours after delivery a woman was noted to be
tachycardic with a low blood pressure. Observations
were not plotted on a suitable chart. She was discharged
for low risk postnatal care. She was seen by the CMW
24 hours later but no observations were taken. On day 4
she was admitted to A&E but was diagnosed ‘dead on
arrival’. Investigations taken in hospital were abnormal.
Bloods indicated sepsis and an HVS culture grew a
group A streptococcus.
Theme: Incomplete Assessment
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Pulse
Blood Pressure
Temperature
&
Respiratory rate
Themes Postnatal
Delay in Diagnosis & Incomplete Assessment
Recommendations
• In the postnatal period health professionals
must perform and record a full set of
physiological vital signs, pulse, blood
pressure, temperature and respiratory rate, in
any woman with symptoms or signs of ill
health.
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NICE Postnatal Care Guideline CG37 & RCOG green-top guideline 64a
• (National Institute for Healthcare Excellence 2006; RCOG 2012)
Theme:
Immediate treatment
Vignette (precis) page 30
• Seven days post delivery a woman returned to the triage
unit. She was tachycardic, tachypnoeic and febrile. She
was diagnosed with sepsis secondary to retained
products of conception, which were removed promptly
following resuscitation and early antibiotics. She made a
full recovery.
• Early recognition, clear advice and prompt treatment led
to a good outcome without any further complications.
Theme:
Immediate treatment
Recommendation
• Where sepsis is suspected a sepsis care bundle must
be applied in a structured and systematic way with
urgency. Each maternity unit must have a protocol for
which bundle to use and audit its implementation.
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RCOG Green-top guidelines 64a & 64b (RCOG 2012; RCOG 2012)
The “sepsis six” care bundle
• - Take an arterial blood gas and give high flow oxygen if required
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- Take blood cultures
- Commence intravenous antibiotics
- Start intravenous fluid resuscitation
- Take blood for haemoglobin and lactate levels
- Measure the urine output hourly
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(The UK Sepsis Trust 2013)
Antibiotics
• Antibiotics within the ‘Golden
Hour’
• Time to administration is a predictor of mortality.
From time of diagnosis each hour’s delay in
administration of antibiotics increases the chance
of death by 8%.
(Kumar et al. Crit Care Med. 2006,34;1589-1596)
• Initially broad spectrum then narrowed as results from
microbiology become available
• Use local prescribing guidance
• Women from outside the UK more likely to be infected by
resistant organisms
Lactate
• Strong indicator of multi-organ failure
• > 1mmol/L occurs in sepsis
• > 4mmol/L establishes severe sepsis
• Postnatal - there may be a transient rise in
lactate BUT do not dismiss if signs of
infection or the rise is sustained.
Fluid Resuscitation
• IV fluid bolus(es) to support the circulation
• Appropriate on going monitoring – Pulse,
Blood Pressure, Urine output.
• If the response is not sustained then
consider inotropes and invasive monitoring
Theme: Assessment & Monitoring
Recommendations
• Early advice from an infectious diseases physician or
microbiologist should be sought; this is essential in
instances where the woman fails to respond to the first
choice antibiotic. The choice of antibiotic may need to be
adjusted to widen the spectrum of organisms being
covered and/or in light of the suspected source of
infection.
• Clinicians should not only document an action plan in
the case record but initiate the actions required such
as the administration of antibiotics and the
commencement of fluids.
Theme: Assessment and Monitoring
Recommendation
• It is recommended that education on the recognition
and treatment of sepsis is integrated into the annual
training already taking place for all staff caring for
pregnant women, especially for those practicing in ‘low
risk’ settings.
Vignette (precis) page 34
• Two women presented in early pregnancy with sepsis
following miscarriage. In both women the sepsis was
diagnosed early and the sepsis resuscitation bundle
applied with speed. Both women had short periods of
level 2/3 care and made complete recoveries.
Theme:
Care setting
• Correct and repeated risk assessments
• Inappropriate ward settings for pregnant women
• Delivery Suite? / ITU? / HDU?
Recommendation
• There should be adequate provision of appropriate critical care
support for the management of a pregnant woman who becomes
unwell. All consultant led delivery suites must have access to
level 2 high dependency unit facilities that are appropriately
equipped and staffed by teams of senior obstetricians,
anaesthetists and midwives, skilled in looking after seriously ill
women especially those with sepsis. Plans should be in place for
provision of critical care on delivery units if this is the most
appropriate setting for a woman with sepsis to receive care.
Theme:
Communication
Vignette (precis) page 36
• A woman in the second trimester with PPROM on
erythromycin, declined admission to hospital. 48 hours
later she developed a vaginal discharge. After a medical
review there was no change in management. 24 hours
later she became unwell. He GP reduced the dose of
erythromycin feeling that her symptoms were side
effects. Later that day she was admitted in irreversible
septic shock and died.
• Communication between professionals
• Communication between units
• Communication with patients.
Theme:
Communication
Vignette (precis) page 36
• Seven hours following a caesarean section a woman
complained of offensive lochia. Twenty-four hours later
she became unwell and shocked. No other observations
were recorded. Medical review did not take place for 4
hours when the request was for a transfer to the delivery
unit. The transfer did not take place for another 4 hours.
Despite treatment she deteriorated further and was
transferred to ITU for 8 days before recovering.
• Incomplete observations, poor communication, including
with consultant staff, and a lack of prioritisation all
contributed to this woman’s deterioration and prolonged
stay on ITU.
Theme:
Communication
Recommendation
• The responsible consultant obstetrician must show
clear leadership and be responsible for liaising with
anaesthetists, midwives, infectious diseases
physicians/microbiologists and all other professionals
who need to be involved in the care of these women.
When a woman is transferred to level 3 / intensive
care, daily consultant obstetric involvement must
remain, even if only in a supportive role, until such time
that the woman is ready to be repatriated to the
maternity unit.
• RCOG Green-top guideline 64b (RCOG 2012)
Theme:
Governance
Recommendation
• A high quality multi-disciplinary serious
incident review / root cause analysis should be
carried out on all maternal deaths and all
women with severe sepsis by the unit in which
the woman was cared for, or when women die in
the community, by the institution responsible for
community services.
Summary
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Think sepsis
Act quickly with therapeutics
Measure & Monitor all vital signs
Obtain senior expert advice