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  • 1. Emergency DepartmentManagement of Sepsis in the 21st Century Otto F Sabando D.O. FACOEP Program Director Emergency Medicine Residency Saint Joseph Regional Medical Center Paterson NJ Sepsis in the Emergency Department
  • 2. Sepsis in the Emergency DepartmentConflicts toreport None Sepsis in the Emergency Department
  • 3. Scope of ProblemED visit related to sepsis 1992- 2001 2.8 million out of 712 million visits over a 10 year period. Severe sepsis diagnosed in about 10% of these sepsis patients. Approximately 1.5 sepsis related visits1000 pop. Top chief complaints: fever, dyspnea, generalized weakness. Septic Shock Mortality 25-40% Sepsis in the Emergency Department
  • 4. Scope of ProblemMore recent evidence suggests a largerproblem 750,000 cases per year. 250,000+ deaths. Incidence increases with age. Yearly number expected to grow as population ages. Sepsis in the Emergency Department
  • 5. Scope of ProblemBaby Boomers: 78 million eligible for Medicare starting in 2011 Rate will be 10000/day beginning 2011
  • 6. Scope of Problem SJRMC Urban, tertiary care hospital. 92,000 ED visits in 2007. 18,000 admissions from ED. 403 severe sepsisseptic shock patients 323 from ED. 80 already admitted patients.Sepsis in the Emergency Department
  • 7. Scope of ProblemSJHMC Infectious origin 40% pneumonia 13% UTI 8% abdominal infections 39% other infections Mortality 48% prior to “Stomp Sepsis” 28% overall mortality 25% mortality of those admitted from ED Sepsis in the Emergency Department
  • 8. Sepsis in the Emergency DepartmentDefine SIRS, sepsis, severe sepsis, septicshock and MODS.Define early goal-directed therapy.Discuss appropriate antibiotic usage intreatment of sepsis.Discuss adjunctive medications used in thetreatment of septic shock. Sepsis in the Emergency Department
  • 9. DefinitionsThe Continuum SIRS Sepsis Severe Sepsis Septic Shock Sepsis in the Emergency Department
  • 10. Definition - SIRSSystemic Inflammatory ResponseSyndrome Manifested by 2 or more of the following: Temperature > 38°C (100.4F) or < 36°C (96.8F) HR > 90 BPM RR > 20/min or PaCO PaCO2 < 32 mm Hg WBC 12,000 or >10 bands Systemic Sepsis in the Emergency Department
  • 11. Definition - SepsisSepsis SIRS PLUS a documented infection Positive CXR Positive U/A Cellulitis /Abscess Positive Blood Culture Sepsis in the Emergency Department
  • 12. Definition – Severe SepsisSevere Sepsis One Sepsis related organ dysfunction (non- chronic) and/or: Signs of hypoperfusion (Lactate>2, oliguria , altered mental status, mottling, desaturation, elevated LFT’s) AND/or Hypotension SBP <90 MAP<60 Sepsis in the Emergency Department
  • 13. Definition – Septic ShockSeptic Shock Severe sepsis with persistent hypotension (refractory to fluid bolus) or: Acute circulatory failure in an infected patient not explained by another cause . Significant vasodilation (low SVR) is primary cause of hypotension . Heart rate, CO, and Stroke Volume are usually good . Sepsis in the Emergency Department
  • 14. Definition - MODSMODS - Multiple Organ DysfunctionSyndrome More than one major system failure. Related to significant mortality. > 50% Sepsis in the Emergency Department
  • 15. From the case files of SJRMC ED
  • 16. From the Case Files of SJRMC EDCC: Fever88 y.o. male sent in by BLS for evaluationof fever. He states that he was dischargedfrom the hospital 1 week ago forpneumonia. Today he had fever, noted bythe atrium to be 103 orally and treated withTylenol. His appetite is decreased and hasno pain and no other complaints.
  • 17. From the Case Files of SJRMC EDPMH: Hypertension, pneumonia, CAD withpacemaker/defibrillator in place, anemia,gout, GERD, and enlarged prostateAllergies: NKDAMeds: Procrit, singulair, toporol XL,vitamin C, Allopurinol, cyanocobalamin,furosemide, hydroxyzine, magnesium,omeprazole
  • 18. From the Case Files of SJRMC EDSH: lives in NH rehab, tobacco 30 packyear history stopped 10 years agoFH: Unremarkable
  • 19. SJRMC CaseVital signs: T: 97.6, P: 76, R: 18 BP 100/50pulse ox 95% RANote the unstable vital signs!
  • 20. Treatment of Septic ShockAppropriate identification leads to moreappropriate treatment.Hypoperfusion – are we aggressive enoughin the emergency department?Source of infection knowing local pathogens.Delays in abx administration. Sepsis in the Emergency Department
  • 21. Sepsis in the Emergency Department
  • 22. Treatment of Septic ShockIdentification Continuous monitoring Pulse, blood pressure, pulse ox, urine output Laboratory tests Blood and urine cultures. Lactate Acid (a marker of tissue hypoxia) Chest Radiography Pneumonia makes up a large portion of the cases. Remember – initial complaints can be nonspecific. Sepsis in the Emergency Department
  • 23. Treatment of Septic ShockIdentification – Search for source Lung-Pneumonia/Lung Abscess UTI/Pyelonephritis Heart -Endocarditis Abdomen-Bowel Perforation Brain-Meningitis Bone-Osteomyelitis Cellulitis Pressure ulcers Sepsis in the Emergency Department
  • 24. Current Two weeks ago
  • 25. Treatment of Septic ShockInitiate broad-spectrumSite specificantibiotics Goal is administration within three hours of arrival in ED. Several studies support the concept of “earlier the better” EarlyAppropriate antibiotics appear to affect outcomes. Cochrane paper underway on subject Sepsis in the Emergency Department
  • 26. Treatment of Septic ShockAntibiotic Choices Base on suspected pathogen information. Remember previous cultures on your patient! Adapt to local pathogensantibiotogram. Consider MRSA coverage Many institutions routinely include. Many paths the Emergency Department Sepsis in to same destination.
  • 27. Antibiotic SelectionPneumonia 3rd generation or greater fluoroquinolone – Levofloxacin (750mg), Moxifloxacin (500mg) + Vancomycin +- Gentamicin Linezolid good coverage for VRE, MRSA, Strep. Pneumo. PiperacillinTazobactam Consider adding an aminoglycoside for pseudomonal coverage. in the Emergency Department Sepsis
  • 28. Antibiotic SelectionUrinary Tract Infection PiperacillinTazobactam (3.375 – 4.5 grams q6) + Gentamicin (7 mgkg, q24hours) May substitute ceftazidime, cefepime, aztreonam, imipenem, or meropenem.Meningitis Dexamethasone 10mg IV (before ABX) Vancomycin 1 gram IV Ceftriaxone 2 grams IV Sepsis in the Emergency Department
  • 29. Antibiotic SelectionVancomycin Only Gram Positive coverage. Best for resistant strains of Strep (MRSA). Rarely used alone .Linezolid In a new class of antibiotics ( oxazolidinones ). Primarily covers aerobic Gram positive organisms (including MRSA). Strep pneumoniae (including multi multi-drug resistant strains). Enterococcus faecium (including VRE). Sepsis in the Emergency Department
  • 30. Antibiotic SelectionPiperacillin/Tazobactam Semi -synthetic penicillin plus a β Lactamase inhibitor. Gram positive and some Gram neg. and anaerobes. Used with an aminoglycoside for Pseudomonas. 3.375 grams to 4.5 grams IVPB Q 6hrs Sepsis in the Emergency Department
  • 31. Antibiotic SelectionCeftazidime /Cefepime 3rd and 4th generation Cephalosporins (respectively). Gram negative>Gram Positive coverage. Good Pseudomonas coverage. Sepsis in the Emergency Department
  • 32. Early Goal Directed Therapy (EGDT)Study from NEJM November 8, 2001Rivers, Patients with severe sepsis and septic shock randomly assigned to get 6 hours EGDT or standard therapy. In-hospital mortality was 30.5% for EGDT group and 46.5% for standard therapy group. NNT was 6 to save one additional life. Sepsis in the Emergency Department
  • 33. Early Goal Directed TherapyTreatment difference was invasivemonitoring of CVP and Central VenousOxygen Saturation. No difference in total volume replacement or inotrope use during initial 72 hours. Front loaded in the treatment group (including use of dobutamine). Treatment group much more likely to have received blood transfusions. Sepsis in the Emergency Department
  • 34. Sepsis in the Emergency Department
  • 35. Early Goal Directed TherapyIn 2004 Surviving Sepsis Campaign Adapted the original Rivers’ Protocol and other research Created practice guidelines. Outlined resuscitation and management bundles. Stated goal was 25% reduction in mortality.Severe Sepsis Resuscitation Bundle.Goal was to perform outlined tasks withinsix hours.Sepsis in the Emergency Department
  • 36. Early Goal Directed TherapyResuscitation Bundle included: Measurement of Lactic acid. Blood cultures prior to antibiotic administration. Appropriate broad spectrum antibiotics in 3 hours (ED arrival). IF hypotension IV fluid bolus (20mlkg initial) IF continued hypotension or lactic acid > 4 Achieve MAP > 65 Achieve central venous pressure 8 mmHg or greater Achieve central venous oxygen sat. of 70% Sepsis in the Emergency Department
  • 37. Early Goal Directed TherapyAchieve MAP > 65 Continued fluid boluses.Adequate fluid resuscitation is a key component. Initiation of vasopressor agents.NorepinephrineDopamine Norepinephrine appears to be the more common choice. Sepsis in the Emergency Department
  • 38. Early Goal Directed TherapyNorepinephrine Extensive a-adrenergic response. Moderate b-adrenergic response. Works mostly through vasoconstrictive actions. Does not change heart rate, cardiac output. 0.05 – 5 microgramkgminute (titrated to effect). Sepsis in the Emergency Department
  • 39. Early Goal Directed TherapyAchieve CVP 8 mmHg or greater Goal is 12 mmHg in intubated patients. Generally measured via an “above the diaphragm” central venous line.SubclavianInternal Jugular (preferred for US guided) Achieved through repeated fluid boluses (normal saline, lactated ringers). Sepsis in the Emergency Department
  • 40. Early Goal Directed TherapyCentral Venous Pressure Pressure in Right Atrium . Reflective of Preload . Normal between 5 and 10 mmHg. Can be measured through a standard triple lumen catheter. Sepsis in the Emergency Department
  • 41. Early Goal Directed TherapyAchieve central venous oxygen sat. of70%– Can be drawn from same central line and run in a blood gas analyzer. (intermittent)– Continual monitoring available from a specialized catheter. (PreSep, Edwards)– If Hb less than 10 mgdl, transfuse PRBCs until you meet this goal.– If Hb already above 10 mgdl, use dobutamine to achieve this goal. Sepsis in the Emergency Department
  • 42. Early Goal Directed TherapyDobutamine Inotrope. Strong beta adrenergic response. Start at 5 mcgkgminute. Maximum of 20 mcgkgminute. May increase hypotension so norepinephrine may be required to counteract this effect. Goal is to increase cardiac output. Sepsis in the Emergency Department
  • 43. Management of Septic Shock in the ED
  • 44. Early Goal Directed TherapySummarizing EGDT Achieve adequate fluid resuscitation. Vasopressors to keep MAP > 65 mmHg. Measure CVP and Central Venous Oxygen Saturation Additional fluids to achieve adequate CVP. CV oxygenation as a marker of adequate tissue perfusion Maximize other parameters first (especially CVP). If anemic transfuse. If not anemic consider an inotrope (dobutamine). Sepsis in the Emergency Department
  • 45. Early Goal Directed TherapySummarizing EGDT Continuing research is being done to fine tune and support this approach. Clearly being more aggressive is beneficial. Septic shock patients tended to be under-resuscitated coming out of ED. Better coordination between ED and ICU is critical. Sepsis in the Emergency Department
  • 46. Thank youDavid Adinaro MD FACEP Member Stomp Sepsis Committee Research Director EDRobert Ameruso MD Chair Internal Medicine Chair Stomp Sepsis Committee
  • 47. Questions?Otto F Sabando DO Sepsis in the Emergency Department
  • 48. BibliographyAngus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in theUnited States: analysis of incidence, outcome, and associated costs of care. Crit CareMed. 2001; 29:1303-1310.Annane D, et al. “Effect of treatment with low doses of hydrocortisone andfludrocortisone on mortality in patients with septic shock.” JAMA. 288(7):862-71, 2002Aug.Briegel J, et al. “Stress doses of hydrocortisone reverse hyperdynamic septic shock: aprospective, randomized, double-blind, single-center study.” Critical care medicine.27(4):723-32, 1999 Apr.Catenacci MH. King K. “Severe sepsis and septic shock: improving outcomes in theemergency department.” Emergency Medicine Clinics of North America. 26(3):603-23,vii, 2008 Aug.Delinger et al. “Surviving Sepsis Campaign guidelines for management of severesepsis and septic shock” . Critical Care Medicine. 32:3. March 2004. De Miguel-Yanes JM. et al . Failure to implement evidence-based clinical guidelines forsepsis at the ED.American Journal of Emergency Medicine. 24(5):553-9, 2006 Sep.Marti-Carvajal, et al. “ Human recombinant activated protein C for severe sepsis.”.Cochrane DatabaseSepsis in the Emergency Department . of Systematic Reviews. 3, 2008
  • 49. BibliographyMarti-Carvajal, et al. “ Human recombinant activated protein C for severe sepsis.”.Cochrane Database of Systematic Reviews. 3, 2008.Nguyen, Rivers, Abrahamian, et al. “Severe Sepsis and Septic Shock: Review of theLiterature and Emergency Department Guidelines”. Annals of Emergency Medicine.48:28-54. July 2006Osborn, Nguyen, Rivers. “Emergency Medicine and the Surviving Sepsis Campaign: AnInternational Approach to Managing Severe Sepsis and Septic Shock”. Annals ofEmergency Medicine. 46:3. Sept. 2005.Pines, Jesse M. “Timing of antibiotics for acute, severe infections.” Emergency MedicineClinics of North America. 26(2):245-57, vii, 2008 May.Sebat, F. “A multidisciplinary community hospital program for early and rapidresuscitation of shock in nontrauma patients”. Chest. Issue 5, pp.1729-1743, 2005 VO:127.Siddiqui, et al. “Early versus late pre-intensive care unit admission broad spectrumantibiotics for severe sepsis in adults. Cochrane Database of Systematic Reviews. 3,2008.Sivayoham N. “Management of severe sepsis and septic shock in the emergencydepartment: a survey of current practice in emergency departments in England.Emergency Medicine Journal. 24(6):422, 2007 Jun.Strehlow, MC et al. “National Study of Emergency Department Visits for Sepsis 1992-2001”, Annals of Emergency Medicine. 48:3. Sept. 2006. Sepsis in the Emergency Department