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  • BACK-UP SLIDE: This slide shows specifically how the monitored parameters in EGDT were maintained.
    “The protocol was as follows: A 500-ml bolus of crystalloid was given every 30 minutes to achieve a central venous pressure of 8 to 12 mm Hg. If the mean arterial pressure was less than 65 mm Hg, vasopressors were given to maintain a mean arterial pressure of at least 65 mm Hg. If the mean arterial pressure was greater than 90 mm Hg, vasodilators were given until it was 90 mm Hg or below. If the central venous oxygen saturation was less than 70 percent, red cells were transfused to achieve a hematocrit of at least 30 percent. After the central venous pressure, mean arterial pressure, and hematocrit were thus optimized, if the central venous oxygen saturation was less than 70 percent, dobutamine administration was started at a dose of 2.5 µg per kilogram of body weight per minute, a dose that was increased by 2.5 µg per kilogram per minute every 30 minutes until the central venous oxygen saturation was 70 percent or higher or until a maximal dose of 20 µg per kilogram per minute was given. Dobutamine was decreased in dose or discontinued if the mean arterial pressure was less than 65 mm Hg or if the heart rate was above 120 beats per minute. To decrease oxygen consumption, patients in whom hemodynamic optimization could not be achieved received mechanical ventilation and sedatives.” (p. 1370)
  • Cause of in-hospital death:
    --Sudden Cardiovascular collapse
    Standard Tx= 25/119 (21%) EGDT 12/117 (10.3%)
    --MODS
    Standard Tx 26/119(21.8%) EGDT 19/117 (16.2%)
    P. 1374
  • Transcript

    • 1. Superbugs and SepsisSuperbugs and Sepsis Overview:Overview: MRSA in your Ambulance!MRSA in your Ambulance! Sepsis: Definitions and PathophysiologySepsis: Definitions and Pathophysiology Role of the EMS Provider in Early GoalRole of the EMS Provider in Early Goal Directed Therapy for Severe SepsisDirected Therapy for Severe Sepsis andand Septic ShockSeptic Shock Prehospital Testing of LactatePrehospital Testing of Lactate
    • 2. FacultyFaculty Michael Schmitz, DO, MSMichael Schmitz, DO, MS Department of Emergency MedicineDepartment of Emergency Medicine Southern Maine Medical CenterSouthern Maine Medical Center Andrew Turcotte, RN, BS, NREMT-P/CCEMT-Andrew Turcotte, RN, BS, NREMT-P/CCEMT- PP Kennebunk Fire RescueKennebunk Fire Rescue
    • 3. Thank youThank you  Cynthia Pernice, MPA, Maine HealthCynthia Pernice, MPA, Maine Health  Jennifer Granata, RN SMMCJennifer Granata, RN SMMC  Christopher Pare, EMT-PChristopher Pare, EMT-P  Matthew Sholl, MD, MPH, FACEPMatthew Sholl, MD, MPH, FACEP
    • 4. MRSA in Your Ambulance!MRSA in Your Ambulance!
    • 5. ObjectivesObjectives  Describe the basic characteristics of the bacteria,Describe the basic characteristics of the bacteria, Staphylococcus aureusStaphylococcus aureus  Discuss the history of drug-resistantDiscuss the history of drug-resistant Staphylococcus aureusStaphylococcus aureus in the hospital and thein the hospital and the communitycommunity  Discuss the types of infections associated withDiscuss the types of infections associated with MRSAMRSA  Present current research describing the prevalencePresent current research describing the prevalence of MRSA in the prehospital environmentof MRSA in the prehospital environment  Describe best Infection Control practicesDescribe best Infection Control practices
    • 6. What is MRSA?What is MRSA? MM ethicillinethicillin RR esistantesistant SS taphylococcustaphylococcus AA ureusureus
    • 7. DefinitionDefinition  Bacteria commonly carried on the skin or in theBacteria commonly carried on the skin or in the nose of healthy peoplenose of healthy people  MRSA may be present without causing infectionMRSA may be present without causing infection  25% to 30% of the population is “colonized”25% to 30% of the population is “colonized”  ““Staph” bacteria are one of the most commonStaph” bacteria are one of the most common causes of skin infections in the U.S.causes of skin infections in the U.S.
    • 8. History - MRSAHistory - MRSA  First described in 1961 in the United KingdomFirst described in 1961 in the United Kingdom  First recognized in the 1970’s causing epidemics in healthcare settings.First recognized in the 1970’s causing epidemics in healthcare settings. These strains are referred to as (HCA-MRSA)These strains are referred to as (HCA-MRSA)  Generally resistant to most antibiotics: all beta-lactams, usuallyGenerally resistant to most antibiotics: all beta-lactams, usually macrolides, clindamycin, quinolones, and tetracyclinesmacrolides, clindamycin, quinolones, and tetracyclines  Risk factors for HCA-MRSA:Risk factors for HCA-MRSA: –– prolonged hospitalizationprolonged hospitalization –– care in an intensive care unitcare in an intensive care unit –– prolonged antimicrobial therapyprolonged antimicrobial therapy –– surgical proceduressurgical procedures –– close proximity to an infected/colonized patientclose proximity to an infected/colonized patient  Usually considered an infection of chronically ill, hospitalized patientsUsually considered an infection of chronically ill, hospitalized patients
    • 9. Community-Acquired Methicillin-ResistantCommunity-Acquired Methicillin-Resistant Staphylococcus aureusStaphylococcus aureus (CA-MRSA)(CA-MRSA)  A new strain of MRSA presenting from the community inA new strain of MRSA presenting from the community in persons without traditional risk factors for MRSApersons without traditional risk factors for MRSA  First known CA infection reported in 1980First known CA infection reported in 1980  Differing from HCA-MRSA in terms ofDiffering from HCA-MRSA in terms of –– EpidemiologyEpidemiology –– Antibiotic sensitivity patternsAntibiotic sensitivity patterns –– VirulenceVirulence –– PresentationPresentation –– TreatmentTreatment  Thought to have evolved separately in the communityThought to have evolved separately in the community based on genetic differencesbased on genetic differences
    • 10. CA-MRSA- PrevalenceCA-MRSA- Prevalence  Infection rates are increasingInfection rates are increasing A recent meta-analysis found CA-MRSA to account for 30%-A recent meta-analysis found CA-MRSA to account for 30%- 37% of all hospitalized MRSA patients37% of all hospitalized MRSA patients  In Los Angeles, a study demonstrated that CA-MRSA was the mostIn Los Angeles, a study demonstrated that CA-MRSA was the most common cause of community-acquired skin/soft tissue infectionscommon cause of community-acquired skin/soft tissue infections presenting to emergency roomspresenting to emergency rooms  A Houston study demonstrated that CA-MRSA accounted for 56% inA Houston study demonstrated that CA-MRSA accounted for 56% in 2000-2001, 57% in 2002 and 78% in 2003 of community-associated2000-2001, 57% in 2002 and 78% in 2003 of community-associated Staph aureus infections in hospitalized pediatric patientsStaph aureus infections in hospitalized pediatric patients  A Rhode Island study has demonstrated that up to 40% of childrenA Rhode Island study has demonstrated that up to 40% of children with MRSA have community acquired strainswith MRSA have community acquired strains
    • 11. MRSA-associated DiseasesMRSA-associated Diseases  Skin/soft tissue 1,266Skin/soft tissue 1,266 (77%)(77%)  Wound (Traumatic) 157Wound (Traumatic) 157 (10%)(10%)  Urinary Tract Infection 64Urinary Tract Infection 64 (4%)(4%)  Sinusitis 61Sinusitis 61 (4%)(4%)  Bacteremia 43Bacteremia 43 (3%)(3%)  Pneumonia 31Pneumonia 31 (2%)(2%)  Fridkin et al NEJM 2005;352:1436-44
    • 12. CA-MRSA Risk FactorsCA-MRSA Risk Factors  CA-MRSA appears to spread by close contactCA-MRSA appears to spread by close contact  In one study 26% of CA hand infections were MRSA-In one study 26% of CA hand infections were MRSA- positivepositive  Factors conducive to spread of the bacteria include:Factors conducive to spread of the bacteria include: –– Close skin to skin contactClose skin to skin contact –– Cuts or abrasionsCuts or abrasions –– Shared contaminated items or surfacesShared contaminated items or surfaces –– Poor hygienePoor hygiene –– Crowded living conditionsCrowded living conditions
    • 13. CA-MRSA: Signs/SymptomsCA-MRSA: Signs/Symptoms  CA-MRSA most often causes severe skin and soft tissueCA-MRSA most often causes severe skin and soft tissue infections.infections.  Skin and soft tissue infections often present as cellulitis,Skin and soft tissue infections often present as cellulitis, boils, or furuncles often in the thighs and buttocks.boils, or furuncles often in the thighs and buttocks.  Patients may think they have been bitten by a spider.Patients may think they have been bitten by a spider.  Children may present with a severe necrotizingChildren may present with a severe necrotizing pneumonia.pneumonia.  More serious infections like blood stream infections,More serious infections like blood stream infections, septic arthritis, osteomyelitis, septic arthritis, andseptic arthritis, osteomyelitis, septic arthritis, and endocarditis are possibleendocarditis are possible
    • 14. EMS and MRSAEMS and MRSA  A 2007 study tested fiveA 2007 study tested five specific areas in a fleet of 21specific areas in a fleet of 21 ambulances for MRSAambulances for MRSA contaminationcontamination – Steering wheel, left patientSteering wheel, left patient handrail, stretcher cushion,handrail, stretcher cushion, work area to the patient’swork area to the patient’s right, yankauer suction tipright, yankauer suction tip  Thirteen samples isolated fromThirteen samples isolated from 10 of the 21 ambulances10 of the 21 ambulances tested were positive (47.6%).tested were positive (47.6%). – 7/13 samples from the work7/13 samples from the work area to the right of the patientarea to the right of the patient tested positivetested positive --Prehospital Emergency Care 2007;11:241-244Prehospital Emergency Care 2007;11:241-244
    • 15. EMS and MRSAEMS and MRSA  A 2009 study examined the prevalence of MRSA on theA 2009 study examined the prevalence of MRSA on the stethoscopes of EMS providersstethoscopes of EMS providers – Stethoscopes, like doctor’s ties, are known fomites for MRSAStethoscopes, like doctor’s ties, are known fomites for MRSA  Of 50 stethoscopes that were swabbed, 16 (32%) were colonizedOf 50 stethoscopes that were swabbed, 16 (32%) were colonized with MRSAwith MRSA  LTTE in subsequent issue challenges this paper’s lab protocolLTTE in subsequent issue challenges this paper’s lab protocol Prehospital Emergency Care 2009;13:71-74
    • 16. PREVALENCE OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS IN AMBULANCES IN SOUTHERN MAINE Robert Brown, OMS-IV, Julianne Minnon, OMS-IV, Stephanie Schneider, OMS-IV, James Vaughn, PhD •Study published in 2010 •Lead author UNE MS-IV •Obtained samples from specified areas in 51 ambulances in southern Maine •25 (49%) had at least one area that was positive for MRSA •No statistical difference between fire- based vs. non-fire based services or based on call-volume •Statistically different lower rate of contamination among services providing paid, 24-hour coverage vs. those that did not
    • 17. PREVALENCE OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS IN AMBULANCES IN SOUTHERN MAINE
    • 18. PREVALENCE OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS IN AMBULANCES IN SOUTHERN MAINE
    • 19. PREVALENCE OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS IN AMBULANCES IN SOUTHERN MAINE
    • 20. Why is EMS at risk?Why is EMS at risk?  Fast turn-around timesFast turn-around times – Difficult to clean thoroughly following a callDifficult to clean thoroughly following a call  Working quickly in a confined spaceWorking quickly in a confined space  Patient’s isolation status may not bePatient’s isolation status may not be shared at time of transfer or be “buried” inshared at time of transfer or be “buried” in the chartthe chart
    • 21. PreventionPrevention  CDC’s “Five C’s”CDC’s “Five C’s” – CrowdingCrowding – Skin to skin contactSkin to skin contact – Compromised SkinCompromised Skin – Contaminated Items and SurfacesContaminated Items and Surfaces – Lack of CleanlinessLack of Cleanliness
    • 22. PreventionPrevention  Keep hands clean by washing thoroughly withKeep hands clean by washing thoroughly with soap and water or using an alcohol-based handsoap and water or using an alcohol-based hand sanitizersanitizer  Keep cuts and scrapes clean and covered with aKeep cuts and scrapes clean and covered with a bandage until healedbandage until healed  Avoid contact with other people’s wounds orAvoid contact with other people’s wounds or bandagesbandages  Avoid sharing personal items such as towels orAvoid sharing personal items such as towels or razorsrazors  If skin is dry, use a moisturizer to preventIf skin is dry, use a moisturizer to prevent crackingcracking
    • 23. HandwashingHandwashing  Without question, theWithout question, the most effective way tomost effective way to prevent transmissionprevent transmission  Alcohol based handAlcohol based hand sanitizers aresanitizers are effective againsteffective against MRSA, must be atMRSA, must be at least 60% alcoholleast 60% alcohol (CDC)(CDC)
    • 24. HandwashingHandwashing
    • 25. HandwashingHandwashing
    • 26. HandwashingHandwashing
    • 27. Celebrity Endorsement?Celebrity Endorsement?
    • 28. Objectives:Objectives:  Discuss the prevalence of sepsis in the UnitedDiscuss the prevalence of sepsis in the United StatesStates  Define systemic inflammatory responseDefine systemic inflammatory response syndrome, sepsis and septic shocksyndrome, sepsis and septic shock  Briefly discuss the pathophysiology of thisBriefly discuss the pathophysiology of this complex problemcomplex problem  Discuss the presentation of the septic patientDiscuss the presentation of the septic patient  Why is this important?Why is this important?
    • 29. Sepsis is….Sepsis is….  COMMONCOMMON  LETHALLETHAL  EXPENSIVEEXPENSIVE
    • 30. Sepsis By the NumbersSepsis By the Numbers  More than 750,000 cases of severe sepsis inMore than 750,000 cases of severe sepsis in the US each yearthe US each year  Mortality about 20% (recent decline)Mortality about 20% (recent decline)  Economic cost of $17 billion each yearEconomic cost of $17 billion each year  Incidence is projected to increase by 1.5%Incidence is projected to increase by 1.5% yearlyyearly  Although prognosis has improved, because ofAlthough prognosis has improved, because of increased incidence, actual deaths per year willincreased incidence, actual deaths per year will increaseincrease
    • 31. What is Sepsis?What is Sepsis?
    • 32. The Sepsis ContinuumThe Sepsis Continuum  A clinical responseA clinical response arising from aarising from a nonspecific insult, withnonspecific insult, with ≥≥2 of the following:2 of the following:  T >38T >38oo C or <36C or <36oo CC  HR >90 beats/minHR >90 beats/min  RR >20/minRR >20/min  WBC >12,000/mmWBC >12,000/mm33 or <4,000/mmor <4,000/mm33 oror >10% bands>10% bands SIRS = systemic inflammatory response syndrome SIRS with a presumed or confirmed infectious process Chest 1992;101:1644. SepsisSIRS Severe Sepsis Septic Shock Sepsis with organ failure Refractory hypotension
    • 33. SEPSIS DEFINED:SEPSIS DEFINED:  ““An inciting infectious event and host-An inciting infectious event and host- pathogen interaction leading topathogen interaction leading to hemodynamic consequences cause byhemodynamic consequences cause by the relationship among proinflammatory,the relationship among proinflammatory, antiinflammatory and apopotic mediators”antiinflammatory and apopotic mediators”  Rackow EC, Astiz ME. JAMA 1991; 266:548-554Rackow EC, Astiz ME. JAMA 1991; 266:548-554
    • 34. Sepsis: PathogenesisSepsis: Pathogenesis  Systemic proinflammatory reactionSystemic proinflammatory reaction causescauses endothelial damage, microvascularendothelial damage, microvascular dysfunction, and impaired tissue oxygenation.dysfunction, and impaired tissue oxygenation.  Excessive antiinflammatory responseExcessive antiinflammatory response triggers anergy and host immunosuppression.triggers anergy and host immunosuppression.  In addition, pro- and anti-inflammatoryIn addition, pro- and anti-inflammatory processes may interfere with each other,processes may interfere with each other, creating a state of destructive immunologiccreating a state of destructive immunologic dissonancedissonance Am J Physiol 1980; 239:F135.
    • 35. SEPSIS:SEPSIS: PRESENTATIONPRESENTATION  Pathogenesis starts before ICU admitPathogenesis starts before ICU admit  Patient vital signs alone may fail to detectPatient vital signs alone may fail to detect global tissue hypoxiaglobal tissue hypoxia  Early presentation may be subtleEarly presentation may be subtle (do not rely on fever alone)(do not rely on fever alone)  Early recognition is the key to successfulEarly recognition is the key to successful treatmenttreatment
    • 36. ROLE OF LACTATEROLE OF LACTATE  Lactate is a marker of anaerobicLactate is a marker of anaerobic metabolismmetabolism  Indicates global tissue hypoxia, criticalIndicates global tissue hypoxia, critical step is recognition and aggressivestep is recognition and aggressive treatmenttreatment  High lactate is associated w/ increasedHigh lactate is associated w/ increased morbidity/mortalitymorbidity/mortality
    • 37. Chest 2006;130;159-1595Chest 2006;130;159-1595
    • 38. SEPSISSEPSIS  Sepsis can be thought of as “a process ofSepsis can be thought of as “a process of malignant intravascular inflammation”malignant intravascular inflammation”  End result: a potentially lethal and complexEnd result: a potentially lethal and complex type of distributive shocktype of distributive shock  Troubling thought: “No autopsy studies haveTroubling thought: “No autopsy studies have revealed why patients with sepsis die.”revealed why patients with sepsis die.” NEJM 2003;348:2 138-150
    • 39. SO WHAT CAN BESO WHAT CAN BE DONEDONE TO INTERVENE ?TO INTERVENE ?
    • 40. EARLY GOAL-DIRECTED THERAPYEARLY GOAL-DIRECTED THERAPY FOR SEVERE SEPSIS AND SEPTICFOR SEVERE SEPSIS AND SEPTIC SHOCKSHOCK
    • 41. Objectives:Objectives: DefineDefine Early Goal-Directed TherapyEarly Goal-Directed Therapy (EGDT)(EGDT) for Severe Sepsis and Septic Shockfor Severe Sepsis and Septic Shock Review the literature evaluating EGDTReview the literature evaluating EGDT Discuss the impact of EGDT for treating sepsisDiscuss the impact of EGDT for treating sepsis Discuss the importance of fluid resuscitation inDiscuss the importance of fluid resuscitation in this patient populationthis patient population Discuss how to apply EGDT in the pre-hospitalDiscuss how to apply EGDT in the pre-hospital environmentenvironment
    • 42. NEJM 2001;345:1368 Purpose: “to evaluate the efficacy of early goal-directed therapy before admission to the intensive care unit”.
    • 43. Early Goal Directed TherapyEarly Goal Directed Therapy ““The administration of IV fluids, pressorsThe administration of IV fluids, pressors and transfusion based upon targets forand transfusion based upon targets for central venous pressure, blood pressure,central venous pressure, blood pressure, urine output, mixed venous oxygenurine output, mixed venous oxygen saturation and hematocrit to reducesaturation and hematocrit to reduce mortality in patients with severe sepsismortality in patients with severe sepsis and septic shock”and septic shock”
    • 44. HistoryHistory Physicians at Henry Ford Hospital hadPhysicians at Henry Ford Hospital had previously established lactate measurement aspreviously established lactate measurement as a screening test for severe sepsisa screening test for severe sepsis ((Chest 1996;110:145SChest 1996;110:145S)) Prevalence study estimated baseline mortality ofPrevalence study estimated baseline mortality of 51% for patients with severe sepsis and septic51% for patients with severe sepsis and septic shock at their facilityshock at their facility ((Acad Emerg Med 1997;4:402-403Acad Emerg Med 1997;4:402-403)) Basis for “standard treatment” arm of protocolBasis for “standard treatment” arm of protocol
    • 45. NEJM 2001;345:1368-77
    • 46. CVP: central venous pressure MAP: mean arterial pressure ScvO2: central venous oxygen saturation Early Goal-Early Goal- Directed TherapyDirected Therapy NEJM 2001;345:1368-77.
    • 47. 49.2% 33.3% 0 10 20 30 40 50 60 Standard Therapy N=133 EGDT N=130 P = 0.01* *Key difference was in sudden CV collapse, not MODS Early Goal-Directed Therapy Results:Early Goal-Directed Therapy Results: 28 Day Mortality28 Day Mortality Sudden CV Collapse MODS 21% vs 10% p=0.02 22% vs 16% P=0.27 NEJM 2001;345:1368-77. Mortality
    • 48. ResultsResults Decrease in incidence of suddenDecrease in incidence of sudden cardiopulmonary complications (cardiaccardiopulmonary complications (cardiac arrest), hypotension or acute respiratoryarrest), hypotension or acute respiratory failure in the EGDT group (p=0.02)failure in the EGDT group (p=0.02) Among survivors, EGDT associated withAmong survivors, EGDT associated with decreased length of stay (LOS) (p=0.04)decreased length of stay (LOS) (p=0.04)
    • 49. Key Components:Key Components: Fluid resuscitation!!Fluid resuscitation!! Appropriate cultures prior to antibioticAppropriate cultures prior to antibiotic administrationadministration Early targeted antibiotics and sourceEarly targeted antibiotics and source controlcontrol Use of vasopressors/inotropes when fluidUse of vasopressors/inotropes when fluid resuscitation optimizedresuscitation optimized
    • 50. The Surviving Sepsis CampaignThe Surviving Sepsis Campaign Launched in Fall 2002 as a collaborative effort toLaunched in Fall 2002 as a collaborative effort to condense management guidelines for sepsis.condense management guidelines for sepsis. Goal: complete “resuscitation bundle” within 6 hoursGoal: complete “resuscitation bundle” within 6 hours EGDT is the earliest step in the implementation of theEGDT is the earliest step in the implementation of the guidelinesguidelines Goal: reduce sepsis mortality by 25% in the next 5 yearsGoal: reduce sepsis mortality by 25% in the next 5 years Guidelines revealed at SCCM in Feb 2004Guidelines revealed at SCCM in Feb 2004  Critical Care MedicineCritical Care Medicine March 2004 32(3):858-87.March 2004 32(3):858-87.  Website: survivingsepsisWebsite: survivingsepsis..orgorg
    • 51. Chest 1992;101:1644.. SepsisSIRS Severe Sepsis Septic Shock Early Goal Directed Therapy Antibiotics and Source Control *
    • 52. The Campaign was associated withThe Campaign was associated with sustained, continuous quality improvementsustained, continuous quality improvement in sepsis care.in sepsis care. AlthoughAlthough not necessarilynot necessarily cause and effect,cause and effect, a reduction in reported hospital mortalitya reduction in reported hospital mortality rates was associated with participation.rates was associated with participation. The implications of this study can serve asThe implications of this study can serve as an impetus for similar improvement efforts.an impetus for similar improvement efforts. CONCLUSIONS:
    • 53. Example:Example: Cooper Hospital (NJ)Cooper Hospital (NJ) No additional staffingNo additional staffing No change in physicalNo change in physical structurestructure + Close cooperation+ Close cooperation All targets achieved inAll targets achieved in under 6 hoursunder 6 hours Mortality decreasedMortality decreased from 43.8 to 18.2%from 43.8 to 18.2% Chest 2006;129:225-32
    • 54. Example:Example: Carolinas MedicalCarolinas Medical Center:Center: 9% absolute mortality9% absolute mortality reduction (33% relativereduction (33% relative risk reduction) afterrisk reduction) after implementation ofimplementation of EGDT in their EDEGDT in their ED ((Chest 2007; 132:425-432)Chest 2007; 132:425-432)
    • 55. EGDT Follow-up Studies:EGDT Follow-up Studies: Survey of centers in 2006 using EGDT:Survey of centers in 2006 using EGDT: 1,298 patient charts reviewed1,298 patient charts reviewed Mean mortality pre-EGDT: 44.8 +/- 7.8%Mean mortality pre-EGDT: 44.8 +/- 7.8% Mean mortality post-EGDT: 24.5% +/- 5.5%Mean mortality post-EGDT: 24.5% +/- 5.5% Average reduction in mortality 20.3%Average reduction in mortality 20.3% (Chest Otero 2006)(Chest Otero 2006) Cost effectiveness: 23.4% reduction in hospitalCost effectiveness: 23.4% reduction in hospital costs for patients w/severe sepsis/shockcosts for patients w/severe sepsis/shock (Crit Care 2003;7(suppl):S116)(Crit Care 2003;7(suppl):S116)
    • 56. Q: How does EGDT compare toQ: How does EGDT compare to other emergency interventions?other emergency interventions? A: It’s HUGE!A: It’s HUGE!
    • 57. Number Needed to Treat:Number Needed to Treat: The reciprocal of the absolute risk reductionThe reciprocal of the absolute risk reduction between two treatment options in a studybetween two treatment options in a study NNT = 100 / Absolute Risk ReductionNNT = 100 / Absolute Risk Reduction NNT for EGDT = 5NNT for EGDT = 5
    • 58. Other NNT examples*:Other NNT examples*: Aspirin, 12-Lead and PCI with ECG to balloon < 90 minutesAspirin, 12-Lead and PCI with ECG to balloon < 90 minutes (NNT = 15)(NNT = 15) ARDS protocol (hospital)ARDS protocol (hospital) (NNT = 12)(NNT = 12) NIPPV for APENIPPV for APE (NNT = 6)(NNT = 6) BiPAP for COPD (ED)BiPAP for COPD (ED) (NNT = 10)(NNT = 10) Clinical hypothermia for cardiac arrest (hospital)Clinical hypothermia for cardiac arrest (hospital) (NNT = 6)(NNT = 6) Defib on scene < 5 minutes vs. < 8 minutesDefib on scene < 5 minutes vs. < 8 minutes (NNT = 8)(NNT = 8) Early identification and defibrillation for v. fibEarly identification and defibrillation for v. fib (NNT = 3)(NNT = 3) NNT is a statistic that is meant to be taken in context !!! Prehospital Emergency Care 2008, Vol 12 (2) 141-151
    • 59. SummarySummary 24 peer reviewed publications24 peer reviewed publications  2,000 patients2,000 patients 28 published abstracts28 published abstracts  10,000 patients10,000 patients All cite significant mortality benefit afterAll cite significant mortality benefit after implementing EGDTimplementing EGDT Proven in both the community andProven in both the community and academic settingacademic setting
    • 60. Universal Acceptance?Universal Acceptance?  NO, not without it’s critics:NO, not without it’s critics: ““Certain components may be more effective”Certain components may be more effective” ““Original study only examines 6 hours of a totalOriginal study only examines 6 hours of a total hospitalization that lasted on avg. 13 days”hospitalization that lasted on avg. 13 days” ““Some components impractical in ED” (SvO2)Some components impractical in ED” (SvO2) ““Too much work, ties up the nurses”Too much work, ties up the nurses” ““Better outcomes through more monitoring”Better outcomes through more monitoring”
    • 61. Crystalloid fluid resuscitation rated asCrystalloid fluid resuscitation rated as “strongly recommended” and supported by“strongly recommended” and supported by “moderate quality of evidence” in SSC“moderate quality of evidence” in SSC literatureliterature (Intensive care med 2008 Jan;34(1):17-60)(Intensive care med 2008 Jan;34(1):17-60)
    • 62. In other words:In other words: EARLYEARLY andand AGGRESSIVEAGGRESSIVE Fluid resuscitation isFluid resuscitation is CRITICAL !CRITICAL !
    • 63. Meta-analysis suggests that early, but notMeta-analysis suggests that early, but not late, hemodynamic optimization reducedlate, hemodynamic optimization reduced mortality in patients with sepsis. Allmortality in patients with sepsis. All patients received EGDT prior to ICUpatients received EGDT prior to ICU arrivalarrival Crit Care Med 2002;30:1686-1692Crit Care Med 2002;30:1686-1692  First 6 hours are important both for diagnosisFirst 6 hours are important both for diagnosis and evaluating effects of therapyand evaluating effects of therapy  Study did not account for EMS interventionStudy did not account for EMS intervention
    • 64. Has early intervention for the patient withHas early intervention for the patient with severe sepsis or septic shock ever beensevere sepsis or septic shock ever been studied in the prehospital environment?studied in the prehospital environment? Should it be?Should it be?
    • 65. OUT-OF-HOSPITAL FLUID IN SEVERE SEPSIS: EFFECT ON EARLY RESUSCITATIONOUT-OF-HOSPITAL FLUID IN SEVERE SEPSIS: EFFECT ON EARLY RESUSCITATION IN THE EMERGENCY DEPARTMENTIN THE EMERGENCY DEPARTMENT Christopher W. Seymour, MD, Colin R. Cooke, MD, MSCE, Mark E. Mikkelsen,Christopher W. Seymour, MD, Colin R. Cooke, MD, MSCE, Mark E. Mikkelsen, Julie Hylton, BS, Tom D. Rea, MD, MPH, Christopher H. Goss, MD, MSc,Julie Hylton, BS, Tom D. Rea, MD, MPH, Christopher H. Goss, MD, MSc, David F. Gaieski, MD, Roger A. Band, MDDavid F. Gaieski, MD, Roger A. Band, MD Objective: “to determine if the delivery of out-of-hospitalObjective: “to determine if the delivery of out-of-hospital fluid in patients with severe sepsis is associated withfluid in patients with severe sepsis is associated with reduced time to achievement of goal-orientedreduced time to achievement of goal-oriented resuscitation in the emergency department.”resuscitation in the emergency department.” Type: Secondary analysis of a retrospective, cohortType: Secondary analysis of a retrospective, cohort study in a metropolitan setting (Philadelphia) with a two-study in a metropolitan setting (Philadelphia) with a two- tier EMS responsetier EMS response..  Note: the original study evaluated use of EGDT inNote: the original study evaluated use of EGDT in their Emergency Departmenttheir Emergency Department Prehospital Emergency Care 14(2) 2010 145-152
    • 66. Key Question:Key Question: Is there an association between delivery ofIs there an association between delivery of out-of-hospital fluid by advanced lifeout-of-hospital fluid by advanced life support providers and the achievement ofsupport providers and the achievement of (EGDT) resuscitation endpoints within 6(EGDT) resuscitation endpoints within 6 hours after triage in the Emergencyhours after triage in the Emergency Department?Department?
    • 67. Twenty-five (48%) of 52 patientsTwenty-five (48%) of 52 patients transported by ALS with severe sepsistransported by ALS with severe sepsis received “prehospital fluid”received “prehospital fluid” ((note:note: quotations added for sarcastic emphasisquotations added for sarcastic emphasis)) Patients receiving these fluids had lowerPatients receiving these fluids had lower mean blood pressure and higher SOFAmean blood pressure and higher SOFA scoresscores
    • 68. Conclusion:Conclusion: Pt receiving prehospital IVF “approached”Pt receiving prehospital IVF “approached” but did not attain a statistically significantbut did not attain a statistically significant increase in the likelihood of achieving goalincrease in the likelihood of achieving goal for MAP w/in 6 hours and showed nofor MAP w/in 6 hours and showed no difference in achieving goal of CVP ordifference in achieving goal of CVP or ScvO2 while in the emergencyScvO2 while in the emergency department.department.
    • 69. Is this a good (strong) study?Is this a good (strong) study? How many patients needed to be enrolled in order toHow many patients needed to be enrolled in order to show a statistically significant difference between the twoshow a statistically significant difference between the two groups?groups? Were the patients in the two groups “equally sick”?Were the patients in the two groups “equally sick”? Why was it retrospective?Why was it retrospective? Does this help or hurt the study?Does this help or hurt the study? Reminder: What was the endpoint in the original EGDTReminder: What was the endpoint in the original EGDT paper? (not the goal)paper? (not the goal) Why did the authors choose a different endpoint?Why did the authors choose a different endpoint?
    • 70. Fluid ResuscitationFluid Resuscitation ““the early, hypovolemic,the early, hypovolemic, hypodynamic phase ofhypodynamic phase of sepsis is treated bysepsis is treated by providing appropriate,providing appropriate, high volume fluidhigh volume fluid resuscitation…resuscitation… crystalloid solutionscrystalloid solutions (6 to 10 L)(6 to 10 L) areare usually required duringusually required during the initial resuscitation”the initial resuscitation” Crit Care Med1999;27:639-660Crit Care Med1999;27:639-660
    • 71. FACT:FACT: One liter of normalOne liter of normal saline addssaline adds 275 ml275 ml to the patient’sto the patient’s plasma volumeplasma volume
    • 72. A Reminder….A Reminder…. GaugeGauge LengthLength Flow RateFlow Rate Minutes/LiterMinutes/Liter 2424 0.75"0.75" 17 mL/min.17 mL/min. 6060 2222 1.00"1.00" 28 mL/min28 mL/min 3535 2020 1.88"1.88" 42 mL/min42 mL/min 2525 1818 1.88"1.88" 79 mL/min79 mL/min 12.512.5 1616 1.88"1.88" 147 mL/min147 mL/min 6.86.8 1616 3.25"3.25" 127 mL/min127 mL/min 7.87.8 1616 5.25“5.25“ 108 mL/min108 mL/min 9.29.2 1414 1.88"1.88" 277 mL/min277 mL/min 3.63.6 1414 3.25"3.25" 249 mL/min249 mL/min 4.04.0 1414 5.25"5.25" 219 mL/min219 mL/min 4.54.5 1212 3.00"3.00" 449 mL/min449 mL/min 2.22.2 1010 3.00"3.00" 609 mL/min609 mL/min 1.61.6
    • 73. Indications:Indications: Appropriate when patient isAppropriate when patient is hemodynamically unstablehemodynamically unstable Goal: Optimize cardiac outputGoal: Optimize cardiac output  Increases tissue oxygen deliveryIncreases tissue oxygen delivery  Improves tissue oxygenationImproves tissue oxygenation  Increases arterial pressure and renalIncreases arterial pressure and renal perfusionperfusion  Decreased lacate levelsDecreased lacate levels  Improve systemic acidosisImprove systemic acidosis
    • 74. QUESTIONS:QUESTIONS: Will I harm my patient?Will I harm my patient? What about the dialysis patient?What about the dialysis patient?
    • 75. Back to RiversBack to Rivers Q: In the EGDT study, which group had aQ: In the EGDT study, which group had a higher rate of intubation and use ofhigher rate of intubation and use of mechanical ventilation?mechanical ventilation? A: The Standard care group!A: The Standard care group!
    • 76. No significant difference in rate of intubation andNo significant difference in rate of intubation and MV in first 6 hours in standard care groupMV in first 6 hours in standard care group (53.8%) vs. EGDT (53%)(53.8%) vs. EGDT (53%) From 7 to 72 hours, 16.8% standard careFrom 7 to 72 hours, 16.8% standard care needed ET/MV vs. 2.6% in EGDT (p < 0.001)needed ET/MV vs. 2.6% in EGDT (p < 0.001) Intubation at any point during hospitalization:Intubation at any point during hospitalization: 70.6% standard care vs. 55.6% in EGDT70.6% standard care vs. 55.6% in EGDT (p < 0.02)(p < 0.02)
    • 77. Back to RiversBack to Rivers Suggests that the need for ET/MV hasSuggests that the need for ET/MV has more to do with failure to resolve SHOCKmore to do with failure to resolve SHOCK w/in the first 24 hours rather thanw/in the first 24 hours rather than respiratory decompensation later.respiratory decompensation later. Timing matters!Timing matters!
    • 78. The Dialysis PatientThe Dialysis Patient Study in subset EGDT patientsStudy in subset EGDT patients 10 standard care, 8 EGDT10 standard care, 8 EGDT ET 50% vs. 29% ( p < 0.01)ET 50% vs. 29% ( p < 0.01) Mortality 70% vs. 14% (p < 0.01)Mortality 70% vs. 14% (p < 0.01) Standard care patients received LESSStandard care patients received LESS fluid overall compared to EGDT patientsfluid overall compared to EGDT patients (Crit Care Med 2004; 8 (suppl)P163(Crit Care Med 2004; 8 (suppl)P163
    • 79. DON’T WITHOLD IV FLUIDS FROM THEDON’T WITHOLD IV FLUIDS FROM THE HYPOTENSIVE, SYMPTOMATICHYPOTENSIVE, SYMPTOMATIC DIALYSIS PATIENT!!!!DIALYSIS PATIENT!!!!
    • 80. WarningsWarnings:: Maine EMS has notMaine EMS has not authorized orauthorized or endorsed an Earlyendorsed an Early Goal DirectedGoal Directed Therapy or SevereTherapy or Severe Sepsis protocol forSepsis protocol for EMS providersEMS providers
    • 81. The Road AheadThe Road Ahead Why is this important?Why is this important?
    • 82. Closing ThoughtsClosing Thoughts - The care of the critically ill- The care of the critically ill patient traverses patientpatient traverses patient location and depends on (thelocation and depends on (the timing of) critical actions bytiming of) critical actions by multiple health caremultiple health care providers and must bridgeproviders and must bridge care between specialties,care between specialties, departments and facilitiesdepartments and facilities - Sepsis is not an “ICU”-- Sepsis is not an “ICU”- limited illnesslimited illness - Peter Safar, MD- Peter Safar, MD (1924-2003)(1924-2003)
    • 83. Dr. Safar’s Roadmap forDr. Safar’s Roadmap for Performance ImprovementPerformance Improvement Must have a pre-determined, objectiveMust have a pre-determined, objective and comprehensive strategyand comprehensive strategy Identify high risk patients based on earlyIdentify high risk patients based on early signs and symptomssigns and symptoms Mobilize resources to interveneMobilize resources to intervene Execute protocol based on best evidenceExecute protocol based on best evidence Continually assess complianceContinually assess compliance Continually assess outcomeContinually assess outcome
    • 84. Does this concept of a “bundle of care”Does this concept of a “bundle of care” sound familiar?sound familiar? AMI, stroke and trauma have all seenAMI, stroke and trauma have all seen improvements in outcome after applicationimprovements in outcome after application of time-sensitive therapies.of time-sensitive therapies. (as well as teamwork)(as well as teamwork) ALL HAVE MULTIPLE CRITICALALL HAVE MULTIPLE CRITICAL PREHOSPITAL INTERVENTIONS!!PREHOSPITAL INTERVENTIONS!!
    • 85. Closing ThoughtsClosing Thoughts - Patient care is improved when- Patient care is improved when key interventions are initiated inkey interventions are initiated in the pre-hospital setting for athe pre-hospital setting for a variety of time-dependentvariety of time-dependent emergenciesemergencies - Evidence-based medicine is- Evidence-based medicine is going to shape how the practicegoing to shape how the practice of emergency medicine in theof emergency medicine in the pre-hospital setting evolvespre-hospital setting evolves - A preponderance of high quality,- A preponderance of high quality, peer-reviewed medical literaturepeer-reviewed medical literature proves that EGDT improvesproves that EGDT improves patient mortality and is cost andpatient mortality and is cost and time-efficienttime-efficient - Photo courtesy of Dan Limmer, used with permission
    • 86. Closing ThoughtsClosing Thoughts - Early and aggressive fluid- Early and aggressive fluid resuscitation for the symptomatic,resuscitation for the symptomatic, hypotensive septic patient ishypotensive septic patient is CRITICAL!CRITICAL! - This strategy is well-supported- This strategy is well-supported by a wide body of peer-reviewedby a wide body of peer-reviewed literatureliterature - There is still ample ground for- There is still ample ground for improvement and researchimprovement and research concerning the benefit ofconcerning the benefit of prehospital intervention for theprehospital intervention for the septic patientseptic patient
    • 87. VISION OF CRITICAL CAREVISION OF CRITICAL CARE ““Critical care is aCritical care is a concept, not a location,concept, not a location, which frequently beginswhich frequently begins with ED intervention andwith ED intervention and culminates in intensiveculminates in intensive care unit admission andcare unit admission and continued management.”continued management.” Peter Safar, MDPeter Safar, MD (1924-2003)(1924-2003) Clin Anesth 1974; 10:65-125
    • 88. Questions?Questions?

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