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Emergency Department Management of Sepsis in the 21st Century

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    Emergency Department Management of Sepsis in the 21st Century Emergency Department Management of Sepsis in the 21st Century Presentation Transcript

    • Emergency Department Management of Sepsis in the 21 st Century Otto F Sabando D.O. FACOEP Program Director Emergency Medicine Residency Saint Joseph Regional Medical Center Paterson NJ Sepsis in the Emergency Department
    • Sepsis in the Emergency Department
      • Conflicts to report
        • None
      Sepsis in the Emergency Department
    • Scope of Problem
      • ED 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
    • Scope of Problem
      • More recent evidence suggests a larger problem
        • 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
    • Scope of Problem
      • Baby Boomers:
        • 78 million eligible for Medicare starting in 2011
          • Rate will be 10000/day beginning 2011
    • 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
    • Scope of Problem
      • SJHMC
        • 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
    • Sepsis in the Emergency Department
      • Define SIRS, sepsis, severe sepsis, septic shock and MODS.
      • Define early goal-directed therapy.
      • Discuss appropriate antibiotic usage in treatment of sepsis.
      • Discuss adjunctive medications used in the treatment of septic shock.
      Sepsis in the Emergency Department
    • Definitions
      • The Continuum
        • SIRS
        • Sepsis
        • Severe Sepsis
        • Septic Shock
      Sepsis in the Emergency Department
    • Definition - SIRS
      • Systemic Inflammatory Response Syndrome
        • 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
    • Definition - Sepsis
      • Sepsis
        • SIRS PLUS a documented infection
          • Positive CXR
          • Positive U/A
          • Cellulitis /Abscess
          • Positive Blood Culture
      Sepsis in the Emergency Department
    • Definition – Severe Sepsis
      • Severe 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
    • Definition – Septic Shock
      • Septic 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
    • Definition - MODS
      • MODS - Multiple Organ Dysfunction Syndrome
        • More than one major system failure.
        • Related to significant mortality.
          • > 50%
      Sepsis in the Emergency Department
    •  
      • From the case files of SJRMC ED
    • From the Case Files of SJRMC ED
      • CC: Fever
      • 88 y.o. male sent in by BLS for evaluation of fever. He states that he was discharged from the hospital 1 week ago for pneumonia. Today he had fever, noted by the atrium to be 103 orally and treated with Tylenol. His appetite is decreased and has no pain and no other complaints.
    • From the Case Files of SJRMC ED
      • PMH: Hypertension, pneumonia, CAD with pacemaker/defibrillator in place, anemia, gout, GERD, and enlarged prostate
      • Allergies: NKDA
      • Meds: Procrit, singulair, toporol XL, vitamin C, Allopurinol, cyanocobalamin, furosemide, hydroxyzine, magnesium, omeprazole
    • From the Case Files of SJRMC ED
      • SH: lives in NH rehab, tobacco 30 pack year history stopped 10 years ago
      • FH: Unremarkable
    • SJRMC Case
      • Vital signs: T: 97.6, P: 76, R: 18 BP 100/50 pulse ox 95% RA
      • Note the unstable vital signs!
    • Treatment of Septic Shock
      • Appropriate identification leads to more appropriate treatment.
      • Hypoperfusion – are we aggressive enough in the emergency department?
        • Source of infection
          • knowing local pathogens.
      • Delays in abx administration.
      Sepsis in the Emergency Department
    • Sepsis in the Emergency Department
    • Treatment of Septic Shock
      • Identification
        • 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
    • Treatment of Septic Shock
      • Identification – 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
      • Current Two weeks ago
    • Treatment of Septic Shock
      • Initiate broad-spectrumSite specific antibiotics
        • 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
    • Treatment of Septic Shock
      • Antibiotic 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 to same destination.
      Sepsis in the Emergency Department
    • Antibiotic Selection
      • Pneumonia
        • 3 rd 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.
      Sepsis in the Emergency Department
    • Antibiotic Selection
      • Urinary 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
    • Antibiotic Selection
      • Vancomycin
        • 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
    • Antibiotic Selection
      • Piperacillin/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
    • Antibiotic Selection
      • Ceftazidime /Cefepime
        • 3rd and 4th generation Cephalosporins (respectively).
        • Gram negative>Gram Positive coverage.
        • Good Pseudomonas coverage.
      Sepsis in the Emergency Department
    • Early Goal Directed Therapy (EGDT)
      • Study from NEJM November 8, 2001 Rivers, et.al
        • 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
    • Early Goal Directed Therapy
      • Treatment difference was invasive monitoring of CVP and Central Venous Oxygen 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
    • Sepsis in the Emergency Department
    • Early Goal Directed Therapy
      • In 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 within six hours.
      Sepsis in the Emergency Department
    • Early Goal Directed Therapy
      • Resuscitation 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
    • Early Goal Directed Therapy
          • Achieve MAP > 65
        • Continued fluid boluses.
          • Adequate fluid resuscitation is a key component.
        • Initiation of vasopressor agents.
          • Norepinephrine
          • Dopamine
        • Norepinephrine appears to be the more common choice.
      Sepsis in the Emergency Department
    • Early Goal Directed Therapy
      • Norepinephrine
        • 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
    • Early Goal Directed Therapy
          • Achieve CVP 8 mmHg or greater
        • Goal is 12 mmHg in intubated patients.
        • Generally measured via an “above the diaphragm” central venous line.
          • Subclavian
          • Internal Jugular (preferred for US guided )
        • Achieved through repeated fluid boluses (normal saline, lactated ringers).
      Sepsis in the Emergency Department
    •  
    • Early Goal Directed Therapy
      • Central 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
    • Early Goal Directed Therapy
          • Achieve central venous oxygen sat. of 70%
            • 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
    • Early Goal Directed Therapy
      • Dobutamine
        • 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
    • Management of Septic Shock in the ED
    • Early Goal Directed Therapy
      • Summarizing 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
    • Early Goal Directed Therapy
      • Summarizing 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
    • Thank you
      • David Adinaro MD FACEP
        • Member Stomp Sepsis Committee
        • Research Director ED
      • Robert Ameruso MD
        • Chair Internal Medicine
        • Chair Stomp Sepsis Committee
    • Questions?
        • Otto F Sabando DO FACOEP
        • [email_address]
        • www.emresidency.info
      Sepsis in the Emergency Department
    • Bibliography
      • Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001; 29:1303-1310.
      • Annane D, et al. “Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock .” JAMA . 288(7):862-71, 2002 Aug.
      • Briegel J, et al. “Stress doses of hydrocortisone reverse hyperdynamic septic shock: a prospective, 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 the emergency department.” Emergency Medicine Clinics of North America . 26(3):603-23, vii, 2008 Aug.
      • Delinger et al. “Surviving Sepsis Campaign guidelines for management of severe
      • sepsis and septic shock” . Critical Care Medicine . 32:3. March 2004.
      • De Miguel-Yanes JM. et al . Failure to implement evidence-based clinical guidelines for sepsis 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 Database of Systematic Reviews . 3, 2008 .
      Sepsis in the Emergency Department
    • Bibliography
      • Marti-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 the Literature and Emergency Department Guidelines”. Annals of Emergency Medicine. 48:28-54. July 2006
      • Osborn, Nguyen, Rivers. “Emergency Medicine and the Surviving Sepsis Campaign: An International Approach to Managing Severe Sepsis and Septic Shock”. Annals of Emergency Medicine . 46:3. Sept. 2005.
      • Pines, Jesse M. “Timing of antibiotics for acute, severe infections.” Emergency Medicine Clinics of North America . 26(2):245-57, vii, 2008 May.
      • Sebat, F. “A multidisciplinary community hospital program for early and rapid resuscitation 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 spectrum antibiotics for severe sepsis in adults. Cochrane Database of Systematic Reviews . 3, 2008.
      • Sivayoham N. “Management of severe sepsis and septic shock in the emergency department: 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