2018 UF ED/Trauma Symposium

1. Faheem Guirgis MD, FACEP
Assistant Professor of Emergency Medicine
Division of Research
Department of Emergency Medicine
UF Health Jacksonville
8 Tips for Treating Sepsis

2. Financial Disclosures
 K23 from NIGMS
 NIH Loan Repayment Program

3. Objectives
 Learn rapid stepwise assessment of possible
sepsis patients
 Learn how to evaluate patients for organ
dysfunction
 Review evidence-based early sepsis management
 Discuss common pitfalls and how to avoid them
 Review and discuss recent literature and
implications for sepsis management

4. Fundamental Question
What is the diagnostic approach
to evaluate a patient with an
infection for sepsis?

5. Stepwise Assessment for sepsis
in patients with infection
Assess and Address:
 1. Critical instability
 2. Clinical signs of organ dysfunction (qSOFA)
 3. Subtle signs of organ dysfunction

6. 1. Critical Instability
 Always start with ABCs
 Immediate interventions
 Hypoxia, respiratory distress, hypotension,
hypoperfusion, hypothermia/hyperthermia, or
hypoglycemia

7. +
2. Bedside assessment
Infection?

8. UF JAX QSOFA

9. qSOFA
“rule-in for high risk sepsis”
NOT
a screening tool

10. 3. Subtle Signs of Organ
Dysfunction
 Lactate > 2 mmol/L
 PaO2/FiO2 < 400, SpO2/FiO2 < 302
 Platelets < 150k
 Tbili > 1.2 (clinical indication)
 MAP < 70
 GCS < 15
 Cr > 1.2

12. Case 1
A 60-year-old man w/ PMH prostate CA (in remission)
presents with burning with urination and fever for the 3
days.
HR 110, BP 130/90, RR 20, SpO2 98%,Temp 102 F.
Exam – Mild suprapubic tenderness, B CVA tenderness
WBC 18k with 5% bands, Cr 1.5, Platelets 130k, UA 80
WBCs, + Nit/LE; Lactate 1.2
AfterTylenol and Fluids, the patient wants to leave…

13. Case 2
A 70 yof with PMH DM, HTN, CVA arrives via EMS from a local
NH for fever and right leg pain.
NH Staff say she’s “not acting right”
EMSVitals: BP 85/50, HR 105, RR 20, 99.5 F, O2 96%, glucose
270 mg/dL.
Exam – AOx1; tender, warm and erythematous right leg;
Crepitus to foot
What next?

14. Ready for the 8 tips?
Stay Tuned…

15. 1. Follow the 4 F’s.
Figure it out early
Fill the tank
Fight the bugs
Fix perfusion

16. 2. Empiric Fluids Plus Ultrasound
(fill the tank)

17. Empiric Fluids
 Currently CMS requires 30 ml/kg fluids to be
given to patients with septic shock in the first
3 hours
 CMS definition of shock =
 Lactate > 4
 Hypotension not responsive to fluids

18.  11k patients, multi-center study
 Improved outcomes for early fluids
compared to delayed fluids (> 120
min)
 Mortality OR increased 1.09 per hr

19.  49k patients, multicenter study
 Higher risk-adjusted mortality
 > 3 hr to bundle completion (1.04 per
hour)
 longer time to antibiotics (1.04 per hour)
 Longer time to fluids was not associated
with increased risk of mortality (1.01)

20. Beyond Empiric Fluids - US
Learn from the experts

21. Cardiac Ultrasound
Quick estimation of EF – Good squeeze

22. Bad Squeeze

23. IVC Ultrasound

24. 3 cm
Spontaneously breathing patient - 40-50% collapse

26. IVC Collapse - Intubated
Neurocrit Care. 2010;13:3 (Intensive Care Med. 2004 Sep;30(9):1834-7)

27. 3. Antibiotics
TIMING IS EVERYTHING

28. Use a full loading dose of
early, broad-spectrum
antibiotics

29. Antibiotics
Antibiotics in the 1st hour (all sepsis)
Studies
49k - 1.04 per hour mortality (Seymour, et al)
35k - increased odds of death (1.09) (Liu et al)
Kumar study – 8% mortality increase/hr
Post-shock = OR 2.4 mortality (Puskarich et al)

30. 4. Source ID and Control

31. “Sepsis is a compulsive search
for a source of infection”
1. Treat the patient like a trauma – fully expose
2. The less the patient can tell you the more
compulsive the search

32. Source Severity should be
proportional to severity of
illness
 Don’t blame the UA!
 Source control ASAP
 Remove infected lines
 IR/Surgery

33. 5. Know your vasoactive meds
2016 Guidelines
 Norepinephrine 1st agent
 Vaso or Epi as 2nd agent
 Dopamine – increased risk of
mortality in septic shock and
cardiogenic shock

34.  Adult patients on norepinephrine of 0.2
mcg/kg/min
 Improved MAP ≥ 75 mm Hg (p< 0.001)
 Improved CV SOFA at 48 hours (p = 0.01)
 No difference in mortality
 FDA warning – increased thrombosis?

36.  Shock, mechanical ventilation, + pressors ≥ 4 hrs
 3800 patients (HC 200 mg/day vs placebo)
 No 90 day mortality difference (27.9% HC,
28.8%P)
 HC patients, shorter time to:
 Shock resolution (3 vs. 4 days, p < 0.001)
 ICU discharge (10 vs. 12 days, p < 0.001)
 Cessation of initial mechanical ventilation (6 vs. 7 days)

37. 6. Recognize “Talk and Die”
Sepsis Patients
 Asplenic Pneumonia
 NSTIs
 CdiffToxic Megacolon/Dead gut
 Meningococcal meningitis
 Post-flu MRSA Pneumonia

38. Watch out for POOP

39. 7. Understand lactate-guided
resuscitation
Strength: High lactate is associated with poor
outcomes.

40. Failure to normalize lactate
Repeat Lactate ≥ 5 has 90% specificity for early death

41. Lactate Limitations
 Lactate can come from many different sources
 Anaerobic metabolism
 Reduced clearance (liver/kidney)
 B1 adrenergic stimulation (Na+/K+ ATPase)
 Altered mitochondrial function or “cytopathic
hypoxia”
 Lactate can be normal in septic shock

42.  26% of High shock index patients became
hypotensive post induction
 Low shock index patients became
hypertensive
8. Optimize Hemodynamics prior
to Intubation

43.  Fluid load
 Push-dose vasopressors or norepinephrine drip
initiated prior to intubation
 Half dose induction meds for RSI, Max dose
paralytics
Intubation for Shock

44. Back to our Cases

45. Case 1 - Stepwise Assessment
60 yom with Fever, Back pain, + UA
 1. Critical Instability? No
 2. Bedside assessment?
 qSOFA negative
 3. Subtle organ dysfunction?
 Yes
 Cr of 1.5 mg/dL
 Platelet count of 130 x 103/mm3

46. Case 1 – 60 yom w/ UTI
 SOFA of 2
 Treated with sepsis bundle
 After his vital signs remained stable, the
patient was admitted to a monitored hospital
bed and was discharged to continue oral
antibiotics 2 days later.

47. Case 2 – Stepwise Assessment
70 yof with AMS and leg pain
 1. Critical Instability?
 Yes - Address hypotension with Fluid bolus
 2. Bedside assessment?
 qSOFA positive (hypotension + AMS)

48. Management
 Resus bay – Sepsis bundle, large bore IVs, 30
ml/kg fluid bolus
 Required norepinephrine (initiated at 10
mcg/min) to maintain a MAP > 65 mm Hg
 XRAY?

49. OR then SICU – discharged back to NH after 10
day hospital admission

50. The End!
 Thank you!
 Email with questions:
Faheem.Guirgis@jax.ufl.edu