Lactate: How Sick Is Your Patient

11,073 views

Published on

Learn about lactate, lactate acidosis, sepsis, and how early goal directed therapy can save lives.

Published in: Education, Business
0 Comments
7 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
11,073
On SlideShare
0
From Embeds
0
Number of Embeds
19
Actions
Shares
0
Downloads
410
Comments
0
Likes
7
Embeds 0
No embeds

No notes for slide
  • Lactate: How Sick Is Your Patient

    1. 1. Lactate: How Sick Is Your Patient? Littleton/Porter/Parker EMS Wayne Guerra, MD, MBA Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    2. 2. Objectives <ul><li>What is lactate? </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Why should I care? </li></ul><ul><li>Sepsis </li></ul><ul><li>Sepsis EMS Pilot Study </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    3. 3. Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    4. 4. Case <ul><li>73 yo female, family calls because of weakness. </li></ul><ul><li>She has no complaints except for nausea and vomiting x2 </li></ul><ul><li>Meds: Remicaide, Lisinipril, Motirin, Vicodin </li></ul><ul><li>PMH: RA, Htn, </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    5. 5. Case contd. <ul><li>105/60, 95, 22, 100.6 </li></ul><ul><li>Lungs: CTA </li></ul><ul><li>Ht: RRR </li></ul><ul><li>Abd: soft NT </li></ul><ul><li>Neuro: nonfocal </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    6. 6. Case contd./ED Course <ul><li>WBC: 12 with 75 Neut, 5 Bands </li></ul><ul><li>7: wnl </li></ul><ul><li>UA: 20-30 WBC, 1+ bact </li></ul><ul><li>CXR: wnl </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    7. 7. Case contd./ED Course <ul><li>Treatment: </li></ul><ul><li>Tylenol </li></ul><ul><li>NS 250 cc/hr </li></ul><ul><li>Levoquin 500mg IV </li></ul><ul><li>Admit to Medicine </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    8. 8. Case contd./ED Course <ul><li>Bed becomes available after 4 hours in ED </li></ul><ul><li>Vitals before going upstairs: </li></ul><ul><li>82/40, 90, 20, 99.2 </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    9. 9. Case contd./ED Hosp Course <ul><li>Second IV placed </li></ul><ul><li>1 liter NS bolus </li></ul><ul><li>SBP remains in 80s </li></ul><ul><li>Lactate: 5.5 </li></ul><ul><li>Patient admitted to ICU </li></ul><ul><li>Dies after 4 days with ARDS and ARF </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    10. 10. History <ul><li>1789: Carl Whilhelm Sheele identified lactic acid in sour milk </li></ul><ul><li>1833: chemical structure identified </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    11. 11. History <ul><li>1922: Otto Meyerhoff and Archibald V. Hill win Nobel prize for energy capabilities of carbohydrate metabolism </li></ul><ul><li>Accepted that lactate production caused acidosis </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    12. 12. History <ul><li>Late 1950s: Huckabee established: </li></ul><ul><li>Hypoperfusion -> Lactic Acidosis </li></ul><ul><li>1976: Cohen and Woods: </li></ul><ul><li>↓ Tissue Oxygenation -> Lactic acidosis </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    13. 13. Is Lactate Bad? <ul><li>Correlation versus causation </li></ul><ul><li>Heart rate and septic shock </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    14. 14. Energy (ATP) Production <ul><li>Aerobic </li></ul><ul><li>Anaerobic </li></ul><ul><li>Creatine Phosphate (CP-ATP) </li></ul><ul><li>CP + ADP -> C + ATP </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    15. 15. Aerobic ATP Production <ul><li>Most complicated </li></ul><ul><li>Can utilize many types of fuel </li></ul><ul><li>Most efficient </li></ul><ul><li>Slowest process </li></ul><ul><li>Occurs within the mitochondria </li></ul><ul><ul><li>Pyruvate + NAD -> CO2 + H2O + NADH </li></ul></ul><ul><li> CoA acetyl-CoA </li></ul><ul><li>Krebs Cycle then produces ATP </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    16. 16. Anaerobic ATP Production <ul><li>Very fast </li></ul><ul><li>Uses locally available glycogen (glucose) </li></ul><ul><li>Also called “Glycolysis” </li></ul><ul><li>Forced pathway with hpoperfusion </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    17. 17. Lactate Production: Glycolysis Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA 2 H+ Glycolysis 2 H+ Glycolysis
    18. 18. Lactate Production: Glycolysis <ul><li>Body’s response is the Cori cycle </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    19. 19. Lactate Clearance: Cori Cycle Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA 2 H+ 2 H+ End Result: *Net loss 4 ATP *If unable to compensate ↑ lactate and acidosis (↑ H+)
    20. 20. Anaerobic Metabolism (Tissue Hypoxia) <ul><li>Increased production of lactate and H+ </li></ul><ul><li>Decreased utilization of lactate and H+ </li></ul><ul><li>End Result </li></ul><ul><ul><li>Increased Lactate </li></ul></ul><ul><ul><li>Acidosis </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    21. 21. Lactate Truths and Myths <ul><li>Does not cause muscle burning or fatigue </li></ul><ul><li>Does not cause acidosis </li></ul><ul><li>Important source of fuel for glucose production in the liver </li></ul><ul><li>Good indirect measure of tissue hypoperfusion </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    22. 22. Definitions <ul><li>Normal lactate: </li></ul><ul><ul><li>Unstressed: 1-0.5 mmol/L </li></ul></ul><ul><ul><li>Stressed: < 2 mmol/L </li></ul></ul><ul><li>Hyperlactatemia: 2-5 mmol/L </li></ul><ul><li>Lactic acidosis: usually > 5 mmol/L with associated metabolic acidosis </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    23. 23. Hyperlactatemia <ul><li>Normal perfusion </li></ul><ul><li>Normal tissue oxygenation </li></ul><ul><li>Transient hypoperfusion </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    24. 24. Lactic Acidosis <ul><li>Type A </li></ul><ul><ul><li>Tissue hypoxia </li></ul></ul><ul><ul><ul><li>Tissue hypoperfusion </li></ul></ul></ul><ul><ul><ul><li>Reduced arterial oxygen content </li></ul></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    25. 25. Lactic Acidosis <ul><li>Type B </li></ul><ul><ul><li>Not due to tissue hypoxia </li></ul></ul><ul><ul><ul><li>Type B1: (common disorders) hepatic failure, DM, cancer, renal failure </li></ul></ul></ul><ul><ul><ul><li>Type B2: (drugs and toxins) biguanides, alcohols, iron, isoniazid, salicylates </li></ul></ul></ul><ul><ul><ul><li>Type B3: is due to inborn errors of metabolism </li></ul></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA http://emedicine.medscape.com/article/768159-overview
    26. 26. Most Common Diseases <ul><li>Shock </li></ul><ul><ul><li>Hemorrhagic </li></ul></ul><ul><ul><li>Septic </li></ul></ul><ul><ul><li>Cardiogenic </li></ul></ul><ul><li>Respiratory failure </li></ul><ul><li>AKA </li></ul><ul><li>Anemia </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    27. 27. Most Common Diseases <ul><li>Toxins </li></ul><ul><li>Glucose-6-Phospahte deficiency </li></ul><ul><li>Inborn errors of metabolism </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    28. 28. Treatment of Lactic Acidosis <ul><li>Correct Tissue Hypoxia </li></ul><ul><ul><li>Increase perfusion </li></ul></ul><ul><ul><li>Increase oxygenation </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    29. 29. Treatment of Lactic Acidosis <ul><li>Increase Perfusion </li></ul><ul><ul><li>Aggressive fluid replacement </li></ul></ul><ul><ul><li>Isotonic saline preferred </li></ul></ul><ul><ul><li>Avoid lactate containing solutions </li></ul></ul><ul><ul><li>Avoid vasoconstrictors </li></ul></ul><ul><ul><li>Treat underlying cause </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    30. 30. Treatment of Lactic Acidosis <ul><li>Increase Oxygenation </li></ul><ul><ul><li>High flow O2 </li></ul></ul><ul><ul><li>CPAP </li></ul></ul><ul><ul><li>Intubation </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    31. 31. Treatment of Lactic Acidosis <ul><li>NaHCO3 </li></ul><ul><ul><li>Can cause increase lactate and H+ </li></ul></ul><ul><ul><li>Reserved for severe metabolic acidosis (<7.15) </li></ul></ul><ul><li>NaHCo3 req = </li></ul><ul><li>(Bicarb desired – Bicarb observed) x .4 x BW(kg) </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    32. 32. Treatment of Lactic Acidosis <ul><li>Experimental Therapies </li></ul><ul><ul><li>Carbicarb </li></ul></ul><ul><ul><ul><li>½ NaHCO3 (sodium bicarbonate) </li></ul></ul></ul><ul><ul><ul><li>½ Na2CO3 (sodium carbonate) </li></ul></ul></ul><ul><ul><ul><li>Animal studies only </li></ul></ul></ul><ul><ul><ul><li>Caused decreased lactate and improved pH </li></ul></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    33. 33. Why <ul><li>Pre-hospital vital signs ≠ hypoperfusion </li></ul><ul><li>Pain and Anxiety -> Epinephrine release </li></ul><ul><li>Occult hypoperfusion, compensated shock, cryptic sepsis </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    34. 34. Why <ul><li>Identify occult hypoperfusion earlier </li></ul><ul><li>Initiate fluid resuscitation earlier </li></ul><ul><li>Increased urgency </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    35. 35. Golden Hour <ul><li>Dr Adams Crowley </li></ul><ul><ul><li>Maryland Shock Trauma </li></ul></ul><ul><ul><li>First statewide EMS </li></ul></ul><ul><ul><li>First civilian use of medical helicopters </li></ul></ul><ul><li>Critics: Dr. Bryan Bledsoe </li></ul><ul><li>Trauma, Stroke, MI, Sepsis </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    36. 36. Why <ul><li>Hypotension -> Increased M & M </li></ul><ul><li>Identify early </li></ul><ul><li>Initiate treatment and urgency </li></ul><ul><li>Prevent hypotension </li></ul><ul><li>The significance of non-sustained hypotension in emergency department patients with sepsis </li></ul><ul><li>http://icmjournal.esicm.org/journals/abstract.html?v=0&j=134&i=0&a=1448_10.1007_s00134-009-1448-x&doi= </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    37. 37. Can Lactate Level Measurement in the Pre-Hospital Setting Identify Occult Hypoperfusion? Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    38. 38. Pre-Hospital Lactate and Mortality Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Critical Care 2008, 12: R160
    39. 39. The prognostic value of blood lactate levels relative to that of vital signs in the pre-hospital setting: a pilot study Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Critical Care 2008, 12: R160: http://ccforum.com/content/12/6/R160
    40. 40. Netherlands Study Conclusions <ul><li>Lactate level > 3.5 mmol/L identifies a high risk group with mortality of 41% (26% for <3.5) </li></ul><ul><li>Lactate level < 3.5 mmol/L had a NPV of 88% for mortality </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    41. 41. Netherlands Study Conclusions <ul><li>Improvement in lactate levels in the EMS setting correlates with ↓ mortality </li></ul><ul><ul><li>Hazard of death decreased 80% for every 63% decrease in lactate level in the pre-hospital setting </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    42. 42. Netherlands Study Conclusions <ul><li>Lactate > 5 mmol/L & pH < 7.35 </li></ul><ul><ul><li>75% Mortality </li></ul></ul><ul><li>Lactic acidosis and shock </li></ul><ul><ul><li>Median survival 28 hours </li></ul></ul><ul><ul><li>Only 17 % discharged from hospital </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    43. 43. Why <ul><li>Vital signs cannot always predict hypoperfusion </li></ul><ul><ul><li>In the hospital </li></ul></ul><ul><ul><li>In the EMS setting </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    44. 44. Future <ul><li>Can the Netherlands results be duplicated? </li></ul><ul><ul><li>Gunnerson, Richmond Virginia </li></ul></ul><ul><li>What EMS Treatments -> ↓ Lactate </li></ul><ul><li>Sepsis EMS Pilot Study </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    45. 45. Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    46. 46. Sepsis Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Suit against Memorial Hermann claims negligence caused man's sepsis, death Mariana Bridi da Costa
    47. 47. Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Sepsis can strike, kill shockingly fast
    48. 48. Sepsis EMS Pilot Study <ul><li>Sepsis </li></ul><ul><ul><li>Estimated 215,000 deaths per year </li></ul></ul><ul><ul><li>Up to 40-50% mortality </li></ul></ul><ul><ul><li>750,000 illnesses </li></ul></ul><ul><li>AMI (2005 CDC Death Rates) </li></ul><ul><ul><li>151,004 deaths </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    49. 49. What Can We Do? <ul><li>Early assessment/recognition </li></ul><ul><li>Early Goal Directed Therapy </li></ul><ul><ul><li>Reduces mortality up to 50% </li></ul></ul><ul><li>Begins in the field with 911 response </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    50. 50. Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    51. 51. Pathophysiology <ul><li>Bacterial Infection </li></ul><ul><li>Chemotaxis - </li></ul><ul><ul><li>Secretes chemical signals – causes reactions </li></ul></ul><ul><ul><ul><li>Capillary vasodilatation </li></ul></ul></ul><ul><ul><ul><li>Increased vascular permeability </li></ul></ul></ul><ul><ul><ul><li>Leukocytes (White Blood Cells) combat infection </li></ul></ul></ul><ul><li>Edema </li></ul><ul><ul><li>Pain, redness and swelling </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    52. 52. Pathophysiology <ul><li>Systemic infection </li></ul><ul><ul><li>Can not maintain perfusion </li></ul></ul><ul><li>Release of pro-inflammatory cytokines </li></ul><ul><ul><li>Powerful vasodilators </li></ul></ul><ul><li>Release of anti-inflammatory mediators </li></ul><ul><ul><li>Inhibit production of inflammatory components. </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    53. 53. Pathophysiology <ul><li>Respiratory System </li></ul><ul><li>Acute Respiratory Distress Syndrome (ARDS) </li></ul><ul><ul><li>40% Mortality Rate </li></ul></ul><ul><li>Surfactant </li></ul><ul><ul><li>Maintains alveolar tension </li></ul></ul><ul><ul><li>Decreases in sepsis </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    54. 54. ARDS Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    55. 55. SIRS <ul><li>Systemic Inflammatory Response Syndrome </li></ul><ul><li>Causes: </li></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Severe Burns </li></ul></ul><ul><ul><li>Pancreatitis </li></ul></ul><ul><ul><li>Ischemia </li></ul></ul><ul><ul><li>Infection </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Infection MODS
    56. 56. SIRS – Signs and Symptoms <ul><li>Two or More </li></ul><ul><li>Temperature: </li></ul><ul><ul><li>>38 C (100.4 F) or <36 C (96.8 F) </li></ul></ul><ul><li>Heart Rate: </li></ul><ul><ul><li>>90 beats/min (Outside Factors?) </li></ul></ul><ul><li>Respiratory Rate </li></ul><ul><ul><li>>20 breaths/min (Mechanically Ventilated) </li></ul></ul><ul><li>White Blood Cell (Leukocyte) Count </li></ul><ul><ul><li>>12,000 or <4,000 or >10% immature </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Infection MODS
    57. 57. Sepsis <ul><li>SIRS with documented or suspected infection. </li></ul><ul><ul><li>Bacterial </li></ul></ul><ul><ul><li>Viral </li></ul></ul><ul><ul><li>Fungal </li></ul></ul><ul><ul><li>Protozoa </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Infection MODS
    58. 58. Sepsis – High Risk Factors <ul><li>Higher Risk </li></ul><ul><li>Extremes of Age </li></ul><ul><li>Multiple co morbidities </li></ul><ul><li>Recent hospitalization </li></ul><ul><ul><li>2 million hospital acquired infections per year. </li></ul></ul><ul><li>Cough Present </li></ul><ul><li>Indwelling Foley/IV </li></ul><ul><li>Wounds/Injuries </li></ul><ul><li>Para/Quadriplegic </li></ul><ul><li>Bedridden </li></ul><ul><li>Recent Antibiotic Use </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Infection MODS
    59. 59. Sepsis <ul><li>Common Causes? </li></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Urinary Tract Infections </li></ul></ul><ul><ul><li>Abdominal Surgery </li></ul></ul><ul><ul><li>Cellulitis </li></ul></ul><ul><ul><li>IV Drug Users </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Infection MODS
    60. 60. Sepsis – High Risk Factors <ul><li>Immune Compromised </li></ul><ul><ul><li>Diabetic </li></ul></ul><ul><ul><li>Cancer - chemotherapy </li></ul></ul><ul><ul><li>HIV </li></ul></ul><ul><ul><li>Systemic steroids </li></ul></ul><ul><ul><li>Anti-rejection medications </li></ul></ul><ul><ul><ul><li>Imuran, Cellcept, Neoral (cyclosporine), Myfortic </li></ul></ul></ul><ul><ul><li>Powerful anti-inflammatory medications </li></ul></ul><ul><ul><ul><li>Humira, Enbrel, Remicade </li></ul></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Infection MODS
    61. 61. Septic Shock <ul><li>Septic shock = sepsis + hypotension </li></ul><ul><li>Classic Distributive Shock Example </li></ul><ul><li> ALSO </li></ul><ul><li>Cardiac Function Compromised (Cardiogenic Shock) </li></ul><ul><li>Massive Fluid Shift (Hypovolemic Shock) </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Infection MODS
    62. 62. MODS <ul><li>Multiple Organ Dysfunction Syndrome </li></ul><ul><ul><li>Damage or dysfunction to more than one organ </li></ul></ul><ul><ul><li>Mortality 20 to 100% </li></ul></ul><ul><ul><li>Most frequent target = lungs </li></ul></ul><ul><ul><ul><li>Cell permeability </li></ul></ul></ul><ul><ul><ul><li>ARDS </li></ul></ul></ul><ul><ul><li>Renal failure </li></ul></ul><ul><ul><li>Heart failure </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    63. 63. Sepsis Alert Pilot Study <ul><li>Can septic patients be identified in the pre-hospital setting? </li></ul><ul><ul><li>Does initiation of pre-hospital EGDT change morbidity and mortality? </li></ul></ul><ul><ul><li>Does Sepsis Alert change ED treatment? </li></ul></ul><ul><ul><li>Does Sepsis Alert change ED/Hospital morbidity and mortality? </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    64. 64. Sepsis Alert (SIRS Criteria) <ul><li>> 18 years old </li></ul><ul><li>Not Pregnant </li></ul><ul><li>Two or More: </li></ul><ul><li>Temperature: >38 C(100.4 ° F) or <36 C (96.8 ° F) </li></ul><ul><li>Heart Rate: >90 beats/min </li></ul><ul><li>Respiratory Rate >20 breaths/min </li></ul><ul><li>And: </li></ul><ul><li>Documented/Known/Suspected Infection </li></ul><ul><li>And </li></ul><ul><li>Hypoperfusion </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    65. 65. Hypoperfusion <ul><li>Three ways to determine: </li></ul><ul><ul><ul><li>Systolic BP less than 90 </li></ul></ul></ul><ul><ul><ul><li>MAP < 65 </li></ul></ul></ul><ul><ul><ul><li>Lactate > 4 mmol/L </li></ul></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    66. 66. Mean Arterial Pressure (MAP) <ul><li>Average pressure during cardiac cycle </li></ul><ul><li>MAP = (2*DBP) + SBP </li></ul><ul><ul><ul><ul><ul><li>3 </li></ul></ul></ul></ul></ul><ul><li>60 is minimum for tissue perfusion </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    67. 67. EMS Lactate Levels <ul><li>Pre-hospital Lactate Meters </li></ul><ul><li>Developed for Endurance Athletes </li></ul><ul><li>Works like a glucometer </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    68. 68. Sepsis Alert Procedure <ul><li>Assess Patient </li></ul><ul><ul><li>Apply criteria to incident </li></ul></ul><ul><ul><li>If it fits: </li></ul></ul><ul><ul><ul><li>Notify Hospital—no destination requirement </li></ul></ul></ul><ul><ul><ul><ul><li>Not all hospitals participating </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Presented at Metro physicians in 11-2008 </li></ul></ul></ul></ul><ul><ul><ul><li>Administer high flow O2 </li></ul></ul></ul><ul><ul><ul><li>2 large bore IVs </li></ul></ul></ul><ul><ul><ul><li>IV fluid boluses, according to protocol </li></ul></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    69. 69. Pre-Hospital Treatment <ul><li>All septic patients require: </li></ul><ul><ul><li>Oxygen therapy </li></ul></ul><ul><ul><li>Fluids </li></ul></ul><ul><ul><ul><li>Boluses – 500 cc initially </li></ul></ul></ul><ul><ul><ul><li>20ml/kg titrated to increase in BP (5 mmHg indicates vascular response) </li></ul></ul></ul><ul><ul><ul><li>Carefully assess lung sounds </li></ul></ul></ul><ul><ul><li>Dopamine </li></ul></ul><ul><ul><li>Check glucose, maintain above 80 </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    70. 70. Sepsis Alert – ER Response Porter/Littleton/Parker <ul><li>Goal is to provide EGDT if needed </li></ul><ul><li>Patient goes to large resuscitation room. </li></ul><ul><li>Hospital Staff </li></ul><ul><ul><li>Nurse/ER Doc </li></ul></ul><ul><ul><ul><li>Ultrasound </li></ul></ul></ul><ul><ul><ul><li>Central Line Kit </li></ul></ul></ul><ul><ul><li>Lab for blood cultures </li></ul></ul><ul><ul><li>X-Ray for CXR </li></ul></ul><ul><ul><li>Respiratory Therapist for rapid lactate measurement </li></ul></ul><ul><ul><li>House Supervisor </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    71. 71. EGDT <ul><li>If treatment goals met within 6 hours: </li></ul><ul><ul><li>Mortality decreased by 30-35% </li></ul></ul><ul><ul><li>Less overall IVFs administered </li></ul></ul><ul><ul><li>Less vasopressors administered </li></ul></ul><ul><ul><li>Decreased transfusions </li></ul></ul><ul><ul><li>Decreased hospital stay of 4 days </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    72. 72. EGDT <ul><li>Goal is < 6 hours for all treatments </li></ul><ul><li>Grade 1C Recommendations: </li></ul><ul><ul><li>Central line placement </li></ul></ul><ul><ul><li>IV fluid boluses until CVP = 8-12 </li></ul></ul><ul><ul><li>MAP between 65-90 mm Hg </li></ul></ul><ul><ul><li>Start vasopressors after CVP > 8 </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    73. 73. EGDT <ul><li>Grade 2C Recommendation: ScvO2 ≥ 70% </li></ul><ul><ul><li>Maximize oxygenation with intubation if necessary </li></ul></ul><ul><ul><li>CVP 8-12 </li></ul></ul><ul><ul><li>MAP between 65 mm Hg and 90 mm Hg </li></ul></ul><ul><ul><li>Transfuse until hematocrit ≥ 30% </li></ul></ul><ul><ul><li>Use inotropic agents to improve cardiac output </li></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    74. 74. Sepsis Alert Criteria <ul><li>18 years and older </li></ul><ul><li>Not Pregnant </li></ul><ul><li>Two or more of the following: </li></ul><ul><ul><ul><li>Temperature (above 100.3 ° or below 96.8 °) </li></ul></ul></ul><ul><ul><ul><li>Pulse > 90 </li></ul></ul></ul><ul><ul><ul><li>RR > 20 </li></ul></ul></ul><ul><li>Suspected or documented infection </li></ul><ul><li>Hypoperfusion, as indicated by </li></ul><ul><ul><ul><li>BP < 90 </li></ul></ul></ul><ul><ul><ul><li>MAP < 65 any one of these </li></ul></ul></ul><ul><ul><ul><li>Lactate > 4 </li></ul></ul></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    75. 75. Case Revisited <ul><li>73 yo female, family calls because of weakness. </li></ul><ul><li>She has no complaints except for nausea and vomiting x2 </li></ul><ul><li>Meds: Remicaide, Lisinipril, Motirin, Vicodin </li></ul><ul><li>PMH: RA, Htn, </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    76. 76. Case Revisited <ul><li>105/60, 95, 22, 100.6 </li></ul><ul><li>Lungs: CTA </li></ul><ul><li>Ht: RRR </li></ul><ul><li>Abd: soft NT </li></ul><ul><li>Neuro: nonfocal </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    77. 77. Case Revisited <ul><li>When asked directly patient admits to dysuria </li></ul><ul><li>SIRS Criteria Met </li></ul><ul><li>Infection Suspected </li></ul><ul><li>Lactate drawn by EMS: 4.4 </li></ul><ul><li>Sepsis Alert Called </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    78. 78. Case Revisited <ul><li>EGDT started immediately </li></ul><ul><li>First CVP: 4 </li></ul><ul><li>Patient given 2 additional liters NS </li></ul><ul><li>Norepinephrine started </li></ul><ul><li>Admitted to ICU </li></ul><ul><li>Patient discharged home after 5 days </li></ul>Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    79. 79. Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
    80. 80. Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA

    ×