Project: Ghana Emergency Medicine Collaborative
Document Title: Sepsis in the ED
Author(s): Vijay Kairam, MD
License: Unle...
Attribution Key
for more information see: http://open.umich.edu/wiki/AttributionPolicy

Use + Share + Adapt
{ Content the ...
Sepsis in the ED

Vijay Kairam MD
Univeristy of Utah Emergency
Medicine
3
Case 1
•  75 yo male arrives to the Orange Zone,
complains of chest pain and shortness
of breath.
•  VS P 110, BP 95/65, R...
Source Undetermined

5
Case 2
•  65 year old female, had the sudden
onset of dysarthria, R sided hemiparesis
about 1.5 hrs ago
•  VS P 75 BP 155/...
Case 3
•  76 yo female, has been feeling
generally weak for the last few days.
Thought she had a fever today and
came to E...
Who is most likely to die in the
next 30 days?
•  Case 1
•  Case 2
•  Case 3

Acute MI - 9%
Cerebrovascular Accident - 15%...
Sepsis, Some Definitions
•  SIRS: Systemic Inflammatory Response
Syndrome
•  Sepsis: SIRS + presence of known or
suspected...
SIRS = 2 or more
• 
• 
• 
• 

T >38 or < 36
HR > 90
RR > 20
WBC > 12 K or < 4 K

10
What does the pt in case 3 have?
88/50, hr 105, t 38.5, rr 20, 95% RA

11
What if her vitals were…
100/65, hr 105, rr 20, t 38.5, 95% on RA

12
Sepsis Demographics
•  750,000 cases of severe sepsis in North
America each year
•  200,000 cases of septic shock each
yea...
Pathophysiology of Sepsis
•  Triggered by bacterial toxins and
inflammatory cascade
•  Progressive end-organ dysfunction
-...
Severe Sepsis
•  End-organ dysfunction
- 
- 
- 
- 
- 

Altered mental status
Decreased urine output
Acute lung injury
Coag...
Early Goal Directed Therapy
•  Patients with severe sepsis or septic
shock (sbp < 90 after 20-30 cc/kg bolus
over 30 min O...
Lena Carleton,
University of Michigan
Original Image: Rivers
et al. 2001 N Eng J
Med: 345(19):1368

17
Early Goal
Directed Therapy
in the Treatment
of Severe Sepsis
and Septic
Shock

Lena Carleton,
University of Michigan
Orig...
EGDT Decreases Mortality
• 

• 

• 

In Hospital Mortality
–  Standard Therapy: 46.5%
–  EGDT: 30.5%
–  ARR: 16.5%
–  NNT:...
Implementing EGDT Reduces
Mortality
•  Carolinas Medical Center -

Puskarich et al Crit Care Med

2009;13:R167

–  1 year ...
Do you need the whole
package?
•  Isn’t it enough to place a line and do
appropriate blood pressure and fluid
management?
...
ScvO2
Just placing a line is not enough
•  Septic patients who were normoxic (ScvO2
70-89%) had lower mortality rate than ...
Cryptic Shock
Normalized VS Are Not Enough
•  86% of standard therapy group had
normalization of vitals signs by 6 hrs (MA...
Sepsis Bundle Goals
1.  Initiate CVP/ScvO2 monitoring within 2
hrs
2.  Antibiotic administered within 4 hrs
3.  EGDT compl...
Sepsis Protocol
•  Identifying Appropriate Patients
•  Nurse Initiated Sepsis Order Set
–  Labs
–  Telemetry
–  Initiation...
Appropriate Patients
•  Inclusion Criteria: SIRS criteria with
known or suspected infection
•  Exclusion Criteria:
–  Acut...
Nurse Initiated Order Set
•  Labs
–  Lactate drawn first (to avoid prolonged tourniquet time)
–  cbc, cmp, troponin, blood...
Sepsis Protocol
•  Initiate if SBP < 90 after 20 cc/kg bolus or
Lactate > 4
•  Notify ED Physician
•  Move pt to Room 1 or...
Central Line Placement < 2hrs
•  Nursing/EMT will do sterile prep for central line
–  Discuss planned site and type of cat...
Early Antibiotics < 4hrs
•  Broad Spectrum
•  Ensure blood cxs drawn x 2
•  ED pharmacist facilitates

30
EGDT

Vijay Kairam, University of Utah

31
Summary
•  Sepsis and septic shock are common
presentations in the ED
•  Vital signs are vital in defining sepsis
•  Early...
Questions?

33
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GEMC: Sepsis in the ED: Resident Training

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This is a lecture by Dr. Vijay Kairam from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC: Sepsis in the ED: Resident Training

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Sepsis in the ED Author(s): Vijay Kairam, MD License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. 2 To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. Sepsis in the ED Vijay Kairam MD Univeristy of Utah Emergency Medicine 3
  4. 4. Case 1 •  75 yo male arrives to the Orange Zone, complains of chest pain and shortness of breath. •  VS P 110, BP 95/65, R 20 SaO2 91% •  PE: Pale, diaphoretic, talking in full sentences 4
  5. 5. Source Undetermined 5
  6. 6. Case 2 •  65 year old female, had the sudden onset of dysarthria, R sided hemiparesis about 1.5 hrs ago •  VS P 75 BP 155/75 R 16 SaO2 96% •  PE: Airway intact but drooling, R sided hemiparesis 6
  7. 7. Case 3 •  76 yo female, has been feeling generally weak for the last few days. Thought she had a fever today and came to ED. •  VS: 88/54, hr 105, t 38.5, 95% RA •  PE: Seems drowsy but will talk when stimulated, nl chest and abd exam 7
  8. 8. Who is most likely to die in the next 30 days? •  Case 1 •  Case 2 •  Case 3 Acute MI - 9% Cerebrovascular Accident - 15% Septic Shock - 40% 8
  9. 9. Sepsis, Some Definitions •  SIRS: Systemic Inflammatory Response Syndrome •  Sepsis: SIRS + presence of known or suspected infection •  Severe Sepsis: Sepsis + end organ dysfunction •  Septic Shock: Sepsis + Shock 9
  10. 10. SIRS = 2 or more •  •  •  •  T >38 or < 36 HR > 90 RR > 20 WBC > 12 K or < 4 K 10
  11. 11. What does the pt in case 3 have? 88/50, hr 105, t 38.5, rr 20, 95% RA 11
  12. 12. What if her vitals were… 100/65, hr 105, rr 20, t 38.5, 95% on RA 12
  13. 13. Sepsis Demographics •  750,000 cases of severe sepsis in North America each year •  200,000 cases of septic shock each year •  30-35% mortality for severe sepsis •  50% mortality for septic shock Surviving Sepsis Campaign 13
  14. 14. Pathophysiology of Sepsis •  Triggered by bacterial toxins and inflammatory cascade •  Progressive end-organ dysfunction - Tissue hypoxia from inadequate O2 delivery - Mitochondrial dysfunction - Microthrombi deposition at capillary level •  Distributive shock 14
  15. 15. Severe Sepsis •  End-organ dysfunction -  -  -  -  -  Altered mental status Decreased urine output Acute lung injury Coagulopathy Cardiac dysfunction • Lactic Acidosis 15
  16. 16. Early Goal Directed Therapy •  Patients with severe sepsis or septic shock (sbp < 90 after 20-30 cc/kg bolus over 30 min OR lactate > 4) •  Randomized to normal ED care vs EGDT Rivers et al. 2001 N Eng J Med: 345(19):1368 16
  17. 17. Lena Carleton, University of Michigan Original Image: Rivers et al. 2001 N Eng J Med: 345(19):1368 17
  18. 18. Early Goal Directed Therapy in the Treatment of Severe Sepsis and Septic Shock Lena Carleton, University of Michigan Original Image: Rivers et al. 2001 N Eng J Med: 345(19):1368 18
  19. 19. EGDT Decreases Mortality •  •  •  In Hospital Mortality –  Standard Therapy: 46.5% –  EGDT: 30.5% –  ARR: 16.5% –  NNT: 7 28 Day Mortality –  Standard Therapy: 49.2% –  EGDT: 33.3% –  ARR: 15.9% –  NNT: 7 60 Day Mortality –  Standard Therapy: 56.9% –  EGDT: 44.3% –  ARR: 12.6% –  NNT: 8 Rivers et al. 2001 N Eng J Med: 345(19):1368 19
  20. 20. Implementing EGDT Reduces Mortality •  Carolinas Medical Center - Puskarich et al Crit Care Med 2009;13:R167 –  1 year mortality pre-implementation vs post-implementation of EGDT protocol: 49% vs 37% P = 0.04 (ARR 12%, NNT 8) •  Robert Wood Johnson Medical Center - Trzeciak et al Chest 2006;129(2):225-232 –  In-hospital mortality pre vs post implementation of EGDT protocol: 43.8% vs 18.2% P = .09 (ARR 25.6%, NNT 4) •  Loma Linda - Nguyen et al Crit Care Med 2007;35(4):1105-12 –  EGDT Sepsis Bundle if completed decreases in-hospital mortality: 20.8% vs 39.5% P < .01 (ARR 18.7, NNT 6) 20
  21. 21. Do you need the whole package? •  Isn’t it enough to place a line and do appropriate blood pressure and fluid management? •  Do I really need to do the whole package if their vital signs stabilize? 21
  22. 22. ScvO2 Just placing a line is not enough •  Septic patients who were normoxic (ScvO2 70-89%) had lower mortality rate than those with hypoxia (ScvO2 < 70%) –  22% (95% CI 18-27%) vs 40% (95% CI 29-53%) •  Septic patients who were initially hypoxic but were resuscitated through EGDT and became normoxic within 6 hrs, had similar mortality rates to those who were initially normoxic. –  22% (95% CI 18-27%) vs 19% (95% CI 13-25%) Pope et al. Ann Emerg Med January 2010 22
  23. 23. Cryptic Shock Normalized VS Are Not Enough •  86% of standard therapy group had normalization of vitals signs by 6 hrs (MAP > 65, CVP > 8, UOP > 0.5 ml/kg/hr) vs 95% of EGDT group •  39.8% had persistent global tissue hypoxia (elevated lactate or ScvO2 < 70) compared to 5% of EGDT group •  In house mortality for this group with cryptic shock was 56.5% vs 30.5% for EGDT group Otero et al Chest 2006;130:1579-1595 23
  24. 24. Sepsis Bundle Goals 1.  Initiate CVP/ScvO2 monitoring within 2 hrs 2.  Antibiotic administered within 4 hrs 3.  EGDT complete within 6 hrs 4.  Corticosteroid given if persistently hypotensive despite vasopressors 5.  Lactate monitored for clearance Nguyen et al Crit Care Med 2007;35(4):1105-12 24
  25. 25. Sepsis Protocol •  Identifying Appropriate Patients •  Nurse Initiated Sepsis Order Set –  Labs –  Telemetry –  Initiation of IVF •  Activation of Sepsis Protocol if pt persistently hypotensive or lactate > 4. 25
  26. 26. Appropriate Patients •  Inclusion Criteria: SIRS criteria with known or suspected infection •  Exclusion Criteria: –  Acute cerebral vascular event –  Acute coronary syndrome –  Acute pulmonary edema –  History of congestive heart failure 26
  27. 27. Nurse Initiated Order Set •  Labs –  Lactate drawn first (to avoid prolonged tourniquet time) –  cbc, cmp, troponin, blood cxs x 2 –  UA - cath UA if unable to void in 30 min •  Other Studies –  Cxr - if respiratory symptoms, RR > 20, or hypoxemia –  EKG - if hypotensive, tachycardic, or having chest pain or SOB •  Telemetry •  If sbp < 90 or lactate > 4 –  Notify MD immediately –  Initiate IVF with 20 cc/kg NS IV over 30 min –  Re-assess after IVF 27
  28. 28. Sepsis Protocol •  Initiate if SBP < 90 after 20 cc/kg bolus or Lactate > 4 •  Notify ED Physician •  Move pt to Room 1 or 2 if available •  Page out “sepsis protocol in ED now” to: –  ED pharmacist –  MICU attending –  MICU resident 28
  29. 29. Central Line Placement < 2hrs •  Nursing/EMT will do sterile prep for central line –  Discuss planned site and type of catheter with MD –  Position the patient –  Prep and drape the patient –  Open and prep the central line kit –  Notify MD that central line is ready for placement •  MD will place line with Nursing/EMT sterile assistance •  CVP monitoring to be recorded with vital signs •  Labs –  VBG with lactate off central line –  PT/INR, PTT –  Type & Screen •  STAT pcxr for line placement 29
  30. 30. Early Antibiotics < 4hrs •  Broad Spectrum •  Ensure blood cxs drawn x 2 •  ED pharmacist facilitates 30
  31. 31. EGDT Vijay Kairam, University of Utah 31
  32. 32. Summary •  Sepsis and septic shock are common presentations in the ED •  Vital signs are vital in defining sepsis •  Early recognition and prompt treatment of sepsis can significantly reduce mortality 32
  33. 33. Questions? 33

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