Emergency Department Management of Sepsis in the 21st Century

Emergency Department Management of Sepsis in the 21st

Century

Otto F Sabando D.O. FACOEPProgram Director Emergency Medicine

ResidencySaint Joseph Regional Medical Center

Paterson NJ

Sepsis in the Emergency Department


Conflicts to report

None


Scope of ProblemED 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 visits\1000 pop.

Top chief complaints: fever, dyspnea, generalized weakness.

Septic Shock Mortality 25-40%


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.


Scope of Problem

Baby Boomers:78 million eligible for Medicare starting in 2011

Rate will be 10000/day beginning 2011

Scope of Problem

SJRMCUrban, tertiary care hospital.

92,000 ED visits in 2007.

18,000 admissions from ED.

403 severe sepsis\septic shock patients

323 from ED.

80 already admitted patients.


Scope of ProblemSJHMC

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 DepartmentDefine 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.


Definitions

The ContinuumSIRS

Sepsis

Severe Sepsis

Septic Shock


Definition - SIRSSystemic 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


Definition - SepsisSepsis

SIRS PLUS a documented infection Positive CXR

Positive U/A

Cellulitis /Abscess

Positive Blood Culture


Definition – Severe SepsisSevere 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

HypotensionSBP <90

MAP<60


Definition – Septic ShockSeptic 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 .


Definition - MODS

MODS - Multiple Organ Dysfunction Syndrome

More than one major system failure.

Related to significant mortality. > 50%


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.


PMH: Hypertension, pneumonia, CAD with pacemaker/defibrillator in place, anemia, gout, GERD, and enlarged prostateAllergies: NKDAMeds: Procrit, singulair, toporol XL, vitamin C, Allopurinol, cyanocobalamin, furosemide, hydroxyzine, magnesium, omeprazole


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


Treatment of Septic ShockIdentification

Continuous monitoringPulse, blood pressure, pulse ox, urine output

Laboratory testsBlood and urine cultures.

Lactate Acid (a marker of tissue hypoxia)

Chest RadiographyPneumonia makes up a large portion of the cases.

Remember – initial complaints can be nonspecific.


Treatment of Septic ShockIdentification – Search for source

Lung-Pneumonia/Lung Abscess

UTI/Pyelonephritis

Heart -Endocarditis

Abdomen-Bowel Perforation

Brain-Meningitis

Bone-Osteomyelitis

Cellulitis

Pressure ulcers


Current Two weeks ago


Initiate broad-spectrum\Site specific antibiotics

Goal is administration within three hours of arrival in ED.

Several studies support the concept of “earlier the better”

Early\Appropriate antibiotics appear to affect outcomes.

Cochrane paper underway on subject



Antibiotic ChoicesBase on suspected pathogen information.

Remember previous cultures on your patient!

Adapt to local pathogens\antibiotogram.

Consider MRSA coverageMany institutions routinely include.

Many paths to same destination.Sepsis in the Emergency Department

Antibiotic SelectionPneumonia

3rd generation or greater fluoroquinolone – Levofloxacin (750mg), Moxifloxacin (500mg)

+ Vancomycin

+\- Gentamicin

Linezolid good coverage for VRE, MRSA, Strep. Pneumo.

Piperacillin\Tazobactam Consider adding an aminoglycoside for pseudomonal coverage.


Antibiotic SelectionUrinary Tract Infection

Piperacillin\Tazobactam (3.375 – 4.5 grams q6)

+ Gentamicin (7 mg\kg, q24hours)

May substitute ceftazidime, cefepime, aztreonam, imipenem, or meropenem.

Meningitis

Dexamethasone 10mg IV (before ABX)

Vancomycin 1 gram IV

Ceftriaxone 2 grams IV


Antibiotic SelectionVancomycin

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).


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


Antibiotic Selection

Ceftazidime /Cefepime

3rd and 4th generation Cephalosporins (respectively).

Gram negative>Gram Positive coverage.

Good Pseudomonas coverage.


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.


Early Goal Directed TherapyTreatment 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.



Early Goal Directed TherapyIn 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.


Early Goal Directed TherapyResuscitation 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 (20ml\kg initial)IF continued hypotension or lactic acid > 4

Achieve MAP > 65Achieve central venous pressure 8 mmHg or greaterAchieve central venous oxygen sat. of 70%


Early Goal Directed Therapy

Achieve MAP > 65Continued fluid boluses.

Adequate fluid resuscitation is a key component.

Initiation of vasopressor agents.Norepinephrine

Dopamine

Norepinephrine appears to be the more common choice.



NorepinephrineExtensive a-adrenergic response.

Moderate b-adrenergic response.

Works mostly through vasoconstrictive actions.

Does not change heart rate, cardiac output.

0.05 – 5 microgram\kg\minute (titrated to effect).



Achieve CVP 8 mmHg or greaterGoal 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).



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.


Early Goal Directed TherapyAchieve 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 mg\dl, transfuse PRBCs until

you meet this goal.– If Hb already above 10 mg\dl, use dobutamine

to achieve this goal. Sepsis in the Emergency Department


DobutamineInotrope.

Strong beta adrenergic response.

Start at 5 mcg\kg\minute.

Maximum of 20 mcg\kg\minute.

May increase hypotension so norepinephrine may be required to counteract this effect.

Goal is to increase cardiac output.


Management of Septic Shock in the ED

Early Goal Directed TherapySummarizing 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).



Summarizing EGDTContinuing 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.


Thank you

David Adinaro MD FACEPMember Stomp Sepsis Committee

Research Director ED

Robert Ameruso MDChair Internal Medicine

Chair Stomp Sepsis Committee

Questions?

Otto F Sabando DO FACOEP

[email protected]

www.emresidency.info


BibliographyAngus 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 severesepsis 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.


BibliographyMarti-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 2006Osborn, 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.


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Emergency Department Management of Sepsis in the 21st Century