Transcript Emergency Department Management of Sepsis in the 21st Century

Emergency Department
Management of Sepsis in the 21st
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 visits\1000 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 sepsis\septic 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 (nonchronic) 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-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
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 pathogens\antibiotogram.
Consider MRSA coverage
Many institutions routinely include.
Many paths
to same destination.
Sepsis in the Emergency Department
Antibiotic Selection
Pneumonia
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.
Sepsis in the Emergency Department
Antibiotic Selection
Urinary 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
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 (20ml\kg 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 microgram\kg\minute (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 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
Early Goal Directed Therapy
Dobutamine
Inotrope.
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.
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 protected]
www.emresidency.info
Sepsis in the Emergency Department
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in the Emergency
Department
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Sepsis in the Emergency Department