Sepsis in the ED

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Authors: Simon Laing, James Rudge / Code: RP6, SLO1, SLO3 / Published: 03/07/2015

Sepsis

There’s no doubt that a case of sepsis will pass through your ED in the next hour or so. It’s a disease that carries a high mortality rate and requires prompt and effective care. In this podcast we’ll run through the following

• Definition of Sepsis
• SIRS
• Severity levels
• The Sepsis 6
• Which patients require treatment within the hour
• What is Early Goal Directed Therapy (EGDT)
• Relevant literature to EGDT that may raise questions over it’s importance?

o   Marik – CVP

o   Nguyen – Lactate clearance

o   Jones – Lactate clearance

o   TRISS – Hb transfusion thresholds

o   Bai – nor adrenaline in patients with septic shock

• Recent trials specifically challenging EGDT, the Process, Arise and Promise trials
• The Surviving Sepsis Campaign and their recent update

There are some fantastic resources out there. The Surviving Sepsis Campaign is resource that must be investigated as a body that sets the standards in the management of sepsis in the UK and further afield. The AORMC gives an overview of sepsis care with specific relevance to its implementation in the Emergency Department.

Specific learning points from the podcast

SIRS

Any 2 or more + suspicion of infective cause = sepsis

Severity of Sepsis and associated mortality

The Sepsis 6

Red flag Sepsis

Commence sepsis 6 immediately if any of the following present

Overview of Early Goal Directed Therapy (EGDT)

SSC bundles

Bundles of care to be completed within a specified time frame from arrival

3 HOUR BUNDLE:

1) Measure lactate level

2) Obtain blood cultures prior to administration of antibiotics

3) Administer broad spectrum antibiotics

4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L

6 HOUR BUNDLE:

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg

6) In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to Table 1.

7. Re-measure lactate if initial lactate elevated.

TABLE 1

DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH:

EITHER

• Repeat focused exam (after initial fluid resuscitation) by licensed independent practitioner including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.

OR TWO OF THE FOLLOWING:

• Measure CVP

• Measure ScvO2

• Bedside cardiovascular ultrasound

• Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

References

1. Rivers, Emanuel, et al. “Early goal-directed therapy in the treatment of severe sepsis and septic shock.” New England Journal of Medicine 345.19 (2001): 1368-1377.
2. Marik, Paul E., and Rodrigo Cavallazzi. “Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense*.” Critical care medicine 41.7 (2013): 1774-1781
3. Nguyen, H. Bryant, et al. “Early lactate clearance is associated with improved outcome in severe sepsis and septic shock*.” Critical care medicine 32.8 (2004): 1637-1642.
4. Jones, Alan E., et al. “Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial.” Jama 303.8 (2010): 739-746.
5. Holst et al. Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock. October 2014 371(15):1381
6. Bai, Xiaowu, Wenkui Yu, Wu Ji, Zhiliang Lin, Shanjun Tan, Kaipeng Duan, Yi Dong, Lin Xu, and Ning Li Early versus delayed administration of norepinephrine in patients with septic shock. Critical care, 2014, 18:532
7. The ProCESS Investigators. N Engl J Med 2014; 370:1683-1693May 1, 2014DOI: 10.1056/NEJMoa1401602
8. The ARISE Investigators and the ANZICS Clinical Trials Group
9. N Engl J Med 2014; 371:1496-1506
10. ProMISe Trial Investigators. N Engl J Med 2015; 372:1301-1311April 2, 2015DOI: 10.1056/NEJMoa1500896