Identification and management of severe sepsis and septic shock Rob Stenstrom M.D. PhD. CCFP-EM

1. Identification and management of severe sepsis and septic shock Rob Stenstrom M.D. PhD. CCFP-EM Learning objectives: 1. to describe the mortality and morbidity burden of sepsis 2. to understand the terminology and definitions of sepsis, severe sepsis, and septic shock 3. to identify high risk patients in your practice 4. to understand the treatment priorities when managing the septic patient 5. to discuss some of the controversies in the literature such as lactate measurement, need for a central line and the role of corticosteroids

2. How is this relevant to your practice? Septic shock traditionally the realm of ICU; maybe ER However, many patients initially admitted to wards look OK then deteriorate What YOU do in the FIRST 6 HOURS has a profound impact on patient outcomes and can save your patient’s life

3. Patients die from sepsis U.S Data: Over 700,000 cases of severe sepsis /year Leading cause of death in non-coronary ICUs Expected to increase as population ages 28 day Mortality %

4. What is a Septic patient? Sepsis Severe Sepsis Infection Infection Inflammatory response to microorganisms, or Invasion of normally sterile tissues Sepsis with 1 organ failure OR lactate > 4.0  2 SIRS + (suspected) infection • Temperature 38oC or 36oC • HR 90 beats/min • Respirations 20/min • WBC > 12,000 or < 4,000 and/or > 10% bands

5. What is Septic Shock? Septic Shock: Distributive/mixed shock state Hypotension (SBP < 90 mm Hg) despite fluid resuscitation (20 ml/kg IV normal saline)

6. What are treatment priorities? • Early recognition is key: • Frequent vital signs • Measure lactate, if you can • Early and aggressive fluids: IV normal saline – in large • amounts • Early broad spectrum antibiotics preceded by blood cultures; in the patient with septic shock, each ½ hour delay in antibiotic administration increases mortality • Source control

7. Why measure serum lactate? Lactate: Normal levels < 2.1 mmol/L Elevated > 4.0 mmol/L associated with increased risk of mortality Lactate thought to be generated by tissue hypoperfusion on septic patients Lactate neither sensitive nor specific for sepsis It is a marker of prognosis and of high risk patients. Most useful in the ongoing assessment of treatment: Septic ED patients who had decreased lactate levels by ONLY 10% between hour 0 and 6 of presentation had less than ½ the mortality rate of those who did not clear lactate (Nguyen et al, 2004)

8. St Paul’s Severe Sepsis/Septic Shock Protocol

9. Pitfalls • Failure to recognize sepsis because of: • Over-reliance on fever as hallmark (many patients in all age groups, but especially elderly/immuno-compromised may not mount a fever) • Over-reliance on elevated WBC as hallmark (as above) • Failure to appreciate time-sensitive nature of sepsis management • Lack of understanding of role of lactate in sepsis • Delay in antibiotic administration • Inappropriate (narrow-spectrum) antibiotic given • Inadequate amount of fluid resuscitation • Delay in source control

10. Resources: Robert S. Green, BSc, MD; Dennis Djogovic, MD; Sara Gray, MD, MPH; Daniel Howes, MD; Peter G. Brindley, MD; Robert Stenstrom, MD, PhD; Edward Patterson, MD; David Easton, MD; Jonathan S. Davidow, MD; on behalf of the CAEP Critical Care Interest Group (C4). Canadian Association of Emergency Physicians Sepsis Guidelines: the optimal management of severe sepsis in Canadian emergency departments.Canadian Journal of Emergency Medicine (CJEM) 2008;10(5):443-59 Surviving Sepsis Campaign : http://www.survivingsepsis.org/ Emanuel P. Rivers MD, MPH, Lauralyn McIntyre MD, MSc, David C. Morro MD, , Kandis K. Rivers MD. Early and innovative interventions for severe sepsis and septic shock: taking advantage of a window of opportunity CMAJ 2005;173(9):1054-65 Evidence to Excellence (sepsis group): http://www.evidence2excellence.ca/