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SEPSIS

SEPSIS. EM Student Lecture Series. CASE STUDY. A 53-year old woman presents complaining of several days of fever, generalized malaise, nausea & vomiting. She has a PMH of diabetes and HTN and takes Glucophage and Lisinopril . Initial VS: 105/54 110 24 100.4 O2 sat 96%

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SEPSIS

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  1. SEPSIS EM Student Lecture Series

  2. CASE STUDY • A 53-year old woman presents complaining of several days of fever, generalized malaise, nausea & vomiting. She has a PMH of diabetes and HTN and takes Glucophage and Lisinopril. • Initial VS: 105/54 110 24 100.4 O2 sat 96% • PE: significant for mild lethargy (but she is A&Ox4); mild diffuse abdominal tenderness to palpation – otherwise WNL

  3. WHAT NOW? • List 5 initial steps in the management of this patient • List 5 differential diagnoses • List 5 tests or interventions

  4. SEPSIS • A continuum … from • SIRS • Sepsis • Severe Sepsis • Septic Shock • DEATH

  5. SIRS • Requires 2 out of 4 of the following: • Temp >38.0 or <36.0 • HR>90 • RR>24 or PaCO2<32 • WBC<4000 or >12000 OR bands >10%

  6. SEPSIS • Systemic response to host infection • SIRS + A SOURCE • Encompasses body’s own response to pathogen – characterized by derangements in inflammation, coagulation & fibrinolysis • May progress to abnormal vasodilation, tissue hypoperfusion, microcirculation thrombosis … to ORGAN DYSFUNCTION • Increased risk in ...

  7. SEVERE SEPSIS • Sepsis + organ failure OR lactate level >4 • CNS • Pulmonary (ALI) • Heme (coags & platelets) • Liver ( bili) • Kidney (AKI) • Circulatory system

  8. SEPTIC SHOCK • Sepsis + hypotension • Unresponsive to initial bolus (20-30 cc/kg) • Most septic patients are UNDER-resuscitated • Hypotension = SBP<90 OR 40 mmHg below baseline • OR MAP <65 mmHg or >25mmHg below baseline

  9. EPI/PATH OF SEPSIS • 10th leading cause of mortality • 750,000 hospitalizations/year • Most common sources: • Lung • Abdomen • GU • Skin/soft tissue • CNS

  10. ED WORKUP OF SEPSIS • CAREFUL history • Complaints may be nonspecific, especially very old/young • VITAL SIGNS ARE JUST THAT … but lack of fever rules out nothing • CAREFUL physical • Inspect every inch/every orifice • BE SUSPICIOUS

  11. ED WORKUP OF SEPSIS • Labs • The usuals – CBC, CMP, U/A, CXR, EKG • The unusuals: • Lactate • ?procalcitonin? • Cultures of every fluid • Imaging • XR • US – RUSH protocol/IVC collapse • CT

  12. >50% collapse during inspiration indicates low CVP/likely fluid responsiveness

  13. TREATING SEPSIS: EGDT • Landmark study (2001) showed that “bundling” sepsis management techniques and starting them in the ED showed mortality benefit (NNT=6) • Focuses on aggressively managing • Preload • Afterload • Oxygenation • Source control

  14. EGDT ALGORITHM

  15. THE ABCs of EGDT • “Are you OK?” • Rapid identification of the septic patient • Initiating diagnostic steps immediately (IV, monitor, early lactate measurement)

  16. THE ABCs of EGDT • A & B – oxygenation status & work of breathing • Obvious airway compromise/respiratory distress = easy! • Measures of poor oxygenation: • Lethargy, restlessness, altered MS • Pulse Ox/RR/PaCO2 • ScvO2 – what the heck is that?? • poor oxygen delivery to tissues/overwhelming oxygen debt • (<70% = poor O2 delivery) • Early intubation & mechanical ventilation

  17. THE ABCs of EGDT • Other adjuncts to A&B • Transfusion if hematocrit <30% • Lactate – measure of anaerobic metabolism of tissues • Even mild elevations (>2) associated with increased mortality

  18. THE ABCs of EGDT • C – circulatory status • BP is an imperfect gauge of true circulation! • Look for subtle signs of hypoperfusion … like: • Going IN: Rapid central venous access (<2hr) • Preload – multiple IVF boluses • Afterload – pressors (generally norepinephrine) • Coming OUT: measure strict UOP

  19. THE ABCs of EGDT • D&E – disability & exposure • WHERE IS THE SOURCE?? Full inspection of the patient • Lung – most common • Kidneys/bladder • Skin/soft tissue • GI • GU/GYN • Other (FBs, CNS, bone, etc) • UNKNOWN in up to 1/3 of cases • BROAD Abx coverage until you know what bug (culture, culture, culture!)

  20. GOALS OF EGDT – when to stop? • Airway/Breathing • ScvO2 >70% • By means of: intubation/ventilation; • transfusion +/- addition of inotrope if Hct<30% • Improving lactate level • Circulation • CVP 8-12 (must measure thru central line; also use IVC) • Uop >0.5 cc/kg/hr • MAP 65-90 mmHg

  21. ADJUNCT SEPSIS THERAPIES • Steroids – very controversial • Generally reserved for the patient in septic shock unresponsive to pressor & fluid therapy • Mechanical ventilation lung-protective strategies • Low TV, low plateau pressures • Aspiration precautions • Tight glucose control • GI/ulcer & DVT prophylaxis

  22. PATIENT DISPO • Admit, admit, admit!! • To the floor ONLY if mild sepsis and responding to ED therapy • THESE PATIENTS GET WORSE QUICKLY • Mortality rates • 20% sepsis • 40% severe sepsis • 60% septic shock • Increase with every organ system involved

  23. BACK TO THE CASE … • Significant labs: • WBC 9,000 15% bands • H/H 9.2/28.3 • Glu 186 • HCO3 16 • U/A + nitrites • CXR clear • How would you manage this patient??

  24. SEPSIS: TIME=MORTALITY

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