Sepsis- Key Steps in Saving Lives

1. Sepsis- Key Steps in Saving Lives Hasan Shabbir MD Emory University Section of Hospital Medicine

2. Objectives • Case Review • Ramifications of “shortcuts” • Selected Landmark Studies • Basic Principles • Opportunities to Improve/Common Pitfalls • Emory Johns Creek Sepsis Protocol

3. 50 yom CC: Dyspnea HPI- short of breath, myalgias, chills Meds-acetaminophen 650mg prn, losartan 50mg, lovastatin 40mg PMHx- HTN, Hyperlipidemia PSHx- 10 days s/p appendectomy ROS- decreased urine output Seen in Urgent Care BP 102/50 HR 103 RR 28 Temp 100.5 F Pulse Ox 94% RA Exam- mild bilateral crackles, tachycardic, tachypneic, ill appearing Case

5. Urgent Care Assessment Viral Syndrome and mild CHF Furosemide 40mg IV Ibuprofen 800mg Sent to get Chem 7 and CBC Na 135 CO3 12 Chl 92 BUN 55 Creat 2.5 WBC 18 (N 85%, Bands 8%) pBNP 2400 Case continued

6. Syncope Unresponsive To ED You are called to help 90 minutes later

7. Sepsis • 1995 -751,000 cases in USA 215,000 deaths* • average cost per case $22,100* • Mortality can be reduced by 25%** *Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29:1303–1310. **South Med J. 2007;100:594-600. Remick D. Pathophysiology of Sepsis Am J Pathol. 2007 May; 170(5): 1435–1444.

8. Mortality Reduction? • Early recognition of sepsis • Timely hemodynamic monitoring • Aggressive Volume Repletion • Prompt cultures and antibiotics • Preventing Hospital Complications • 25% reduction in mortality

9. Early Goal Directed Therapy • Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine. 2001;345:1368–1377.

10. EGDT Lactate >4 or SBP <90 CVP monitor 500ml NS Q30min until CVP >8 If MAP <65- pressors If SCvO2 <70 Tranfused to Hct 30 Dobutamine to get SCvO2 to 70 263 Patients in ED 133 Standard Care, 130 EGDT Mortality 46.5% vs 30.5% (p=0.009) Early Goal Directed Therapy (cont.)

11. Hydrocortisone Therapy for Patients with Septic Shock Sprung C Jan 2008 499 septic patients 251 Randomized to 50mg of IV hydrocortisone vs 248 patients to placebo q6hrs x 6 days No change in mortality Increase in new infections in steroid group CORTICUS

12. Other Important Papers • Dellinger- Guideline • PROWESS- Drotecogin Alfa • ARDSNET- Lower tidal Volume • Brunkhorst- Glycemic Control in Sepsis • Varpula- pBNP in sepsis

13. Part I -Resuscitate • Serum Lactate Measured • Blood Cultures Obtained Prior to Antibiotic Administration • Improve Time to Broad-Spectrum Antibiotics • Treat Hypotension and/or Elevated Lactate with Fluids • Apply Vasopressors for Ongoing Hypotension • Maintain Adequate Central Venous Pressure • Maintain Adequate Central Venous Oxygen Saturation

14. PART II- Management 1st 24hrs • Maintain Adequate Glycemic Control • Prevent Excessive Inspiratory Plateau Pressures • Administer Drotrecogin Alfa (Activated) by a Standard Policy

15. Delay of diagnosis Order lactic acid liberally Patients with sepsis may initially look “okay” Use of automated triggers to order lactates Absence or Delay of CVP monitoring Unable to replete volume promptly/properly Vasopressor administration? Essential for SCvO2 monitoring Opportunities and Challenges

16. If acidemia- INTUBATE!!! Do not wait for sudden deterioration Avoid bicarbonate unless pH <7 Once intubated, use permissive hypercapnea If ALI or ARDS, Tidal Volume should be 6ml/kg (will mostly prevent high insp. presures) pBNP- what does it mean in sepsis??? Opportunities and Challenges (cont.)

17. Order Set ED Pathway for Possible Sepsis Place INT x 2  Diagnostic Test (Please collect all labs STAT) Lactate (this test is collected on ice) Chem Comp CBC PT/INR, PTT Blood Cultures x 2 ABG EKG Portable CXRay UA/Urine Culture  CK, CKMB, Troponin - I  Other Labs __________________________________

18. ED Order Set Continued • IV Normal Saline bolus 1L Q15minutes (use pressure bag) until MAP>65 or until 50% FiO2 required via face mask or ventilator • If unable to get MAP>50 in 30minutes, or unable to get MAP>65 in one hour, begin Levophed gtt at 5mcg/kg/min and titrate • If possible, please avoid Etomidate if intubation needed • Antibiotics •  Zosyn 4.5g IV x 1 OR Ceftazidime 2g IV x 1 OR  Azactam 2g IV x 1 • AND •  Vancomycin 20mg/kg IV x 1 • AND •  Tobramycin 7mg/kg IV x 1 OR Levaquin 750mg IV x 1

19. Diagnose Early • If Patient has all 3 of the criteria specified, initiate • Sepsis Protocol • □ 1.Suspected Infection? • □ 2. Two out of four of the following? • □Temperature greater than 100.4°F (38°C) or less than 96.8°F (36°C) • □Heart rate greater than 90 bpm • □ Respiratory rate greater than 20 or PaCO2 less than 32mmHg or mechanical ventilation • □ WBC greater than 12,000 or less than 4,000 mm³ • □ 3. Systolic BP less than 90 mmHg after 1L fluid bolus OR Serum lactate greater than or equal to 4 mmol/L?

20. Tracker

21. Sepsis Protocol • Fill out for Case Presentation

22. Summary • Possible Sepsis?--- Check Lactate • EGDT- don’t talk yourself out of it • Corticosteroids do NOT help in sepsis • pBNP should NOT guide fluid management • Keep BG < 150, but avoid hypoglycemia • Intubate Early for acidemia- avoid the code • Keep insp. plateau pressures low (use low tidal volumes) • Protocols are there to help remind you of EBM