sepsis in the ed
TRANSCRIPT
SepsisIan Turner
SepsisWhat it isWhat worksWhat doesn’tWhat’s next
Severe Sepsis and Septic Shock. N Engl J Med. 2013 Aug;369(9):840-51.
Language
Sepsis
Severe sepsis
Septic shock
Severity
More organ systems = more badness
~20% increase in mortality with each failing organ
6 major systems that fail
CVS : Resp : Renal : Hepatic : CNS : Haem
Australian Stats2000: 35% mortality
2012: 18.4% mortality
Sites: 50.3% pulmonary19.3% intra-abdominal
Mortality Related to Severe Sepsis and Septic Shock Among Critically Ill Patient in Australia and New Zealand. JAMA. 2014 Apr;311(13):1308-1316
Adult-population Incidence of Severe Sepsis in Australia and New Zealand Intensive Care Units. Intensive Care Med. 2004 Apr;30(4):589-96.
Emergency Role
We treat these patients
We are sometimes looking after them for longer
Text
Sepsis Six Pack
Antibiotics(+ airway)BroadCultureAvoid delayDe-escalateDuration of Hypotension Before Initiation of Effective Antimicrobial Therapy is the Critical Determinant of Survival in Human Septic Shock. CCM 2006 Jun;34(6): 1589-96
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BreathingLow tidal volumesModest fluid resuscitationVentilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for ALI and the ARDS. N Enlg J Med. 2000; 342:1301-1308.Comparison of Two Fluid-management Strategies in Acute Lung Injury. N Enlg J Med. 2006 Jun;354(24):2564-75.
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CirculationEnd-pointsEarly goal-directed therapyFluid choicesVasopressor choices
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CirculationEnd-points:CVPMAPUO
threeLactateScvO2
CirculationEarly goal-directed therapy2001: 30.5% vs 46.5% mortality2014/15: No difference, lower mortalities (~20-29%)
Early Goal-directed Therapy in the Treatment of Severe Sepsis and Septic Shock. N Engl J Med. 2001 Nov;345(19):1368-77A Randomised Trial of Protocol-based Care for Early Septic Shock. N Engl J Med. 2014 May;370(18):1683-93Goal-directed Resuscitation for Patients with Early Septic Shock. N Engl J Med. 2014 Oct;371:1496-1506Trial of Early, Goal-Directed Resuscitation for Septic Shock. N Engl J Med. 2014 Apr;372:1301-1311
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CirculationFluid choicesConflicting evidenceToo much = bad lungsToo little = reliance on vasopressorsAfrican experienceCrystalloid or colloidNo starches
Mortality After Fluid Bolus in African Children with Severe Infection. N Engl J Med 2011;364:2483-2495.A Comparison of Albumin and Saline for Fluid Resuscitation in the ICU. N Engl J Med. 2004 May;350(22):2247-56.Hydroxyethyl Starch 130/0.42 Versus Ringer’s Acetate in Severe Sepsis. N Engl J Med. 2012 Jul;367(2):124-34.Association of Hydroxyethyl Starch Administration with Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation: a Systematic Review and Meta-analysis. JAMA. 2013 Feb;309(7):678-88.
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CirculationVasopressor choicesNoradrenaline then maybe vasopressin
Comparison of Dopamine and Norepinephrine in the Treatment of Shock. N Engl J Med. 2010 Mar;362(9):779-89.Vasopressin Versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med. 2008 Feb;358(9):877-87.
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CirculationYou can start noradrenaline peripherallyArms obs
Central or Peripheral Catheters for Initial Venous Access of ICU Patient: a RCT. Crit Care Med 2013 Sep;41(9):2108-15.
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DrugsInsulinCorticosteroidsActivated Protein C
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DrugsInsulinTight control has been debunkedAim to keep <10mmol/LIntensive Insulin Therapy in Critically Ill Patients. N Engl J Med. 2001 Nov;345(19):1359-67.Intensive Versus Conventional Glucose Control in Critically Ill Patients. N Engl J Med. 2009 Mar;360(13):1283-97.
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DrugsCorticosteroidsOften given when noradrenaline requirements are high (>20mcg/min)
Effect of Treatment with Low Doses of Hydrocortisone and Fludrocortisone on Mortality in Patients with Septic Shock. JAMA. 2002 Aug;288(7):862-71.Hydrocortisone Therapy for Patients with Septic Shock. N ENGL J Med. 2008 Jan;358(2):111-24.
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DrugsActivated Protein CAnti-inflammatoryAnti-thromboticPro-fibrinolytic2001: 24.7% vs 30.8% mortality
Efficacy and Safety of Recombinant Human Activated Protein C for Severe Sepsis. N Engl J Med. 2001 Mar;344(10):699-709.
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DrugsActivated Protein C2012No mortality benefit at 28 or 90 days
Drotrecogin Alfa (Activated) in Adults with Septic Shock. N Engl J Med. 2012 May;366(22):2055-64.
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Source controlClinicallyImagingDon’t delay ABs
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Source controlIntervene within first 12 hours of diagnosis being madeThe least physiologically insulting interventionSurviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Crit Care Med. 2013 Feb;41(2):580-637.
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SupportiveHead-upSedation and analgesiaDVT prophylaxisStress ulcer prophylaxisNutritionCare goals
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SummaryWe are getting betterRecognise earlyGive fluid but not too much2014 trilogy of sepsis trialsRemember the 20% rule-of-thumb when talking to patient and familiesCarry a six-pack with you
Case73 F presents to you 8-bed rural ED
3/7 worsening abdo pain. Now vomiting with shakes and chills.
PHx – stage II NHL (completed 4th cycle of 4 of CHOP 1/52 ago), managed in the city. HPT. Hyperchol.
Meds – perindopril/HCT, metoprolol, atorvastatin
Allergies – penicillin (“whole body swelling”)
SHx – lives with husband, independent
O/E – in pain, 38.1C, 92/60, HR 92, SaO2 91%, RR 23, GCS 15, lower zone creps, RUQ tenderness, with positive Murphy’s
Red FlagsAge + abdo painImmunosuppressedAbnormal vitalsMedications masking vitalsLocation
Working Diagnosis?
Sepsis – probably severeSource – likely intra-abdominalPossible pulmonary component
Early Decisions
Stabilisation – how?Best location for treatment and ongoing careNeed for transfer – when, and by who?
StabilisationAttend to vitalsMonitoring – how extensive?IV access and fluids – how much?AnalgesiaAntiemeticsAntibiotics – choice?
InvestigationsVBG
pH 7.18CO2 39HCO3 14Na 132K 5.4Cl 99Glucose 7.1Lactate 4.1
Investigations
FBEHb 95WCC 8.1Plt 89
UECUr 16.8Cr 169
Investigations
LFTBili 26ALP 198GGT 154ALT 31AST 24TP 77Alb 34Lipase 58
Investigations
CoagsINR 1.6APTT 39Fibrinogen 1.1
Progress
Following 1.5L crystalloid, IV Abs, analgesia
HR 95, BP 84/60, SaO2 95% on 8L, RR 22
Next steps?
Next Steps
Maybe more fluid
Vasopressors
More monitoring
Do we need to control ventilation and oxygenation?
Source control
ProgressAnother 500mL crystalloid
Noradrenaline 8mcg/min
BP 101/65 (MAP 77), HR 90, SaO2 95% on 8L, UO 32mL/hr
Remains stable
Accepted for admission at regional centre ICU
Six PackEmpirical then adjusted ABs
Invasive ventilation not required (yet)
Fluids and vasopressors
Fancy drugs – no
Source control – yes, but needs transport
Supportive care