Sepsis

Theres no doubt that a case of sepsis will pass through your ED in the next hour or so. Its a disease that carries a high mortality rate and requires prompt and effective care. In this podcast well 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 its 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 RCEM Sepsis Toolkit gives a fantastic 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

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Severity of Sepsis and associated mortality

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The Sepsis 6

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Red flag Sepsis

Commence sepsis 6 immediately if any of the following present

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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

WHC DEM