Thursday, February 26, 2015

Fighting Sepsis in the Emergency Department

by Jeffrey F. Jones, MD, FACEP
Medical Director & Chair, Trinity Medical Center Department of Emergency Medicine

Sepsis is an infection and subsequent immune response that causes whole-body inflammation. Sepsis is usually caused by a bacterial infection, and the resulting mortality can be 30-50%. Severe sepsis has an even poorer prognosis, and is defined as sepsis along with poor organ function as a result of insufficient blood flow to tissues. Signs of organ dysfunction with severe sepsis include altered mental status, tachypnea, tachycardia, decreased urine output, and delayed capillary refill.

Sepsis is defined as infection plus the systemic inflammatory response syndrome, or SIRS. A technical diagnosis of sepsis requires presumed infection and at least 2 of the following SIRS criteria:

• Temperature < 96.8° F or > 100.4° F

• Heart rate > 90 beats per minute

• Respiratory rate > 20 breaths per minute

• White blood cell count < 4000/mm3, > 12,000/mm3, or >10% bands (immature forms)

In a major study in 2001, Dr. Manny Rivers reported a great reduction in the mortality of septic patients with an aggressive treatment approach he called "early goal-directed therapy". Starting in the emergency department, Dr. Rivers attempted to keep a patient's central venous pressure, mean arterial pressure, urine output, venous oxygen saturation, and hematocrit above certain levels. This often involved early and aggressive use of mechanical ventilation, fluid resuscitation, vasopressors, and transfusions.

This work led to the Surviving Sepsis Campaign. This group of experts issues guidelines for the treatment of sepsis. They favor "bundles", or groups of evidence-based interventions that result in better outcomes when implemented together. The campaign has a 6-hour bundle that applies for inpatient care, and the following elements of a 3-hour bundle that are intended to be completed within 3 hours of patient presentation (usually in the emergency department):

• Measure lactate level

• Obtain blood cultures before giving antibiotics

• Administer broad spectrum antibiotics

• Administer 30 mL/kg of crystalloid solution for hypotension or for a lactate > 4 mmol/L

Many hospitals are adopting protocols for the early identification and aggressive treatments of sepsis. At Trinity Medical Center, every patient presenting to the emergency department is screened for signs of sepsis (questioned regarding possible infection or altered mental status; measurements taken for hypotension, hypoxia, and the above SIRS criteria). If a patient is positive for the screening criteria items, the ED provider is notified. He or she then has access to computerized order sets to efficiently order all tests and interventions that are part of the sepsis bundles or are likely to be necessary for a septic patient. Additional protocols are in place for inpatient use. These efforts and more will hopefully achieve the 25% reduction in sepsis mortality that is the goal of the Surviving Sepsis Campaign and of Trinity Medical Center.

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