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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, April 13, 2015

Modern Management of Sepsis - May be less is more!


Hi,

It would not be fair if we don't do a post on sepsis after the completion of the sepsis trio -  ARISE, PROCESS and PROMISE trials that compared EGDT with "the standard care". All of them eventually came to the same conclusion: Standard Care is as good as EGDT! So lets see what the modern sepsis bundle looks like:


EGDT is a concept, don't use it like a mandatory protocol!


                         
Pic Courtesy : http://shirtoid.com/13876/sepsis/

With full credit to Rivers for coming up with EGDT in 2001 and actually sensitising us about the importance of early resuscitation of these critically ill patients (Fluids/Abx/Pressors). Now, we have realised that, may be we are being too invasive, too many lines and tubes does not sound like a good idea anymore.


May be we need to use the "teaching" analogy here, where LESS IS CONSIDERED AS MORE.

So this is what Modern Sepsis Care Bundle looks like:


  1. Recognise Early and be aggressive
  2. Early IV Fluids 
  3. Early and Appropriate Abx
  4. Early Pressors (NorEpi, Add Dobut if ECHO shows a lousy heart)
  5. Early Source Control
  6. Check lactate and repeat to see how you are doing
  7. ICU/Supportive Care

Lets go through each one of this:

1) Recognise Early and be aggressive

Early recognition is the key. We do not have a foolproof method of recognising sepsis, SIRS too has limitations. Eventually only 26% are found to be in sepsis who come in SIRS and we need to understand SIRS is not infallible, it misses about 1 in 8 with an underlying source of infection. If you are convinced that they are septic, be aggressive with them.


2) Early IV Fluids 

Crystalloids or Plasmalyte can be used as the resus fluid of choice for these patients. Too much NS causes hyperchloremic acidosis/renal injury. Plasmalyte is more physiological. And, 30cc/Kg is not the limit for everyone. Use IVC/Lung USG/ECHO to gauge fluids in septic patients.
3) Early and Appropriate Abx
 Early and appropriate antibiotics are important. I want to emphasise the word "appropriate". The Abx should be administered keeping in mind the common bugs causing that particular infection. Therefore, EARLY and APPROPRIATE, and not just any Abx. They key with Antibiotics is Hit them hard and then deescalate if needed. Each hour of delay in antimicrobial administration over the ensuing 6 hrs is associated with an average decrease in survival of 7.6%. Bottom-line is give them Antibiotics ASAP. 

4) Early Pressors

Norepi is the go to pressor for septic shock. Some also recommend to start it early, along with the IVF bolus. Add Dobutamine to norepi, if you see a poorly contracting heart on the ECHO. In case of refractory shock, add Vasopressin to norepi preceded by supplemental IV steroids. Give them a hydrocortisone 100mg before putting them on a second vasopressor.

5) Early Source Control


If there is a septic source that can be removed, then that is the priority. Plan ahead with your surgical colleagues (ex Necrotising Fascitis, Fournier's, Intraabd septic focus). Get them involved early and get rid of the septic focus. There is no point in giving Fluids/Abx/Pressors even you are not doing anything about the focus of infection.


6) Check lactate and repeat to see how you are doing

You need to check your performance, get a STAT lactate for them on arrival and repeat once you have given them fluids/Abx/Pressors. You are doing good if lactate is getting down.

7) ICU care - Give them some time + supportive care.



And what about CVP and ScVO2?


CVP: Checking CVP gets too invasive for everyone. Sometimes they don't look that toxic when they are normotensive with a slightly elevated lactate. So I try to get away with an EJV catheter for pressors. If they look really sick, I go head and place the CVC and when I place a CVC I check the CVP as well, though I am not a big fan of CVP (Use CVP values like a trend without relying on single values, if you still believe on CVP!)


ScVO2: If you have USG available, you don't really need ScVO2 before you start Dobutamine. Get rid of it. Too invasive, Instead use lactate.


And now, Getting a CVP and SCVO2 are both optional based on the clinician's discretion as per a recent statement made by Surviving Sepsis Campaign. 


Rigid sepsis protocols, that mandates central venous access based only on the lab parameters (lactate, creatinine, platelets, P/F Ratio) regardless of the clinical appearance of the patient needs to be updated. These algorithms and protocols should be flexible, also incorporating a physician's clinical acumen and gestalt. 


Key Points on Sepsis:

  1. Catch them early, give them Fluids, Abx, Pressors (Be aggressive)
  2. Check/Recheck lactate, Control source --> ICU
  3. Don't chase those numbers (8-12, >70%, >65mmHg)
  4. Use EGDT as a concept, not a protocol.

Further Reding:

http://pulmccm.org/main/2014/review-articles/resuscitation-fluids-in-critical-illness-review-nejm/
http://www.scancrit.com/2015/03/21/egdt-dead-long-live-egdt/
http://www.nejm.org/doi/full/10.1056/NEJMoa1415236
http://stemlynsblog.org/surviving-sepsis-update/
http://www.ncbi.nlm.nih.gov/pubmed/16625125
http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf

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