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Sepsis power point presentation
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ESSEX COUNTY FIRE CHIEFS ASSOCIATION
SEPSIS SPECIAL PROJECT WAIVER
SepsisHow sick is your patient?
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Objectives
Understand the causes and risk factors of sepsis.
Be able to indentify a septic patient.
Understand and follow the components of the Special Project Waiver
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Why is this important?
Mortality*
More than 750,000 severe sepsis cases are reported annually in the U.S. and, of those, 215,000 patients die.
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Why is this important?
SepsisAccording to the most recent CDC statistics: Sepsis is the
11th leading cause of death in the United States.
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Cost!
The present annual cost is estimated at $16.7 billion
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SIRS
Systemic Inflammatory Response Syndrome-It’s the first step in the path to sepsis
Causes: Trauma Severe Burns Pancreatitis Ischemia Infection (Can Lead to Sepsis)
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SIRS – Signs & Symptoms
Two or More White Blood Cell (Leukocyte) Count
> 12,000 or < 4,000 Respiratory Rate:
> 20 breaths.min or mechanically ventilated Heart Rate:
> 90 beats/min Temperature:
> 38 C (100.4 F) or < 36 C (96.8 F)
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Sepsis is Defined as:
Sepsis is SIRS with documented or suspected infection. Bacterial Viral Fungal Protozoa
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Sepsis
Common Causes Pneumonia Urinary Tract Infection Abdominal Surgery Cellulitis IV Drug Users Ear Infections
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Sepsis – High Risk Factors
Higher Risk Extremes of Age Multiple Co-morbidities Recent Hospitalization
2 million Hospital Acquired Infections per year.
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Sepsis – High Risk Factors
Cough PresentIndwelling Foley/IVWounds/InjuriesPara/QuadriplegicBedriddenRecent Antibiotic Use
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Sepsis – High Risk Factors
Immune Compromise Diabetic Cancer HIV Systemic Steroids Anti-rejection Medications Powerful Anti-inflammatory Medications
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Severe Sepsis/Septic Shock
Septic Shock = Sepsis + Hypoperfusion
Systolic Less than 90 mm Hg
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Pathophysiology
Immune and inflammatory response causes vasodilation, and so reduces venous return and cardiac output.
The immune response is where bacteria invade phagocytes, causing damage or even death to the cell. This leads to the release of histamine and proteolytic enzymes leading to vasodilatation
Also can cause poor tissue perfusion and tissue death (necrosis).
All of this increases cellular metabolism which causes the cells to switch to anerobic metabolism.
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MODS
Multiple Organ Dysfunction Syndrome (MODS) Presence of altered organ dysfunction in the septic
patient. Last stop before death.
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How can we help????
Early recognition and treatment are the key to better patient outcomes. Good thorough assessment including measure of lactate
Identifying these patients and notifying hospital staff early, has shown to decrease mortality 30%.
The main goal of our assessment of the patient is to identify the septic patient to facilitate transition to goal directed therapy at the hospital.
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What is Lactate???
It is a measure of tissue perfusion, it can tell you how well cells are being oxygenated regardless of blood pressure.
When cells do not receive enough oxygen, they convert to anaerobic metabolism
The byproduct of anaerobic metabolism are lactate and hydrogen ions.
Unit of Measurement is mmol/l (millimoles per liter)
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EMS Lactate Levels
Pre-Hospital Lactate MetersDeveloped for Endurance AthletesWorks just like a Glucometer
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EMS Treatment
Early Recognition KeyHistoryPhysical exam
Look for Infection
Strict Aseptic Practices Patient already compromised
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EMS Treatment
Fluid Resuscitation Large Bore IVs 30 ml/kg bolus if no signs or history of CHF* Or CRF.
20 ml/kg if signs or hx of CHF or CRF*
*This is specific to this special project
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EMS Treatment
Increased Oxygen Demand Hypermetabolism Impaired Oxygen Extraction
Respiratory Failure Occurs Rapidly
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EMS Treatment
Slightly Increased Rate due to cellular metabolism
Consider supplemental O2
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EMS Treatment
Pharmacological SupportDopamine 2-20 mcg/kg/minMaintain SBP of 90 mm HgMay need higher doses
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EMS Treatment
Place supine with feet elevated. NOT Trendelenberg May Impede Breathing
Rapid TransportOur hand off report must include the results
of assessment and suspicion of sepsis as well as our Lactate Measure.
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ER Treatment
Early Goal Directed Therapy (EGDT)Goal Oriented Manipulation of:
Cardiac Preload Cardiac Afterload Contractility
Balanced between oxygen delivery and oxygen demand
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EGDT - Goals
Resuscitation Bundle (< 6 hours):Serum Lactate LevelsBlood Cultures Prior to AntibioticsAntibiotic therapy within 1 hour of diagnosis
Each hour of delay during the first 6 hours of hypotension was associated with a 7.6% increase in mortality
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6 Hour Resuscitation Bundle
Early IdentificationEarly Antibiotics and CulturesEarly Goal Directed Therapy
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EGDT - Treatment
Mean Arterial Pressure (MAP)Maintain at 65-70 mm Hg
Vasoactive AgentsNorepinephrineDopamine
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EGDT - Results
Severe Sepsis or Septic Shock after 72 hours
EGDT Standard TherapyMortality 30.5% 46.5%
ScvO2 70.4% 65.3%
Lactate 3.0 mmol/L 4.4 mmol/L
Rivers, E, Et Al. Early Goal directed Therapy in the treatment of Severe Sepsis and Septic Shock. N Engl J Med 2001; 19:1368-1377.
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EGDT - Results
EGDT save livesMeeting all EGDT goals in less than 6 hours
decreases mortality Studies support even better results with
earlier intervention
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EMS Sepsis Special Project
GoalIdentify Septic Shock PatientsStart Fluid Resuscitation
Start Pressors (if needed)
Transfer to closest appropriate facility Consider emergent Transport
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EMS Sepsis Notification Criteria
Initiate sepsis special project waiver for patients18 years and olderNOT Pregnant
TWO or more of the below SIRS Criteria (Systemic Inflammatory Response Syndrome)
Temperature >38 C (100.4 F) or <36 C (96.8 F)Pulse >90Respiratory rate > 20
AND
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EMS Sepsis Notification Criteria
Suspected or Documented Infection
AND
One of the following:Hypoperfusion evidenced by SBP < 90 Lactate ≥ 4
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Treatment Flowchart
S e p s i s
Age ≥ 18
If no, follow STP
Suspected or Documented Infection
If no, follow STP
At least 2 of the Following • HR ≥ 90/min • RR ≥ 20/min • Temp <96.8f or >100.4f
If no, follow STP
AND any of the Following • SBP <90mmHg • MAP <65 • Lactate ≥4mmol/L
If patient satisfies all criteria, administer NS 30cc/kg over 1st hour unless history of or signs and symptoms of CHF/CRF in which case administer 20cc/kg NS in first hour and oxygen. Alert hospital to septic shock identification.
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Case #1 – EMS Findings
56 y/o FemaleResponsive to painful stimuliWitnessed SeizureHR: 135Temp: 103.5 FBP: No Radial PulseGlucose: High
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Case #1 – EMS Findings
History: Flu-like Symptoms Weakness X 2 Days Diabetes Headaches
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Case #1 – EMS Findings
Allergy: Codeine
Medications: Oral hypoglycemic (prescribed to husband)
occasionally.
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ER Findings
Pulse: 134BP: 75/39Resp: 8Temp: 39.8 C (103.6 F)Lactate 7.7Glucose: >1,600
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ER Findings
WBC: 6.4 Jumped to >20 in 24 hours
Infection Sites: Urinary tract Infection Bacteria in blood Fungus is Blood
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ER Treatment
IntubatedCentral Line Placement (CVP)DopamineNormal Saline
6 liters!!!!
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ER Treatment
AntibioticsInsulinAdmitted to ICU
Diagnosis: Sepsis, DKA andBleeding Gastric Ulcer
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Hospital Treatment
Nor-epi InfusionVecuronimAnd 30 others
Electrolyte Balance pH Balance Pain Control
2,400 ml Blood Products
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Hospital Treatment
Normal Saline First 72 Hours – 37 liters!!! Total stay – 76 liters!!!
Intubated: 9 daysTotal stay: 28 Days
Discharged Alert to Rehab
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Documentation
Lactate level should be documented in “Lactate Level” intervention
Intervention Tab
Lactate Level
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Documentation
Fields should be completed
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Case #2 – EMS Findings
59 y/o FemaleChief Complaint:
Altered LOC and Breathing Problems
Temp: 105.5 FPulse: 180 bpmResp: 32
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Case #2 – EMS Findings
Diagnosed with: Upper Respiratory Infections Sinus Infection
BP: 102/74MAP: 83
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Case #2 – EMS Findings
Lactate: 4.0
Cryptic Sepsis
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ER Findings
Temp: 105 FResp: 24Pulse: 148BP 79/40MAP: 53
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Hospital Treatment
IntubationCentral lineNormal Saline
First 72 hours – 22 Liters!!! Total – 51 Liters!!!!
Antibiotics
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Cryptic Sepsis
Patients with severe sepsis accompanied by lactic acidosis may display global tissue hypoxia in the absence of hypotension.
Early identification and goal-directed therapy of this subgroup leads to a reduction in morbidity and mortality.
Donnino, M, Et. Al. Cryptic Septic Shock: A Sub-analysis of Early, Goal-Directed Therapy. Chest 2003; 124 (4): 90 Henry Ford Hospital, Detroit, MI
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Outcome
Spent 17 days in hospital.Discharged home
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Questions?
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Notify your EMS director each time you use the Lactate Meter.
All cases will be reviewed by the EMS director as well as the affiliate medical director.