Sepsis 3 is based on SOFA. This is definitely confusing. Part of the challenge in discussing this topic is separating out the QI guidelines from what is actually relevant to patient care based on the latest evidence-based medicine. Nachi : That seems fair. Is there a reason they are sticking to their current criteria? Nachi : What a struggle.
The CMS metrics are slightly different from the sepsis guidelines also. Take a look at Table 2 of the article for a quick comparison of sepsis-3, sepsis, and cms side-by-side. Nachi : Oh absolutely. And to make matters worse - this is a HUGE problem. Compounding this, sepsis results in death in approximately 1 out of 4 cases. Not only is it lethal, it is also very costly -- 17 billion dollars per year in the US alone! Previously, it was believed that the bacterial infection itself was the cause of the clinical syndrome of sepsis. However, we now know now that the syndrome of sepsis is due to the inflammatory and immunosuppressive mediators that were triggered by the infection.
Normal immune regulatory safeguards fail and this leads to the syndrome. And interestingly, several studies have shown that critically ill septic patients experience reactivations of specific viruses that were previously limited to patients with severe immunosuppression. Jeff : Definitely something to look out for in your critically ill septic patients.
In order, these are: pneumonia, intra-abdominal infections, and urinary tract infections. No surprises there! That takes us to our next potentially controversial topic - blood cultures. Jeremy : This is another interesting topic that has received plenty of attention.
CMS loves blood cultures. We looked at our patients with lactates between 2.
So what do we do? We draw cultures before pushing antibiotics. Is that helpful? Sometimes yes, does it waste money? Does it help us meet our metrics, yes. But remember the source can be anywhere. Be sure to also think of pyelonephritis, central line associated bloodstream infections, prosthetics, endocarditis, necrotizing fasciitis, and meningitis.
Of course, these numbers would vary significantly based on where you practice. Jeff : So get this -- one study showed that out-of-hospital shock index and respiratory rate were highly predictive of ICU admission. So clearly early recognition and therapy may play a role here.
Another study, however, showed knowledge gaps by advanced EMS providers in diagnosis and management of sepsis. Out of hospital fluids were started in only half of patients with severe sepsis. In essence, there is likely a strong role here for pre hospital protocols for identifying and treating sepsis. Prehospital sepsis protocols have been described, but in general more research is needed in this area. EMS should focus primarily on stabilizing vital signs and providing efficient transport.
Nachi : And of course, oxygen for the hypoxic patients! Moving on to history and physical for your presumed septic patient. Jeremy, what are the big hitting things here that you always ask and check for, and that you make sure your residents are doing? The other thing is to try and find the source.
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Finding the source lets you make wise choices about therapy. That being said, not every cause of elevated lactate is sepsis. There is this animal called Type B lactic acidosis can come from numerous drugs like albuterol. That being said, we know that patients with sepsis do better when they clear lactate. Jeff : Seems like the evidence is definitely in favor of serial lactate testing….
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Jeremy : For sure. At least until you have a reasonable trend towards improvement. We know lactate clearers do better. Interestingly, the takeoff point for sepsis seems to be around 2. Meaning that patients with altered vitals and lactates above 2. But, there is a broad ddx to elevated lactate.
What is true, though, is that lactate is a marker for badness. Since procalcitonin becomes elevated in those with bacterial infections, intuitively, this should be a valuable marker to assess in potentially septic patients. Unfortunately procalcitonin lacks negative predictive value so most literature supports its use in diagnosing pulmonary infections and for antibiotic de-escalation. Based on current studies, the authors recommend focused imaging only. One, lung ultrasound can be really useful to find that occult pneumonia or differentiating pneumonia from CHF.
Two, your ultrasound is your best tool for assessing volume status. I try to look at the IVC of all my septic patients and echo them when possible. Nachi : Right. Whether you like it or not, we have to discuss CMS. Jeremy : Just to clarify before we start. Then, within the first 6 hours, you must apply vasopressors to achieve a MAP of at least 65, re-assess volume status and perfusion, and remeasure a lactate. Nachi : This begs the question - are these recommendations evidenced based? Surprisingly, they showed no difference.
But how do we determine who needs more fluids and how much more they need. There must be an endpoint to all of this? Jeremy : Another million dollar question. How much is too much? I think we need to be smart about our fluids. Some patients will need less and some will need much more. Do something to monitor volume status. Nachi : Very important.
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Put your ultrasound skills to work here. Jeff : Sounds good. Current guidelines recommend that broad spectrum antibiotics be administered within the first hour of presentation for those with sepsis or septic shock, ideally with blood cultures being drawn beforehand. Since this study, other studies have had mixed results - with studies showing increased odds of death with delays in abx administration and others showing only a benefit in those with septic shock with or without hypotension with no benefit to those without shock.
Table 5 of the article is very thorough and should be kept as a quick reference.
Mechanisms of Sepsis-Induced Organ Dysfunction and Recovery | E. Abraham | Springer
Jeremy do you have any specific recommendations for our listeners on how we should approach antibiotic usage in the septic patient? Jeremy : I like to think about antibiotics a little more simply than referencing a table. I ask a couple questions. Does my patient need MRSA coverage? Does my patient need Pseudomonal coverage? If the answer is no and no, then narrow your coverage.
Also, have a look at your local antibiogram. The benefits of sepsis protocols are measured one patient at a time, but the harms are only measured in the aggregate. What does that mean? So think more about your antibiotics, and know your local biograms. The data is pretty clear on this one - norepinephrine is the recommended first line vasopressor for septic shock.