1. No category

Glenn G. Druckenbrod, M.D.
Medical Director
Department of Emergency Medicine
Inova Fairfax Hospital
Best Practices, Inc.
Ponte Vedra 6/21/2012
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40 year old male
c/c – HA, abdominal pain, feels weak
PMH – HBP
Vitals – 104/68, P – 114, RR – 22, T – 98.9
PE – Looks well, AAO X 3, Mild suprapubic tenderness
Labs – WBC 9.9, BUN/Cr – 24/1.9, U/A – 5 – 10 WBCs, lactate 2.4
Treatment –One liter IV NS, IV ABX
Repeat vitals – 101/64, P – 118, RR - 24, T – 98.7
Admitted to the floor
Ponte Vedra 6/21/2012
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Four hours after admission “rapid response” called for
BP 60/p
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Eventual diagnosis: prostatitis
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Blood cultures positive for E. Coli
Ponte Vedra 6/21/2012
Sepsis clues –
persistent tachycardia
 BP (relatively) low for a hypertensive patient
 Increasing RR
 Elevated creatinine
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Ponte Vedra 6/21/2012
Provider discounted sepsis risk because –
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The patient looked “well”
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Tachycardia noted and was the reason for admission
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Elevated creatinine thought due to dehydration
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RR on chart never noted
Ponte Vedra 6/21/2012
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60 year old female
Throat cancer, recent chemo with c/c of weakness, difficulty
eating, sore throat and no fever by history
BP - 97/52, P – 126, RR – 25 (non labored), T – 99oF
PE – looks well, mucous membranes dry
Labs – WBC 0.8, BUN/Cr 44/1.9, Lactate 2.8, CXR RLL
consolidation
Subsequent vitals – 104/56, P - 129, RR - 29 and 118/57, P – 129,
RR – 28, T – 98.7
Treatment – NS X 1 L, Zosyn and Vancomycin
Admit intermediate care (i.e., ICU step down)
Ponte Vedra 6/21/2012
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Dropped blood pressure within 4 hours
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Transferred to ICU
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Eventually succumbed
Ponte Vedra 6/21/2012
Sepsis clues –
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BP
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Pulse
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RR
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Renal insufficiency
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Immune status
Ponte Vedra 6/21/2012
Provider follow-up –
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Patient looked good despite vitals
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Recognized immune state
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Pulse felt secondary to dehydration and underlying debilitated
status
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RR noted but not processed. No evidence of distress
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Creatinine elevation caused by dehydration
Ponte Vedra 6/21/2012
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60s female BIBA difficult to arouse. PMH remarkable for recent
kidney stone, on narcotic pain medication. Denies other
symptoms.
Vitals – 77/45, P – 94, RR – 22, T – 97.1oF
PE – awake and alert, oriented X 3. Abd: min L tend, + L flank
tenderness
Labs – WBC 10.7, BUN/Cr 70/5.5, Lactate 3.4, D-dimer 4067, UA
10-15 WBC
Subsequent vitals – 82/50, P – 96 and 95/55, P – 109
Initially admitted to step down unit, ABX 4 hours after arrival.
Ponte Vedra 6/21/2012
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While boarding in ED patient suffered cardiac arrest: successfully
resuscitated
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Blood and urine cultures positive.
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Infected, obstructed kidney stone
Ponte Vedra 6/21/2012
Sepsis clues –
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Renal insufficiency
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Hypotension
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Elevated lactate
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Elevated D-dimer
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Tachypnea
Ponte Vedra 6/21/2012
Provider follow-up
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BP felt secondary to narcotics
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Renal status from stone
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Lactate noted, uncertain of significance
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D-dimer level not understood
Ponte Vedra 6/21/2012
Sepsis
Early goal directed therapy (EGDT)
in treatment of severe sepsis
and septic shock. *
*Rivers, et al Nov 8
th
2001 in NEJM
Ponte Vedra 6/21/2012
Mortality:
•Standard Therapy – 46.5%
•EGDT – 30.5%
Ponte Vedra 6/21/2012
Mortality Benefit*:
•Thromobolytics – 12%
•PCI – 7%
*Danami-2 Study 2002
Ponte Vedra 6/21/2012
Adjusting cardiac preload, afterload and
contractility to balance oxygen delivery with
oxygen demand.
Ponte Vedra 6/21/2012
River’s Study:
•263 patients
•130 EGDT- 30.5% mortality
•133 Standard Therapy – 46.5% mortality
Ponte Vedra 6/21/2012
Keys to EGDT
Central Venous Catheter capable of central venous O2 sat.
6 Hours of intense treatment in the ED.
500 CC boluses q30 minutes for CVP 8-12 mm/hg.
MAP <65 mm/hg vasopressors utilized.
MAP >90 mm/hg vasodilators utilized.
Central Venous O2 sat of <70% RBC’s transfused to HCT of 30.
Optimized patients had Dobutamine begun if central venous O2 sat
remain <70.
• Mechanical ventilation and sedation for non optimized patients to
reduce O2 demand.
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Ponte Vedra 6/21/2012
Sepsis – Presence of infection in
conjunction with the systemic
inflammatory response syndrome (SIRS).
Ponte Vedra 6/21/2012
SIRS
Two or more of the following:
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Source of infection
Lactate >4
Temperature <36C or >38C
HR >90 BPM
RR >20 or PACO2 <32
WBC >4,000 or >12,000 or bands >10%
Ponte Vedra 6/21/2012
Severe Sepsis – Sepsis with evidence of organ
dysfunction
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Altered mental status
Creatinine increase >0.5 mg/dl from baseline
Coagulation abnormalities
Thrombocytopenia
Oliguria
Arterial hypoxemia
Ponte Vedra 6/21/2012
Septic Shock
Severe sepsis and hypotension unresponsive to
20 cc/kg bolus
Ponte Vedra 6/21/2012
Lactate – Easily available
marker of severity of illness.
Ponte Vedra 6/21/2012
Lactate
Mortality
0-2.5
4.9%
2.6-4
9%
>4
36%
Ponte Vedra 6/21/2012
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Lack of fever
End organ dysfunction, typically increased creatinine, attributed
to dehydration
Anchoring on another diagnosis
Ignoring tachycardia or increased RR
Patients “look good”
Ponte Vedra 6/21/2012
Septic patients look good.
Then they die.
Ponte Vedra 6/21/2012
Institutional Response to Sepsis
Surviving Sepsis Campaign –
• Build Awareness and increase use of proper treatment saw mortality
decrease when management bundles were utilized.
•Database use has markedly decreased over time.
Ponte Vedra 6/21/2012
CMS added sepsis to ruling
regarding hospital infection.
Goal is to shift cost to providers. (2010)
Ponte Vedra 6/21/2012
Hours of in hospital Sepsis
meetings……..
Ponte Vedra 6/21/2012