Sepsis… What’s The Big Deal Gordon Feibish, DO Emergency Physician/EMS Fellow St Joseph’s Regional Medical Center Paterson, NJ Disclosures   None   I will accept monetary endorsements Objectives                   Define the Terminology that relates to sepsis Review the Epidemiology Discuss the diagnosis and differentiation of the various Stages of sepsis Discuss the Pathophysiology of sepsis Acknowledge the importance of early recognition and treatment of sepsis Discuss what can be done in the pre-hospital arena to improve patient outcomes Review some of the literature Learn a few things Improve patient care A Few Cases Case #1         You are called to respond for a “sick person” You arrive at a private residence to find a 72 y/o female who is, according to the husband, lethargic and confused Husband states she has been ill for several days with fever and cough Pt is on ABX prescribed by PMD yesterday and has been taking Acetaminophen for fevers (last taken 2 hours ago) Case #1 (cont)         PMHx: HTN, Dyslipidemia, DM Meds: Appropriate for Hx (hasn’t taken any in 2 days due to nausea) Allergies: NKDA Physical Exam:   BP-102/57 HR-105 RR-22 O2-93%(RA) T-99.6 F   Awake and alert but mentating slowly   Pale with cool clammy skin   Crackling as lung bases b/l (R>L)   EKG-Sinus tachycardia   Blood Sugar - 287 Case #2         You are called to respond to a “sick person” You arrive at a nursing home to find and 87 y/o male with fever and SOB (as per NH staff) NH staff informs you that pt had fever of 102.7 and appeared short-of-breath PMD has requested pt go to the ED for evaluation Case #2 (cont)   PMHx: Dementia, HTN, COPD, Prostate Cancer   Pt       is non-verbal and has in-dwelling urinary catheter Meds: Appropriate for Hx, uses O2 at night Allergies: PCN Physical Exam:   BP-133/72 HR-114 RR-26 O2-93%(RA) T-102.3F   Awake and responsive (at baseline)   Warm and flush appearing   No Rash, No cough, No appreciable change in mental status   Urine in Foley bag appears cloudy   EKG: RBBB with Sinus tachycardia   Blood Sugar: 97 Case #3   You are called to respond to a “sick person”   You arrive to an apartment to find a 46 y/o male, paraplegic war veteran, who is complaining of fever, congestion, cough, myalgias and fatigue for the past 3 days Case #3 (cont)         PMHx: HTN, T12 spinal cord injury Meds: Enalapril Allergies: NKDA Physical Exam   BP-128/78 HR-108   Awake, alert and well RR-20 02-99%(RA) oriented   Pt is flush and feels Hot (Skin otherwise normal)   Lungs are clear   Blood Sugar: 84 The Terminology The Basic Terms…   SIRS: (Systemic Inflammatory Response Syndrome)   Presence of 2 or more of the following criteria   Fever >100.4F or <96.8F   WBC count: >12,000 or < 4,000 (or > 10% Bands)   Hear Rate > 90 beats/min   Resp Rate ≥ 20 breaths/min   Sepsis = SIRS + confirmed/suspected source of infxn Severe Sepsis = Sepsis + organ dysfunction or signs   Septic Shock = Severe Sepsis + hypotension despite   of poor tissue perfusion attempted IV fluid resuscitation   Decompensated Septic Shock = Septic Shock w/o response to vasopressors Some Other Terms…   Organ Dysfunction:             Hypotension Oliguria  urine output < 0.5 mL/Kg/hr Elevated Serum Creatinine Altered Mental Status Respiratory Failure Poor skin perfusion           Lactate > 2 mmol/L Hypotension:     Pale skin Delayed Capillary Refill Cool/clammy SBP < 90 mmHg ---or--- 40 mmHg below baseline pressure Refractory Hypotension:   Hypotension non-responsive to IV fluid bolusing The Numbers Epidemiology Some of the Numbers…   Top 5 leading causes of death/yr in the US   Acute MI – 600,000   Cancers – 570,000   Chronic Lung Disease – 138,000   Stroke – 128,000   Trauma – 117,000     SEPSIS There are > 200,000 deaths due to Sepsis and Septic Shock each year Once the septic process has advanced to Septic Shock associated mortality may be 50% or more (ranging from 18-80% depending on the study and the subgroup) - 10,319,418 cases of sepsis over 22 years - Men > Women - Non-whites > Whites - Increase in incidence by 8.7% annually from 1979-2000 - 1979 164,000 cases (82.7/100,000 ppl) - 2000 660,000 cases (240.4/100,000 ppl) - In-hospital Mortality - 1979-1984 27.8% 27.8% x 164,000 = 45,592 - 1995-2000 17.9% 17.9% x 660,000 = 118,140 Deaths Some More Numbers…   “The Association of Sepsis Syndrome and Organ Dysfunction With Mortality in Emergency Department Patients with Suspected Infection”   In-hospital Mortality Rates:   Suspected Infection without SIRS  2.1%   Sepsis  1.3%   Severe Sepsis  9.2 %   Septic Shock  28%   Overall Mortality Rates   In-hospital  4.1%   1-Year Mortality Rate  22% Ann Emerg Med. 2006 Nov;48(5):583-90, 590.e1. So How Does This Apply To You? Your Numbers…   “Has The Time For Advanced Pre-Hospital Care of Severe Sepsis Finally arrived?”   3-4% of all non-arrest/non-traumatic EMS encounters are for patients ultimately diagnosed with Severe Sepsis   This is higher volume than Heart Attacks and Strokes   40% of all hospitalizations for severe sepsis were transported by EMS   Only 37% of septic patients had IV access upon arrival to the Emergency Department   Mortality rate of Severe Sepsis = ~20%     Acute Myocardial Infarction (MR) ~10% Stroke (MR)  12% American Journal of Respiratory and Critical Care Medicine, Vol 186, 2012 pg Sepsis Is A Spectrum of Disease The Spectrum… ` Infection Microorganism invading sterile tissue SIRS Sepsis   A clinical response arising from a nonspecific insult, with ≥2 of the following:   T >38oC or <36oC   HR >90 beats/ min   RR >20/min   WBC >12,000/ mm3 or <4,000/mm3 or >10% bands Severe Sepsis Septic Shock SIRS with a presumed or confirmed infectious process Sepsis with organ failure  Vascular collapse  Renal  Hemostasis  Lung Severe Sepsis with Refractory hypotension A Venn Perspective… Parasite SIRS Pancreatitis Virus Severe Sepsis Infection Sepsis Fungus Shock Bacteria Trauma Burns What’s Actually Going On? Pathophysiology Macrophage Infection Endotoxin/ Exotoxin released monocyte TNF released Amplified response of inflammatory cascade (Humeral Inflammatory Mediator) Direct Myocardial Suppression degr anul ation Leukotrienes Loss of Cardiac Output and Hypotension Platelet IL Activators Activation of Complement Cascade 3rd Spacing Decreased Venous Return to the Heart Prostaglandins Decreased Systemic Vascular Resistance Capillary Fluid leakage Vascular Endothelial Damage Systemic Vasodilation Increased levels of circulating vasodilators (NO, Serotonin, Bradykinin, Histamine) Direct Inhabition of Plasminogen Activator Inhibitor-1 Vascular Endotelial Damage Inhibition of Fibrinolysis Stimulates Thrombin Direct Stimulation of Tissue Factor Coagulation Uncontrolled Coagulation (DIC) So Now What? This Is What We Do… (The Doctors) EGDT So What Can You Do… (The Pre-hospital Personnel) Know that what you see in these patients and how you manage them will play an integral role in their overall care What You Can Do… Early Recognition   Early identification of illness and it’s severity will enhance care down the road  The two factors that have the greatest impact on outcome…   Early IV fluid resuscitation   Early Antibiotics What You Can Do… Just bringing them to the hospital helps   Patients arriving by EMS:   Received ABX an average of 36 minutes faster (116/152)   Received IVF an average of 34 minutes faster (34/68)   No change in overall mortality once adjusted for severity of illness That’s Great But What Else Can You Do…? Gather Information…   Allergies   Medication lists   Detailed Hx of current illness (from the family)   Sick Contacts   Nursing home records And   Think of possible sources Things To Look For…   Upper Respiratory       Urinary Tract     Productive cough, pleuritic chest pain, ausculatory changes   Erythema, warmth, edema, lymphangitis, decubitus ulcer Meningial Symptoms         Abdominal pain, distension, N/V, diarrhea Intra-abdominal   Peritoneal signs     Rigidity, rebound, pain w/ movement Lines and Catheters     Neck pain/stiffness Photophobia Gastrointestinal   Urgency, Hesitancy, Dysuria, foul smell, cloudy urine Skin/Soft Tissue Central Nervous   Pharyngeal inflammation, exudates, swelling, Lymph nodes Lower Respiratory     Foley, PICC, Shiley Cath… Peritoneal Dialysis   Cloudy PD fluid, abdominal pain Isn’t There Anything Else I Can Do? (some cutting edge things) Measurement of Lactate In a Prehospital Setting Is Related To Outcomes   Lactate measured in 2 subgroups of patients who presented via EMS   Subgroup 1(Non-shock)   Median Lactate = 3.2   Mortality Rate = 12.2%   Subgroup 2 (Shock)   Median Lactate = 5.0   Mortality Rate = 44.3%   Lactate ≥ 4 in “shock” patients was independently associated with higher mortality rate 35% vs 7% Van Beest PA et al. European Journal of Emergency Medicine: Dec 2009 - Vol 16 – Iss 6 - pp 318-322 Sepsis Alert…   Pre-hospital notification of septic patients  Mobilize resources needed for diagnosis and treatment  Initiate EGDT in the ambulance   IVF Bolusing   Airway management   MAP monitoring (>65)   Vasopressors Back To the Cases Case #1   72 y/o Female with cough, fever and AMS.       BP-102/57 HR-105 RR-22 O2-93%(RA) T-99.6 F On ABX from PMD Rales at lung bases (R>L)   What’s the Diagnosis?   Severe Sepsis!       Tachycardia, Tachypnea, Fever(?) Suspected source of infection + End-organ damage  AMS Case #2   87 y/o Male with Hx of COPD, Dementia, Prostate CA. Has fever, SOB, cloudy urine by Foley Cath     BP-133/72 HR-114 RR-26 O2-93%(RA) T-102.3F At baseline mental status   What’s the diagnosis   Sepsis!       Tachycardia, Tachypnea, Fever Suspected Source Hemodynamically Stable without signs of end-organ damage Case #3   46 y/o paraplegic male with fever, congestion, cough, myalgias and fatigue.         BP-128/78 HR-108 RR-20 02-99%(RA) Skin is flush and warm Awake, alert and oriented Lungs clear   What’s the Diagnosis?   SIRS!       Tachycardia, Tachypnea, fever No clear source of infection Hemodynamically stable without signs of end-organ damage The End References…           Aghababian, Richard V. Essentials of Emergency Medicine; Chapter 67 “Sepsis.” Jones and Bartlett Publishers, Boston, 2006 Jawad, Issrah, et al. Assessing Available Information on the Burden of Sepsis: Global Estimates of Incidence, Prevalence and Mortality. Journal of Global Health, June 2012, Vol 2, No 1 Herlitz et al. Suspicion and Treatment of Severe Sepsis. An Overvoew of the Prehospital Chan of Care. Scandinavian Journal of Trauma and Emergency Medicine, 2012, 20:42 Page, David. Research Studies Measure Prehospital Identification of Sepsis. Journal of Emergency Medical Services (online). 3/23/2012 Mayfield, Ryan T. Spotlight on Sepsis. EMS 10: Innovators in EMS, 2009