Sepsis in the ED

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There’s no doubt that a case of sepsis will pass through your ED in the next hour or so. It’s a disease that carries a high mortality rate and requires prompt and effective care. In this podcast we’ll run through the following

  • Definition
  • SIRS
  • Severity levels
  • The Sepsis 6
  • Which patients require treatment within the hour
  • What is Early Goal Directed Therapy (EGDT)
  • Relevant literature to EGDT that may raise questions over it’s importance?

We’ll look at the following papers

  • Marik – CVP
  • Nguyen – Lactate clearance
  • Jones – Lactate clearance
  • TRISS – Hb transfusion thresholds
  • Bai – nor adrenaline in patients with septic shock
  • Recent trials specifically challenging EGDT, the Process, Arise and Promise trials
  • The Surviving Sepsis Campaign and their recent update

There are some fantastic resources out there. The Surviving Sepsis Campaign is resource that must be investigated as a body that sets the standards in the management of sepsis in the UK and further afield.  The RCEM Sepsis Toolkit gives a fantastic overview of sepsis care with specific relevance to its implementation in the Emergency Department.   References Rivers, Emanuel, et al. “Early goal-directed therapy in the treatment of severe sepsis and septic shock.” New England Journal of Medicine 345.19 (2001): 1368-1377. Marik, Paul E., and Rodrigo Cavallazzi. “Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense*.” Critical care medicine 41.7 (2013): 1774-1781 Nguyen, H. Bryant, et al. “Early lactate clearance is associated with improved outcome in severe sepsis and septic shock*.” Critical care medicine 32.8 (2004): 1637-1642. Jones, Alan E., et al. “Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial.” Jama 303.8 (2010): 739-746. Holst et al. Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock. October 2014 371(15):1381 Bai, Xiaowu, Wenkui Yu, Wu Ji, Zhiliang Lin, Shanjun Tan, Kaipeng Duan, Yi Dong, Lin Xu, and Ning Li Early versus delayed administration of norepinephrine in patients with septic shock. Critical care, 2014, 18:532 The ProCESS Investigators N Engl J Med 2014; 370:1683-1693May 1, 2014DOI: 10.1056/NEJMoa1401602 The ARISE Investigators and the ANZICS Clinical Trials Group N Engl J Med 2014; 371:1496-1506October 16, 2014DOI: 10.1056/NEJMoa1404380 ProMISe Trial Investigators N Engl J Med 2015; 372:1301-1311April 2, 2015DOI: 10.1056/NEJMoa1500896  

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One thought on “Sepsis in the ED

  1. gavin denton says:

    In the latter half of the sepsis podcast, there was discussion around measures of fluid responsiveness. Specifically, it was suggested that the use of passive leg raises (PLR) as a measure of fluid responsiveness was only applicable in patients that are ventilated, with volume control and sinus rhythm. However, this caveat applies to the use of stroke volume (SVV) or pulse pressure variation (PPV) on its own as a measure of fluid responsiveness, restricting its utility to the theatre environment. The benefit of using the PLR is that it allows you to use SVV, PVV, a percentage change in cardiac index or stroke volume in patients that are making spontaneous respirations (intubated or self-ventilating) and in the context of arrhythmia. It can also be applied across different modalities i.e transthoracic ultrasound, pulse contour analysis trans-oesophageal doppler and even MAP (although with less sensitivity and specificity).

    Marik produced a nice paper on the subject http://www.annalsofintensivecare.com/content/pdf/2110-5820-1-1.pdf

    5 rules of PLR http://www.ccforum.com/content/19/1/18

    EMCRIT podcast on fluid responsiveness with paul marik http://emcrit.org/podcasts/fluid-responsiveness-with-dr-paul-marik/

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