Identification and management of severe sepsis and septic shock Rob Stenstrom M.D. PhD. CCFP-EM

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Identification and management of severe sepsis
and septic shock Rob Stenstrom M.D. PhD. CCFP-EM
Learning objectives 1. to describe the mortality
and morbidity burden of sepsis 2. to understand
the terminology and definitions of sepsis, severe
sepsis, and septic shock 3. to identify high risk
patients in your practice 4. to understand the
treatment priorities when managing the septic
patient 5. to discuss some of the controversies
in the literature such as lactate measurement,
need for a central line and the role of
corticosteroids
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How is this relevant to your practice?
Septic shock traditionally the realm of ICU
maybe ER However, many patients initially
admitted to wards look OK then deteriorate What
YOU do in the FIRST 6 HOURS has a profound impact
on patient outcomes and can save your patients
life
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Patients die from sepsis
U.S Data Over 700,000 cases of severe sepsis
/year Leading cause of death in non-coronary
ICUs Expected to increase as population ages
28 day Mortality
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What is a Septic patient?
Sepsis
Severe Sepsis
Infection

Infection Inflammatory response to
microorganisms, or Invasion of normally sterile
tissues
Sepsis with ?1 organ failure OR lactate gt 4.0

• ? 2 SIRS (suspected) infection
• Temperature ?38oC or ?36oC
• HR ?90 beats/min
• Respirations ?20/min
• WBC gt 12,000 or lt 4,000 and/or gt 10 bands

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What is Septic Shock?
Septic Shock Distributive/mixed shock
state Hypotension (SBP lt 90 mm Hg) despite
fluid resuscitation (20 ml/kg IV normal saline)
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What are treatment priorities?

• Early recognition is key
• Frequent vital signs
• Measure lactate, if you can
• Early and aggressive fluids IV normal saline
  in large
• amounts
• Early broad spectrum antibiotics preceded by
  blood cultures in the patient with septic shock,
  each ½ hour delay in antibiotic administration
  increases mortality
• Source control

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Why measure serum lactate?
Lactate Normal levels lt 2.1 mmol/L Elevated gt
4.0 mmol/L associated with increased risk of
mortality Lactate thought to be generated by
tissue hypoperfusion on septic patients Lactate
neither sensitive nor specific for sepsis It is
a marker of prognosis and of high risk patients.
Most useful in the ongoing assessment of
treatment Septic ED patients who had decreased
lactate levels by ONLY 10 between hour 0 and 6
of presentation had less than ½ the mortality
rate of those who did not clear lactate (Nguyen
et al, 2004)
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St Pauls Severe Sepsis/Septic Shock Protocol
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Pitfalls

• Failure to recognize sepsis because of
• Over-reliance on fever as hallmark (many patients
  in all age groups, but especially
  elderly/immuno-compromised may not mount a fever)
  
• Over-reliance on elevated WBC as hallmark (as
  above)
• Failure to appreciate time-sensitive nature of
  sepsis management
• Lack of understanding of role of lactate in
  sepsis
• Delay in antibiotic administration
• Inappropriate (narrow-spectrum) antibiotic given
• Inadequate amount of fluid resuscitation
• Delay in source control

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Resources
Robert S. Green, BSc, MD Dennis Djogovic, MD
Sara Gray, MD, MPH Daniel Howes, MD Peter G.
Brindley, MD Robert Stenstrom, MD, PhD Edward
Patterson, MD David Easton, MD Jonathan S.
Davidow, MD on behalf of the CAEP Critical Care
Interest Group (C4). Canadian Association of
Emergency Physicians Sepsis Guidelines the
optimal management of severe sepsis in Canadian
emergency departments. Canadian Journal of
Emergency Medicine (CJEM) 200810(5)443-59
Surviving Sepsis Campaign
http//www.survivingsepsis.org/ Emanuel P.
Rivers MD, MPH, Lauralyn McIntyre MD, MSc, David
C. Morro MD, , Kandis K. Rivers MD. Early and
innovative interventions for severe sepsis and
septic shock taking advantage of a window of
opportunity CMAJ 2005173(9)1054-65 Evidence
to Excellence (sepsis group)
http//www.evidence2excellence.ca/