Summary by Lia Losonczy, MD, MPH
Sepsis:
“Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016” https://www.ncbi.nlm.nih.gov/pubmed/28101605
- Had over 90 recommendations
Pearls:
- SSC acknowledges but does not endorse Sepsis 3 definitions; more research/data needed
- CMS has its own definition
- Eliminated term “severe sepsis” –> sepsis = evidence of infection + end-organ dysfunction
- Septic shock= above + lack of response to fluids + elevated lactate
Fluids
- EGDT no
longer recommended (based on ProMISe, ProCESS, ARISE trial)
- No longer recommended because there’s no benefit it over “usual care”
- Fluids: 30mL/kg crystalloid in first 3 hours
for sepsis-induced hypotension
- ProMISe, ProCESS, ARISE had less fluid given after enrollment than in Rivers’ study
- However, many of these patients (including those with ESRD & CHF) already had fluid from EMS and ED prior to enrollment, so actual fluid total was almost 30mL/kg; Rivers’ study did not report pre-enrollment IVF quantity, so those patients likely got >30 mL/kg
- Additional IVF after reassessment using dynamic methods rather than static measures
Antibiotics
- IV antibiotics ASAP within 1 hour of recognition of sepsis and septic shock;
- Dose based on pharmacokinetic dynamic principles:1 gm of vanc not necessarily appropriate for all patients, need weight based
- Combination abx therapy for septic shock; although not necessarily born out in literature, this is the recommendation
Vasoactives
–
First-line: norepinephrine
- Second-line: either epinephrine or vasopressin
- Arterial line as soon as practical
Steroids
- Suggest for pts with persistent shock despite fluids + pressors
- Recommended hydrocortisone at 200 mg/day
Mechanical Ventilation
- Suggest low-tidal volume ventilation in adults even WITHOUT ARDS
- Elevate HOB to 30-35 degrees
Sepsis Resuscitation in 2017:
-Early identification
-Appropriate abx
-Fluid resuscitation and reassessment
-Lactate
Early identification:
- Sepsis 3 definition: SOFA in the ICU, but qSOFA outside the ICU
- Clinical decision-making tools and injury severity tools are different concepts, despite being used interchangeably: BE CAREFUL about confusing them!
- qSOFA better than SIRS at predicting mortality
“Quick Sequential Organ Failure Assessment and Systemic Inflammatory Response Syndrome Criteria as Predictors of Critical Care Intervention Among Patients With Suspected Infection.”
- Looked at
qSOFA as predictor of critical care intervention (CCI) among patients with
suspected infection:
- 24,164 pts in retrospective cohort
- 6,693 admitted to ICU
- >66% got CCI
- Of ppl with >2 on qSOFA, 48% had CCI, and 13.4% died.
- The majority had score <2, but still 13.5% had a CCI, and >3% died
- In fact 23% of pts with qSOFA of 1 still needed CCI
***Caution when using qSOFA as clinical decision-making tool: predicts mortality, but not sensitive for all critical illness (sensitivity 13%)***
Antibiotics:
“Increased Time to Initial Antimicrobial Administration Is Associated With Progression to Septic Shock in Severe Sepsis Patients.”https://www.ncbi.nlm.nih.gov/pubmed/28169944
- Looked at association of abx timing with progression to septic shock from sepsis
- Retrospective review, single academic center
- Excluded those already in shock
- 3,929 patients
- 25% progressed to septic shock
- Each hour delay between ED triage and abx administration: Risk of progression to septic shock by 8% per hour! Important to get abx early
“Delayed Second Dose Antibiotics for Patients Admitted From the Emergency Department With Sepsis: Prevalence, Risk Factors, and Outcomes.”https://www.ncbi.nlm.nih.gov/pubmed/28328652
- Descriptive
analysis of current prevalence of delay to second dose of antibiotics
- Retrospective cohort study, single urban ED
- Adult pts with sepsis or septic shock
- Defined as major delay: greater than 25% of the recommended interval (based on Sanford’s Guide)
- Primary outcome: how often major delay, Secondary Outcome: association with mortality
- Results: 33% had major delay in 2nd dose, median delay was closer to 79% of the time
- Boarding pts identified as independent risk factor for delay to 2nd dose
- Associated with 1.6x mortality and 2.4x odds of mechanical ventilation
“Antipyretic Therapy in Critically Ill Septic Patients: A Systematic Review and Meta-Analysis.” https://www.ncbi.nlm.nih.gov/pubmed/28221185
- Systematic review: included RCTs and observational trials
- Looked at effect of antipyretic therapy on mortality
- Primary outcome: 28-day mortality
- Found 16 trials: 8 RCTs, 8 observational
- Results: No difference in mortality
- HR and minute ventilation also not different between two groups: maybe tachycardia and tachypnea not due to fever after all?
Sepsis Summary:
- EDGT no longer recommended
- 30mL/kg crystalloid in the first 3 hours
- Dynamic markers for fluid responsiveness
- IV abx ASAP- within 1 hour
- Target ≥65 for MAP
- Use norepinephrine as first line pressor, followed by vasopressin or epinephrine
- LTV ventilation even in absence of ARDS
- Be careful using qSOFA to rule out sepsis- not meant for that!
- 1 in 3 pts had major delay to the 2nd dose of abx, which impacts mortality
- Antipyretic therapy does not change mortality
Cardiac Arrest Care
-Team Leadership
-High Quality CPR
“Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” https://www.ncbi.nlm.nih.gov/pubmed/26472993
– As team leader you need to ensure high quality CPR
- Rate 100-120
- Chest compression fraction >60%
- Depth 5-6 cm
- Allow full chest recoil
- Avoid leaning
- Minimize interruptions: Airway (speaking about cardiac arrest especially), pulse checks, ETCO2 (USE it!!), ultrasound
“Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions.” https://www.ncbi.nlm.nih.gov/pubmed/?term=ultrasound+use+during+chest+compression+huis
- Prospective cohort at UMMC ED, single academic ED
- Does POCUS affect CPR pause duration?
- Videotaped medical codes in resus rooms
- Primary Outcome: pulse check duration
- 23 pts with 123 pulse checks
- No POCUS pauses 13s versus with POCUS 21s
- Only 1 pt survived to hospital discharge, so can’t say anything about mortality
- Similar study out of Highland Hospital also found No POCUS pauses 11s vs with POCUS 17s
- “Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: A prospective cohort study.”https://www.ncbi.nlm.nih.gov/pubmed/29175356
Take Home: POCUS lengthens duration of pulse checks, may increase interruptions in CPR **Pay Attention to Time with POCUS***
Post-Arrest Care
A comprehensive approach
- Optimise oxygenation and ventilation
- Optimize hemodynamics
- Targeted temperature management
- Emergent PCI
“Favorable Neurocognitive Outcome with Low Tidal Volume Ventilation after Cardiac Arrest.” https://www.ncbi.nlm.nih.gov/pubmed/28267376
– Retrospective cohort, non-traumatic OHCA, vented at least 2 days
– Time weighted TV over 48 hours
– Primary outcome: Neurologic outcome
– 256 pts
– 38% > 8ml/kg
– Low tidal volume (LTV) ventilation was associated with favorable neurologic outcome (OR 1.61)
– Also more days without shock and ventilator-free days
“Targeted Temperature Management for 48 vs 24 Hours and Neurologic Outcome After Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.”https://www.ncbi.nlm.nih.gov/pubmed/28742911
– Multicenter RCT
– 10 ICUs in 6 European countries
– Adult pts with OHCA due to presumed cardiac etiology
– GCS <8
– Cooled to 33c x48 hrs vs 33c x24 hours (control)
– Primary outcome: Neuro outcome at 6 months: No difference
– Secondary outcomes: No difference in 6 month mortality, increased “adverse events” in 48-hour group (esp hypotension), also cooling longer –> longer vent and longer ICU stay
– Limitations: 60% of those screened were excluded, sample size based on 15% absolute difference (more pts may have shown a difference, not powered to detect smaller difference)
Take home: Did not help neuro outcomes to cool longer, but increased time in ICU
Post Cardiac Arrest Summary:
– POCUS: pay attention to time using ultrasound during CPR pauses!
– Use LTV ventilation in post-arrest
– No difference in neuro outcomes between cooling 24 v 48 hrs
Mechanical Ventilation
“Analgosedation Practices and the Impact of Sedation Depth on Clinical Outcomes Among Patients Requiring Mechanical Ventilation in the ED: A Cohort Study.” https://www.ncbi.nlm.nih.gov/pubmed/28645462
– Secondary analysis of prospective cohort, single tertiary academic center, assess relationship btwn ED sedation depth and worse outcomes
– Defined deep sedation as RASS -3 to -5
– Primary Outcome: hospital mortality
– 14.3% no analgesic, 15.2% no sedation
– Deep sedation occured in 64%, and was associated with increased mortality (OR 0.77 mortality with lighter sedation)
“Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial.” https://www.ncbi.nlm.nih.gov/pubmed/28259481
-Pre/Post Intervention 2009-20014 (retrospective) after educational campaign and getting tape measure for accurate height in ED and then doing Lung-Protective Ventilation: 6mL/kg TV, limit plateau <30, elevated HOB to 30-45 degrees
-LPV increased in ED over 48.4%
-LPV increased by ICU 30.7%
-Mortality 14.5% absolute risk reduction
