POPULARITY
2 episodes with qsofa
2 episodes with qsofa
2 episodes with qsofa
2 episodes with qsofa
2 episodes with qsofa
2 episodes with qsofa
Dr. John Toney, Professor of Medicine at the USF Morsani College of Medicine, presents an update on the management of Sepsis. Dr. Toney begins by discussing the pathophysiology regarding sepsis and septic shock. He then shares the most recent sepsis guidelines. Next, he presents the stages of sepsis and covers the qSofa score. Next, Dr. Toney covers the management of sepsis, including resuscitation, antibiotics, and therapies that were once recommended which have either gone by the wayside or have been modified in the modern era.
Sepsis remains an increasingly common emergency department condition that is tied to higher morbidity and mortality across the United States as well as the rest of the world. Sepsis as a disease process has been difficult to both clearly define and quickly recognize. Many metrics for recognition and management of sepsis are dependent upon various scoring systems, including SIRS, SOFA, qSOFA, and MEWS, none of which were designed for the acute detection of sepsis within the emergency department. This journal club recap will look at an article by Knack et al looking at physician gestalt vs scoring systems for the detection of sepsis.
In this conversation, Dennis, Doug, and Justin discuss the development of a Sepsis Clinical Practice Guideline (CPG) for prolonged field care. They highlight the importance of early recognition and antibiotic administration in sepsis management. They also discuss the use of scoring systems like QSOFA and NEWS2 to aid in the identification of septic patients. The conversation covers the role of lactate monitoring and the potential confounding factors. They emphasize the need for a comprehensive assessment of the patient and the importance of not relying solely on one marker or number. The conversation also touches on the importance of proper catheter insertion and the consideration of prophylactic catheter replacement in austere environments. They discuss the use of fluids as the first-line treatment in septic patients and caution against over-resuscitation. The conversation concludes with a reminder to pay attention to the patient's response and not blindly adhere to formulas or protocols. In this conversation, the speakers discuss various aspects of sepsis management, including fluid resuscitation, the use of colloids, the importance of monitoring urine output, and the decision to initiate vasopressors. They also touch on the use of antibiotics and wound management in sepsis cases. The conversation provides valuable insights and practical tips for healthcare providers in austere environments. Takeaways Early recognition and timely administration of antibiotics are crucial in sepsis management. Scoring systems like QSOFA and NEWS2 can aid in the identification of septic patients. Lactate monitoring can be confounded by various factors, and a comprehensive assessment of the patient is necessary. Proper catheter insertion and prophylactic catheter replacement should be considered in austere environments. Fluids are the first-line treatment in septic patients, but over-resuscitation should be avoided. Pay attention to the patient's response and use clinical judgment rather than blindly following formulas or protocols. In sepsis cases, fluid resuscitation is crucial, and the choice of fluid depends on availability. Balanced electrolyte solutions like Ringer's lactate or plasma light are preferred, but normal saline can be used if that's all that's available. Colloids may be used in sepsis patients with high output losses or compartment syndrome. Options include FFP, albumin, or freeze-dried plasma. Monitoring urine output is important in assessing the response to fluid resuscitation. If urine output increases, it indicates a positive response. However, if urine output remains high despite fluid administration, it may indicate over-resuscitation. When considering the use of vasopressors, the decision should be based on the patient's blood pressure and mental status. If the patient remains hypotensive and shows no improvement after a substantial amount of fluid, vasopressors may be initiated. Antibiotics should be given empirically in sepsis cases, and the choice of antibiotic depends on the suspected source of infection. Wound management, including effective debridement and irrigation, is crucial in preventing infection. Regular assessment of wounds is important to identify any signs of infection or non-viable tissue. In austere environments, it may be necessary to make treatment decisions based on the patient's clinical presentation and endemic risk, even without confirmatory tests. The conversation highlights the importance of collaboration and mentorship in developing clinical practice guidelines and acknowledges the contributions of healthcare professionals in the field. Thank you to Delta Development Team for in part, sponsoring this podcast. deltadevteam.com For more content go to www.prolongedfieldcare.org Consider supporting us: patreon.com/ProlongedFieldCareCollective or www.lobocoffeeco.com/product-page/prolonged-field-care
Dr. Casey Clements spent two hours breaking down the history and influences in sepsis care over the past three decades and going through the best practices in today's emergency medicine. Do you know how Sepsis is defined currently? What is the difference between SEP - 1 and surviving sepsis campaign? What is the role of steroids or vitamin C? Can you resuscitate these patients with albumin? These and so many more questions will be answered in this two part series. So join Venk like vancomycin, and Alex (aka Zosyn) and Casey "not-cidal" Clements in these amazing episodes. CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS SOFA Score: Vincent JL, MOreno R, Takala J, et al. The SOFA (Sepsis-related organ failure assessment) score to describe organ dysfunction / failure. On Behalf of the working group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996 Jul;22(7):707-10 Vincent JL, de Mendonca A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ dysfunction / failure in intensive care units: results of a multicenter, prospective study. Working group on ‘sepsis-related problems' of the European Society of Intensive Care Medicine. Crit Care Med. 1998;26(11):1793-1800 Ferreira FL, Bota DP, Bross A, Merlot C, Vincent JL. Serial evaluation of the SOFA score to predict outcomes in critically ill patients. JAMA. 2001 Oct 10;286(14):1754-8 Cardenas-Turanzas M, Ensor J, Wakefield C, Zhang K, Wallace SK, Price KJ, Nates JL. Cross-validation of a sequential organ failure assessment score-based model to predict mortality in patients with cancer admitted to the intensive care unit. J Crit Care. 2012 Dec;27(6):673-80 qSOFA score Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):762-774 Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a new definition and assessing new clinical criteria for septic shock: For the Third International Consensus Definitions for Sepsis and SEptic Shock (Sepsis-3). JAMA. 2016;315(8):775-787 Freund Y, Lemachatti N, Krastinova E, et al. Prognostic accuracy of Sepsis-3 Criteria for in-hospital mortality among patients with suspected infection presenting to the emergency department. JAMA. 2017;317(3):301-308 Raith EP, Udy AA, Bailey M, et al. Prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit. JAMA. 2017;317(3):290-300 Comparing Prognostic scores Henning DJ, Puskarich MA, Self WH, Howell MD, Donnino MW, Yealy DM, Jones AE, Shapiro NI. An Emergency Department validation of the SEP-3 Sepsis and Septic Shock definitions and comparison with 1992 consensus definitions. Ann Emerg Med. 2017 Oct;70(4):544-552 IDSA concern Rhee C, Chiotos K, Cosgrove SE, Heil EL, Kadri SS, Kalil AC, Gilbert DN, Masur H, Septimus EJ, Sweeney DA, Strich JR, Winslow DL, Klompas M. Infectious diseases society of america position paper: Recommended revisions to the National Severe Sepsis and Septic Shock early management bundle (SEP-1) Sepsis Quality Measure. Clin Infect Dis. 2021 Feb 16;72(4):541-552 About Barcelona Declaration Slade E, Tamber PS, Vincent JL. The Surviving Sepsis Campaign: raising awareness to reduce mortality. Crit Care. 2003;7:1-2 1- hour surviving sepsis bundle guidance Freund Y, Khoury A, Mockel M, et al. European Society of Emergency Medicine position paper on the 1-hour sepsis bundle of the Surviving Sepsis Campaign: expression of concern. Eur J Emerg Med. 2019 Aug;26(4):232-233 Early Goal Directed Therapy Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM. 2001 Nov 8;345(19):1368-77 SEP - 1 Quality Measure National Quality Forum Measure submission and evaluation worksheet 5.0 for NQF #0500 Severe Sepsis and Septic Shock: Management Bundle, last updated Date: Oct 05, 2012. Website link Accessed 01-31-2024: https://www.qualityforum.org/Projects/i-m/Infectious_Disease_Endorsement_Maintenance_2012/0500.aspx National Quality Forum: NQF Revises Sepsis Measure. Website link accessed 01-31-2024: https://www.qualityforum.org/NQF_Revises_Sepsis_Measure.aspx Faust JS, Weingart SD. The Past, Present, and Future of the Centers for Medicare and Medicaid Services Quality Measure SEP-1 - the early management bundle for severe sepsis / septic shock. Emerg Med Clin N Am. 2017; 35:219-231 Affordable care act Patient Protection and Affordable Care Act, Public Law 148, U.S. Statutes at Large 124 (2010):119-1024. Website link accessed 01-31-2024: https://www.govinfo.gov/app/details/STATUTE-124/STATUTE-124-Pg119/summary. Fluids for sepsis in concerning populations Pence M, Tran QK, Shesser R, Payette C, Pourmand A. Outcomes of CMS-mandated fluid administration among fluid-overloaded patients with sepsis: A systematic review and meta-analysis. Am J Emerg Med. 2022 May:55:157-166 Zadeh AV, Wong A, Crawford AC, Collado E, Larned JM. Guideline-based and restricted fluid resuscitation strategy in sepsis patients with heart failure: A systematic review and meta-analysis. Am J Emerg Med. 2023 Nov:73:34-39 WANT TO WORK AT MAYO? 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September is Sepsis Awareness Month, so host Sarah Lorenzini is throwing it back to one of the earliest Rapid Response RN podcast episodes with guest Yesha APRN. This episode tells the story of a patient with sepsis, and it's one of Sarah's favorite episodes because it exemplifies all of the classic signs and symptoms of sepsis as well as the important role the nurse plays in caring for septic patients.Last week, you learned about fluid resuscitation and the potential harm of fluid overload in the treatment of sepsis. In this episode, you'll hear how Sarah and Yesha's patient responded to fluid boluses and what made them advocate for a different treatment approach.Sarah then goes deeper into the pathophysiology of sepsis, indicators of sepsis using SIRS criteria and the qSOFA score, and more indicators any nurse can test without a tool. You'll also find out how to treat a patient with sepsis, which diagnostics to run, and what you can do to promote a return to homeostasis in your patient.Tune in to learn the signs and symptoms of sepsis and septic shock, and how to facilitate early detection. Plus, hear Yesha's takeaways from this patient story that will benefit all nurses in their treatment of sepsis!Topics discussed in this episode:Yesha's nursing journey and updates on her careerHow Yesha's patient presented and his response to fluid administrationWhat made her decide to call a rapid response nurse, SarahSarah's assessment of the patient and how they treated himThe pathophysiology of sepsisSIRS criteria and qSOFA score for prediction of sepsisWhat happens in the “septic inflammatory cascade of awfulness”How to detect sepsis earlyTreatment and management of a sepsis patientRead the article, “Fluid selection & pH-guided fluid resuscitation” by Dr. Josh Farkas, here:https://emcrit.org/ibcc/fluid/Mentioned in this episode:AND If you are planning to sit for your CCRN and would like to take the Critical Care Academy CCRN prep course you can visit https://www.ccrnacademy.com and use coupon code RAPID10 to get 10% off the cost of the course! Rapid Response and Rescue Intro CourseIf you would like to check out Sarah's 1hr, 1 CE course, go to: http://www.rapidresponseandrescue.com To get the FREE Rapid Response RN Assessment Guide and the coupon code for $10 off the cost of the course, message Sarah on Instagram @TheRapidResponseRN and type the word PODCAST!
The First Principles of Sepsis that can get you through any placement: What is it? How do you recognise it? What do you do about it? Is a lumbar puncture a bedside investigation? === Other Links === Check out our new website 1pm.wiki for the Notion document, free Anki flashcards, and podcast episodes. Check out our Instagram: https://www.instagram.com/firstprinciplesofmedicine/ Recorded 28 February 2023 Co-hosts: Joshua Naylor, Jason D'Silva, Jayanth Cheyyur feat. Nhien Huynh. Produced by JT Yeung & Adian Izwan. If you have any ideas or feedback, comment on this Notion document, or shoot us an email at hello@1pm.wiki *** We're really excited to be collaborating with Becky from Becky's notes, a UK based resource, to produce infographics for our visual learners out there. Becky's notes brings together all the key topics medical students need to know in a readily available place, reviewed by specialists in the field. These visually striking notes are a refreshing change from all the boring textbooks. You can check her out on instagram at @beckysnotes01 and get her books at https://linktr.ee/Beckysnotes === Timestamps === (00:56) Defining sepsis (02:24) Causes of sepsis (04:29) Risk factors (06:12) BASIC (07:00) Pathophysiology of sepsis (13:22) Disseminated Intravascular Coagulation (15:03) Clinical features (19:49) qSOFA (21:19) Investigations (25:36) Management (28:56) Antibiotics according to ETG (30:03) Complications (31:32) 3 Key Takeaways
Sepsis is a common presentation in the prehospital and retrieval environment, with most cases having a respiratory, urinary or soft tissue origin. However the best practice for identifying and management sepsis in the prehospital environment remains unclear. Despite sepsis having been a priority for in hospital guidelines and protocols for decades now, relatively little attention has been paid to prehospital sepsis management. Traditional teaching is that early antibiotics in sepsis save lives, however trials examining this are observational and confounded by outdated ICU care. An appropriately sensitive and specific tool for the prehospital identification of sepsis remains elusive. NEWS2 is common and lactate-modified QSOFA emerging (although prehospital lactate measurement remains difficult). The role of prehospital antibiotics, and the most appropriate one are also unclear. Most ambulance services that carry antibiotics use ceftriaxone. The retrieval environment is similar, with sepsis probably being the single commonest reason to call a retrieval service. For more head to our podcast page #CodaPodcast
Le score qSOFA (pour quick SOFA) est plus simple que le score SOFA. Un nombre de critères ≥ 2 identifie un patient ayant un risque de mortalité par sepsis à 10% voire plus Fréquence respiratoire ≥ 22 Trouble des fonctions supérieures (Confusion, désorientation, Glasgow
Hola!!! Esta semana conversamos sobe la sepsis. Detección precoz del cuadro y manejo inicial. Son algunos de los elementos que conversamos en este episodio. Hablamos además del qSOFA y Mottling Score. Espero que les sea de utilidad Suscribete al podcast y compártelo con tus amigos Siguenos en instagram: Instagram: https://www.instagram.com/Emergencia24.7podcast Un abrazo David Larrondo Fonseca
Rick Body, Deputy Editor of EMJ, and Sarah Edwards, Social Media Editor of EMJ, talk through the very best of the Emergency Medicine Journal with most of the papers we published in April 2022. We cover everything from sepsis and qSOFA scoring to how to manage traumatic pneumothoraces and how to recognise cervical spine injuries. We even look at the problem we have with convenience sampling in Emergency Medicine clinical research studies. Do we need to make big changes? Have a listen and find out! Read the highlights: https://emj.bmj.com/content/39/4/269 If you enjoy our podcast, please consider leaving us a review or a comment on the EMJ Podcast iTunes page (https://podcasts.apple.com/us/podcast/emj-podcast/id445358244).
2021 Surviving Sepsis Campaign Guideline Updates Special Guests: Carolyn Bell PharmD, BCCCP and Brittany Bissell, PharmD, PhD, BCCCP, FCCM Reference List: https://pharmacytodose.files.wordpress.com/2022/02/2021-sepsis-guideline-updates-references.pdf 05:00 – General thoughts and historical perspective; 12:10 – qSOFA; 14:44 – Author diversity; 19:10 – IV fluids; 27:15 – Vasopressors; 33:12 – Antibiotics (and antifungals); 46:10 – Adjunctive treatments; 57:40 – Hopes for future guidelines; 61:35 – Gender inequity and sexual harassment in pharmacy PharmacyToDose.Com @PharmacyToDose on Twitter PharmacyToDose@Gmail.com
W 31. odcinku Anestezjologicznej Prasówki, czyli subiektywnego wyboru najciekawszych artykułów z ostatniego dwóch miesięcy, zawartych oczywiście w kilku najważniejszych pismach z dziedziny anestezjologii, przyjrzę się kilku nowym artykułom. W odcinku opowiem m.in. o kolejnych badaniach związanych z hipotermią terapeutyczną (temat w sam raz na połowę listopada), w jaki sposób tryb Pressure Support może pomagać na sali wybudzeń a także jakie jest miejsce skali qSOFA i skal wczesnego ostrzegania na etapie przyjęcia do szpitala. Zapraszam! Zobacz dodatkowe materiały i źródła na stronie Laryngoskop.eu!
Bir çoğumuzun Sepsis Kılavuzu diye kısaltacağı "Surviving sepsis campaign: international guidelines for management of sepsis and septic shock" kılavuzunun 2021 güncellemesi BUGÜN yayınlandı.1 Önümüzdeki günlerde önceki versiyonları ile kıyaslayarak tartışacağımız bu kılavuzun öneriler bölümlerini hemen Türkçeye kazandırmak istedik. Aşağıda başlıklar halinde önerileri bulabilirsiniz. Çeviri sırasında İngilizce "Recommend" kelimesini "öneri", "suggest" kelimesini ise "uygun" gibi çevirerek farklarını belirgin hale getirmeye çalıştık. Öneri maddelerinin hemen altındaki kanıt düzeylerine bakılarak, önerinin güç düzeyini değerlendirebilirsiniz. Sepsis ve Septik Şoklu Hastalar için Tarama 1- Hastaneler ve sağlık sistemleri için, akut hastalar, yüksek riskli hastalar için sepsis taraması ve tedavi için standart uygulama prosedürleri dahil olmak üzere, sepsis için bir performans iyileştirme programı kullanılmasını öneririz.Tarama için güçlü öneri, orta kalitede kanıtStandart operasyon prosedürleri için güçlü öneri, çok düşük kalitede kanıt 2- Sepsis veya septik şok için tek bir tarama aracı olarak SIRS, NEWS veya MEWS'ye kıyasla qSOFA'nın kullanılmamasını öneririz.Güçlü öneri, orta kalitede kanıt 3- Sepsis olduğundan şüphelenilen yetişkinler için kan laktat ölçümü yapılması uygundur.Zayıf öneri, düşük kaliteli kanıt İlk Resüsitasyon 4- Sepsis ve septik şok tıbbi acil durumlardır ve tedavi ve resüsitasyonun hemen başlamasını öneririz.En İyi Uygulama Bildirimi 5- Sepsis kaynaklı hipoperfüzyon veya septik şoklu hastalar için resüsitasyonun ilk 3 saati içinde en az 30 mL/kg intravenöz (IV) kristaloid sıvı verilmesi uygundur.Zayıf öneri, düşük kaliteli kanıt 6- Sepsis veya septik şoku olan yetişkinlerde; sıvı resüsitasyonuna rehberlik etmek için, fizik muayene veya tek başına statik parametreler yerine dinamik ölçümlerin kullanılması uygundur.Zayıf öneri, çok düşük kalitede kanıtYorumDinamik parametreler, atım hacmi (SV), atım hacmi varyasyonu (SVV), nabız basıncı varyasyonu (PPV) veya varsa ekokardiyografi kullanılarak pasif bacak kaldırmaya veya sıvı bolusuna yanıtı içerir. 7- Sepsis veya septik şoku olan yetişkinler için, laktat düzeyi artmış hastalarda serum laktatını azaltacak şekilde resüsitasyonun yönlendirilmesini, serum laktatının kullanılmamasına göre uygundur.Zayıf öneri, düşük kaliteli kanıtYorumAkut resüsitasyon sırasında, serum laktat düzeyi klinik durum ve laktat yüksekliğinin diğer nedenleri göz önünde bulundurularak yorumlanmalıdır. 8- Septik şoklu yetişkinler için, diğer perfüzyon önlemlerine ek olarak resüsitasyona rehberlik etmesi için kapiller dolum süresinin kullanılması uygundur.Zayıf öneri, düşük kaliteli kanıt Ortalama Arteriyel Basınç (MAP) 9- Vazopresör ihtiyacı olan septik şoklu yetişkinler için, daha yüksek ortalama arter basıncı (MAP) hedeflerine kıyasla 65 mm Hg'lik bir başlangıç hedef MAP'ı öneriyoruz.Güçlü öneri, orta kalitede kanıt Yoğun Bakıma Yatış 10- Yoğun bakım ünitesine yatış yapılması gereken sepsis veya septik şoklu yetişkinler için, hastaların 6 saat içinde yoğun bakım ünitesine yatışı uygundur.Zayıf öneri, düşük kaliteli kanıt ENFEKSİYON Enfeksiyon Tanısı 11- Sepsis veya septik şok şüphesi olan ancak enfeksiyonu teyit edilmemiş yetişkinler için, sürekli olarak yeniden değerlendirmeyi ve alternatif tanıları araştırmayı ve alternatif bir hastalık nedeni gösterildiğinde veya bu yönde kuvvetli şüphe ortaya çıktığında ampirik antimikrobiyallerin kesilmesini öneriyoruz.En İyi Uygulama bildirimi Antibiyotik Zamanlaması 12- Olası septik şoku olan veya sepsis olasılığı yüksek olan yetişkinler için, antimikrobiyallerin hemen, ideal olarak tespitten sonraki 1 saat içinde verilmesini öneririz.Güçlü öneri, düşük kanıt kalitesi (Septik şok)Güçlü öneri, çok düşük kanıt kalitesi (şokun eşlik etmediği sepsis) 13- Şokun eşlik etmediği olası sepsisi olan yetişkinler için, akut hastalığın muhtemel bulaşıcı olan ve olmayan nedenlerine karşı hızlı bi...
Resp 3: Sally and Harry talk about Sepsis, the qSOFA score and the Sepsis Six. This episode was vetted by Dr. Meehar Shah, Consultant in Emergency Medicine at Chelsea & Westminster Hospital, London.
Check out Dr. Josh Farkas' post about fluid selection and pH balanced fluid resuscitation for a more in depth understanding of why normal saline isn't always your patient's best option for fluid resuscitation.https://emcrit.org/ibcc/fluid/
Fred, Pedro, Rapha e João selecionaram quatro tópicos polêmicos de sepse para discutir nesse episódio! Um tema relevante para todos. Ficou com alguma dúvida, quer mandar alguma sugestão ou crítica? Entra em contato com a gente através do Instagram ou Twitter @tadeclinicagem ou e-mail tadeclinicagem@gmail.com. Assina nossa Newsletter semanal com os temas mais interessantes da clínica médica! O link está disponível no Instagram e no Twitter. MINUTAGEM Em breve REFERÊNCIAS 1. FUJII, Tomoko et al. Effect of vitamin C, hydrocortisone, and thiamine vs hydrocortisone alone on time alive and free of vasopressor support among patients with septic shock: the vitamins randomized clinical trial. Jama, v. 323, n. 5, p. 423-431, 2020 2. DE GROOTH, Harm-Jan; ELBERS, Paul WG; VINCENT, Jean-Louis. Vitamin C for Sepsis and Acute Respiratory Failure. Jama, v. 323, n. 8, p. 792-792, 2020 3. TRUWIT, Jonathon D. et al. Effect of vitamin C infusion on organ failure and biomarkers of inflammation and vascular injury in patients with sepsis and severe acute respiratory failure: the CITRIS-ALI randomized clinical trial. Jama, v. 322, n. 13, p. 1261-1270, 2019 4. CHANG, Ping et al. Combined treatment with hydrocortisone, vitamin C, and thiamine for sepsis and septic shock (HYVCTTSSS): A randomized controlled clinical trial. Chest, 2020 5. VENKATESH, Balasubramanian et al. Adjunctive glucocorticoid therapy in patients with septic shock. New England Journal of Medicine, v. 378, n. 9, p. 797-808, 2018. 6. ANNANE, Djillali et al. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intensive care medicine, v. 43, n. 12, p. 1751-1763, 2017. 7. ROCHWERG, Bram et al. Corticosteroids in sepsis: an updated systematic review and meta-analysis. Critical care medicine, v. 46, n. 9, p. 1411-1420, 2018 8. ANTAL, Oana, et al. "Initial Fluid Resuscitation Following Adjusted Body Weight Dosing in Sepsis and Septic Shock." The Journal of Critical Care Medicine 5.4 (2019): 130-135 9. SEYMOUR, Christopher W., et al. "Time to treatment and mortality during mandated emergency care for sepsis." New England Journal of Medicine 376.23 (2017): 2235-2244 10. OUELLETTE, Daniel R., and Sadia Z. Shah. "Comparison of outcomes from sepsis between patients with and without pre-existing left ventricular dysfunction: a case-control analysis." Critical Care 18.2 (2014): R79 11. RAJDEV, Kartikeya, et al. "Fluid resuscitation in patients with end-stage renal disease on hemodialysis presenting with severe sepsis or septic shock: A case control study." Journal of critical care 55 (2020): 157-162 12. BHATTACHARJEE, Poushali, Dana P. Edelson, and Matthew M. Churpek. "Identifying patients with sepsis on the hospital wards." Chest 151.4 (2017): 898-907 13. HAYDAR, Samir, et al. "Comparison of QSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis." The American journal of emergency medicine 35.11 (2017): 1730-1733 14. JIANG, Jianjun, et al. "Head-to-head comparison of qSOFA and SIRS criteria in predicting the mortality of infected patients in the emergency department: a meta-analysis." Scandinavian journal of trauma, resuscitation and emergency medicine 26.1 (2018): 56 15. GOULDEN, Robert, et al. "qSOFA, SIRS and NEWS for predicting inhospital mortality and ICU admission in emergency admissions treated as sepsis." Emerg Med J 35.6 (2018): 345-349
In this episode, we discuss treatment recommendations found in recent literature, in regards to fluid administration in septic shock. We also discuss the updates to the definition of sepsis, and the criteria for diagnosing a patient with sepsis. In this episode, we discuss SOFA, and QSOFA, as well as the elimination of SIRS and "Severe Sepsis" from the sepsis spectrum. Join us as we dive in to the pathophysiology of septic shock, and how fluid administration is still considered a staple treatment. We discuss how third spacing occurs secondary to overzealous fluid administration, resulting in potential worsening of hypoperfused tissues and organs. In this episode, we also discuss the ProMISe, ARISE, and CENSER trials, and discuss the suggestions of early vasopressor therapy using norepinephrine has proven to be beneficial. We also briefly discuss the potential benefits of pre-hospital administration of broad spectrum antibiotics, and the Phantasy trial, and propose to revisit a similar study with more objective methods. Please like, subscribe, follow, and share, and look for Episode 10!|www.medicclasscitizen.com| "Subscribe" to receive email updates on the status of the store, and exciting things to come. Facebook: @medicclasscitizenInstagram: @medic_class_citizenTwitter: @medic_citizen
Welcome to the final episode of Series 2 of Bolus. We are joined by Prof Mervyn Singer, a UCLH intensivist, researcher and teacher. He famously lead the international task force to redefine sepsis in 2016, known as Sepsis-3. Our wide ranging conversation covers a number of interesting and thought provoking questions: Is sepsis over diagnosed? Can you predict who will develop sepsis following an infection? Is a rapid, broad spectrum approach to antibiotics causing more problems than it solves? What's best for spotting sepsis at the bedside qSOFA or NEWS? Hyperlactataemia, is it always bad? How to assess for intravascular depletion and how should fluid resuscitation be administered? See you in 4 weeks for Series 3.
Heute geht es um die Geschichte der Sepsis Definitionen.
El 13 de septiembre ha sido instituido como Día Mundial de la Sepsis, con el objetivo de crear conocimiento y conciencia sobre esta patología que todavía buscamos definir e identificar de forma mas precisa. Así que en nuestro episodio de esta semana vamos a interrumpir la serie que veníamos realizando sobre resistencia y vamos a dedicarlo a la sepsis. La idea es mencionar aspectos novedosos e interesantes sobre este concepto que han surgido sobre los últimos dos años. Referencias: Goulden R, Hoyle M-C, Monis J y Colaboradores. qSOFA, SIRS and NEWS for predicting inhospital mortality and ICU admission in emergency admissions treated as sepsis. Emerg Med J 2018;35:345–349. Usman OA y colaboradores. Comparison of SIRS, qSOFA, and NEWS for the early identification of sepsis in the Emergency Department. American Journal of Emergency Medicine 37 (2019) 1490–1497. Hernandez G y colaboradores. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019;321(7):654-664. doi:10.1001/jama.2019.0071. Semler MW y colaboradores. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med 2018; 378:829-839. Self WH y colaboradores. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med 2018; 378:819-828. Permpikul C y colaboradores. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial. Am J Resp Crit Care Med 2019; 199 (9): 1097-1105. Annane D y colaboradores. Hydrocortisone plus Fludrocortisone for Adults with Septic Shock. New Engl j Med 2018; 378:809-18. La Frase de la Semana: Esta semana la tomamos de Jean-Paul Sartre nacido el 21 de junio de 1905 en París, Francia, y fallecido el 15 de abril de 1980 en París. Fue novelista, dramaturgo y exponente francés del existencialismo, una filosofía que aclama la libertad del ser humano individual. Fue galardonado con el Premio Nobel de Literatura en 1964, pero lo rechazó. La Frase dice: “Como todos los soñadores, confundí el desencanto con la verdad”
SIRS, qSOFA ou NEWS? No dia mundial da sepse, não perca esse episódio extra sobre o escore NEWS2 e como utiliza-lo para ajudar a identificar pacientes com SEPSE. Entrevista com o médico escocês Dr. Kevin Rooney, referência mundial em trabalhos sobre sepse, direto do evento presencial do Projeto Sepse nas UPAS. A tradução da entrevista esta no instagram: @topicospodcast.
In der ersten Folge gibt es ein Interview mit Fabian (Oberarzt auf einer Notfallstation) über die Highflow-Oxygen-Therapie, eine kurze Vorstellung des QSOFA und zum Abschluss ein Lied von Dobu&Trex.
In this podcast Dr. Sara Gray, intensivist and emergency physician, co-author of The CAEP Sepsis Guidelines, answers questions such as: How does one best recognize occult septic shock? How does SIRS, qSOFA and NEWS compare in predicting poor outcomes in septic patients? Which fluid and how much fluid is best for resuscitation of the septic shock patients? What are the indications for norepinephrine, and when in the resuscitation should it be given, in light of the CENSER trial? What are the goals of resuscitation in the patient with sepsis or septic shock? When should antibiotics administered, given that the latest Surviving Sepsis Campaign Guidelines recommend that antibiotics be administered within one hour of arrival for all patients suspected of sepsis or septic shock? What are the indications for a second vasopressor after norepinephrine? Given the conflicting evidence for steroids in sepsis, what are the indications for steroids? Should we be considering steroids with Vitamin C and thiamine for patients in septic shock? What are the pitfalls of lactate interpretation, and how do serial lactates compare to capillary refill in predicting poor outcomes in light of the ANDROMEDA trial? Is procalcitonin a valuable prognostic indicator in septic patients? and many more... The post Ep 122 Sepsis and Septic Shock – What Matters from EM Cases Course appeared first on Emergency Medicine Cases.
Due to the increase in the amount of bacterial infections in ill individuals, Dr. David Larson (Ridgeview Medical Center) speaks in this podcast, about sepsis, septic shock, and the 2018 SSC guidelines. Objectives: Upon completion of this podcast, participants will be able to: Describe what the surviving sepsis campaign is. Define the current definition and the guidelines of sepsis and septic shock. Select treatments and management for sepsis and septic shock. Explain medical decision algorithms such as qSOFA. CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: Sepsis, Septic Shock and 2018 SSC Guidelines (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.” FACULTY DISCLOSURE ANNOUNCEMENT It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos. Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’ll be talking Updates and Controversies in the Early Management of Sepsis and Septic Shock. We have a special episode for you this month… We’ve brought Dr. Jeremy Rose, one of the peer reviewers, and a sepsis expert, on with us to talk through the content this month. Jeremy: Dr. Jeremy Rose here. Thanks for having me in on this conversation. I’m always happy to talk about this topic because it’s clearly important. There’s a great deal of confusion around sepsis and I hope that in the next couple minutes we can clarify things in a way that really help your average front line doc trying to get it right. Nachi: So Dr. Rose, before we get started, tell us a bit about your background and your interest in sepsis… Jeremy: I’m the Assistant Medical Director and Sepsis Chair at Mount Sinai Beth Israel in Manhattan. For those listening, my hospital probably looks a little bit like yours. We’re busy, interesting, and just a little rough around the edges. We like it that way. More importantly, though, we mirror the national averages regarding sepsis. Roughly half of in-hospital mortality is associated with septic in some fashion. Pretty incredible when you think about it. Half. Jeff: Sepsis chair... clearly this is an important topic if it warrants it’s own chair at a major hospital in NYC. But getting back to the article this month. This month’s issue was authored by Faheem Guirgis, Laurent Page Black, and Elizabeth DeVos of the University of Florida, Department of Emergency Medicine. Nachi: And it was peer reviewed by Michael Allison, Assistant Director of the Adult ICU at Saint Agnes Hospital, and Jeremy Rose and Eric Steinberg of Mount Sinai Beth Israel. Jeff: So as well all know Sepsis is bread and butter emergency medicine, but, what is sepsis? It seems that every month or so we have a new guideline, bundle, definition, or whatever… I think it’s best to start with the basics - At its core, sepsis is a dysregulated response to infection that can be life-threatening. Nachi: Right and it’s the combined inflammatory with immunosuppressive features of sepsis that lead to the devastating organ dysfunction and even death. Optimal management of septic patients has been a source of intense research, stemming from the landmark study by Rivers in 2001. Jeremy, can you give us a little historical context there? Jeremy: Rivers was a real pioneer. He found a 16% mortality reduction with randomization to an early aggressive care bundle. Amazing work. That being said, many components of that bundle have since been disregarded. For example, Manny Rivers would measure CVP in all of his patients, something we rarely do. Nachi: Not to cut you off and steal your thunder there, but we’ll get to the most recent updates in management shortly. Let’s first talk definitions and terminology, and specifically, diagnosis, which is definitely a big elephant in the room. As Jeff mentioned a few minutes ago, diagnostic criteria have undergone so so so many changes. Jeff: Yes it has! 1991 marked the first standardized definition. Then in 2001, sepsis-2 was introduced. In 2014, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine started a task force, and by 2016, updated definitions were out again! Sepsis-3!! A lot of this came after the realization that SIRS was just too broad and was overly sensitive and non-specific. Jeremy, why don’t you take us through Sepsis 3. Jeremy: So just to back up a little and frame this: Here’s the fundamental problem: As we likes to say, “there’s no troponin for sepsis.” And if you look at our patients, we tend not to miss the hypotensive, tachycardic, febrile patient. We know they’re septic. But how do we find the ones who don’t look as sick. Frequently elderly, possibly with normal-ish vitals and no fever. Those can be a lot harder to spot, but they may indeed be septic. Also, for research purposes we have to have a common definition, so Sepsis 3 came up with something called the SOFA score. The problem with the SOFA score is that its difficult to perform in the ED. It has parameters like bilirubin that often aren’t available when we want to screen out very sick patients. Fortunately there is the abridged version qSOFA, which identifies non-icu patients who are at high risk of inpatient mortality. So here it is, and if you get one thing from this episode, this is it: There are ONLY 3 criteria to the qSOFA. 3 Criteria. RR > 22; AMS; SBP 2. So quite a few changes! Jeff: And Jeremy, sticky topic coming up here. Center for Medicare and Medicaid Services (or CMS) quality measures - They haven’t really caught on to and adapted to Sepsis-3 yet, have they? Jeremy: The CMS mandate is based on the presence of SIRS criteria. Sepsis 3 is based on SOFA. This is definitely confusing. Part of the challenge in discussing this topic is separating out the QI guidelines from what is actually relevant to patient care based on the latest evidence-based medicine. Nachi: That seems fair. We’re really going to put you in an uncomfortable spot for a second and push you here Jeremy. Do you have any insight into why CMS isn’t interested in following the mountains of research that have led to sepsis-3? Is there a reason they are sticking to their current criteria? Jeremy: I think some of it is the slow pace of bureaucracy and the time that it takes to develop a consensus on management. Even if we can agree on who is septic, it’s really hard, if not impossible to link the care to a pay-for-performance metric which is what CMS ultimately would like to see. That’s not how Sepsis-3, or for that matter, SIRS, was designed to be used. You’re trying to take a tool which was originally designed for research and mold them into a tool used for pay for performance. Nachi: What a struggle. The CMS metrics are slightly different from the 2001 sepsis guidelines also. Take a look at Table 2 of the article for a quick comparison of sepsis-3, 2001 sepsis, and cms side-by-side. And for those on twitter, we’ll be sure to tweet this table out too for your review. Jeff: With so many different scores and definitions, I think that adequately sets the stage for the challenge this month’s authors faced coming up with real evidenced based guidelines. Nachi: Oh absolutely. And to make matters worse - this is a HUGE problem. We’re talking up to 850,000 ED visits annually in the US, and 19 million cases worldwide. Compounding this, sepsis results in death in approximately 1 out of 4 cases. Not only is it lethal, it is also very costly -- 17 billion dollars per year in the US alone! Jeff: And don’t forget importantly the 30-day hospital readmission rate. Sepsis is coming in at a higher readmission rate and cost per admission than acute MI, CHF, COPD, and PNA. Nachi: Let’s speak briefly on the etiology and pathophysiology of sepsis: we all know that sepsis is due to local infections that then become systemic. Previously, it was believed that the bacterial infection itself was the cause of the clinical syndrome of sepsis. However, we now know now that the syndrome of sepsis is due to the inflammatory and immunosuppressive mediators that were triggered by the infection. Normal immune regulatory safeguards fail and this leads to the syndrome. And interestingly, several studies have shown that critically ill septic patients experience reactivations of specific viruses that were previously limited to patients with severe immunosuppression. Jeff: Definitely something to look out for in your critically ill septic patients. We should talk briefly about the most common inciting infections that lead to sepsis. In order, these are: pneumonia, intra-abdominal infections, and urinary tract infections. No surprises there! Nachi: Yeah, that basically parallels my own experience, so that’s reassuring! That takes us to our next potentially controversial topic - blood cultures. Jeremy - we’re going to punt this one back to you Jeremy: This is another interesting topic that has received plenty of attention. CMS loves blood cultures. It’s an easy metric to track. That doesn’t mean they’re always helpful. We looked at our patients with lactates between 2.1 and 4.0 which had “severe sepsis.” These patients were normotensive though, In other words, the ones that aren’t that sick. We found that blood cultures are useful about 20% of the time. That’s not bad. So what do we do? We draw cultures before pushing antibiotics. Is that helpful? Sometimes yes, does it waste money? Debatable. Does it help us meet our metrics, yes. Jeff: And I think that gets at the crux of the problem here: we don’t want to delay antibiotics on anybody, but we must balance this with the potential harm of further increasing the drug resistant bacterial population via sound antibiotic stewardship. Remember also that there is a broad differential for sepsis, with several “sepsis mimics”. To name a few, we have PE, MI, CHF, acute pulmonary edema, DKA, thyroid storm, GI bleeds, drug intoxications, and withdrawal syndromes, just to name a few. In case that wasn’t enough check out Table 3 of the article. Nachi: And we already mentioned the leading causes of sepsis, that’s pneumonia, intra abdominal infections, and uti’s. But remember the source can be anywhere. Be sure to also think of pyelonephritis, central line associated bloodstream infections, prosthetics, endocarditis, necrotizing fasciitis, and meningitis. Jeff: I don’t think we need to dwell on this much longer - basically the differential is huge. Let’s move on to my favorite section - prehospital care. Jeremy: 20 pages of evidenced based recommendations and your favorite is the prehospital section, what’s up with that? Jeff: I’m an EMS fellow, what can I say… Anyway, on to my favorite section -- prehospital care. This is always a hot topic because the prehospital period is a special opportunity to get early interventions in for septic patients as 40 - 70% of all severe sepsis hospitalizations arrive via EMS. Nachi: And in one study taking place in a large metropolitan area, prehospital care time was over 45 minutes, and less than 37% arrived with IV access. Of course, these numbers would vary significantly based on where you practice. Jeff: So get this -- one study showed that out-of-hospital shock index and respiratory rate were highly predictive of ICU admission. So clearly early recognition and therapy may play a role here. Another study, however, showed knowledge gaps by advanced EMS providers in diagnosis and management of sepsis. And yet another study showed that only 18 to 21% of confirmed septic patients were suspected of having sepsis by EMS. Out of hospital fluids were started in only half of patients with severe sepsis. In essence, there is likely a strong role here for pre hospital protocols for identifying and treating sepsis. Nachi: In terms of pre hospital treatments though, prehospital IV fluids haven’t been shown to improve mortality, but have been associated with shorter hospital stays. Prehospital sepsis protocols have been described, but in general more research is needed in this area. Jeff: While prehospital care hasn’t yet been shown to improve the prognosis of septic patients, those presenting via EMS do have shorter delays to initiation of antibiotics, IV fluids, and early care bundles. EMS should focus primarily on stabilizing vital signs and providing efficient transport. If it’s possible to establish an IV and initiate fluids without delaying transport, EMS should do that as well. Nachi: And of course, oxygen for the hypoxic patients! Moving on to history and physical for your presumed septic patient. Jeremy, what are the big hitting things here that you always ask and check for, and that you make sure your residents are doing? Jeremy: After ABC’s and glucose, AMS is really important, it’s in the QSOFA SCORE. Unfortunately, this can be hard in many septic patients where they’re baseline mental status is less than perfect. The other thing is to try and find the source. Finding the source lets you make wise choices about therapy. Jeff: Great point about the mental status - so many of our older population have an altered baseline, but recognizing changes from that baseline is key. Nachi: Absolutely, with that in mind, let’s talk diagnostic studies, especially lactate. Where I trained, basically everybody was getting a lactate, even tired looking residents seemed to be having their lactates checked, and trust me, they weren’t looking that good... Jeremy: Brace yourself: lactate is really important in septic patients. That being said, not every cause of elevated lactate is sepsis. There is this animal called Type B lactic acidosis can come from numerous drugs like albuterol. Just because you see elevated lactate doesn’t mean you can forget about the other causes. That being said, we know that patients with sepsis do better when they clear lactate. Jeff: Seems like the evidence is definitely in favor of serial lactate testing… Jeremy: For sure. At least until you have a reasonable trend towards improvement. We know lactate clearers do better. We’ve looked at our own lactate numbers. Interestingly, the takeoff point for sepsis seems to be around 2.5. Meaning that patients with altered vitals and lactates above 2.5 tend to do worse. But, there is a broad ddx to elevated lactate. What is true, though, is that lactate is a marker for badness. If your patient’s lactate is rising, yours should be too. Nachi: I bet I’m a “lactate clearer”. I may add “lactate clearer to my CV,” sounds impressive. But I digress… Next up we have Procalcitonin. Since procalcitonin becomes elevated in those with bacterial infections, intuitively, this should be a valuable marker to assess in potentially septic patients. Unfortunately procalcitonin lacks negative predictive value so most literature supports its use in diagnosing pulmonary infections and for antibiotic de-escalation. Jeff: Good to know, I’ve seen it being used a lot more recently and wondered how evidence based this test was. Jeremy: Honestly, I don’t see Procalcitonin changing ED management at the moment. If you’re waiting for Procalcitonin to start antibiotics or fluids, you’re waiting too long. Nachi: Moving on, let’s talk imaging. Based on current studies, the authors recommend focused imaging only. In addition, they also note that our good friend, the point of care ultrasound, likely plays a role, as in one study, POCUS demonstrated a 25% improvement in sensitivity from clinical impression alone. Jeremy: I think there are two ways POCUS comes in. One, lung ultrasound can be really useful to find that occult pneumonia or differentiating pneumonia from CHF. Two, your ultrasound is your best tool for assessing volume status. I try to look at the IVC of all my septic patients and echo them when possible. Nachi: Right. So now we’ve examined, drawn labs and cultures, checked a lactate, may be obtained imaging… next up we should probably start treating the patient. Whether you like it or not, we have to discuss CMS. Jeremy: Just to clarify before we start. CMS defines “severe sepsis” as SIRS + infection with a lactate of 2.1-4.0. Septic shock is SIRS + infection with hypotension or a lactate > 4.0. That’s where we’re at. Jeff: Good point. Back to treatment: within the first 3 hours, for any patient with sepsis and septic shock, you must measure a lactate, obtain 2 sets of blood cultures, administer antibiotics, and give an isotonic fluid challenge with 30 cc/kg to patients with hypotension or a lactate greater than 4. Then, within the first 6 hours, you must apply vasopressors to achieve a MAP of at least 65, re-assess volume status and perfusion, and remeasure a lactate. Nachi: This begs the question - are these recommendations evidenced based? Jeremy…. Jeremy: I’m so glad you asked that . Let’s start with fluids. Patient’s need adequate fluid resuscitation. Interestingly there are 3 large RCT’s, PROMISE, PROCESS and ARISE, that compared a Rivers type bundle to usual care. Surprisingly, they showed no difference. But when your drill down into these 3 trials, you see that “the usual care,” now generally includes at least 2 liters of fluid. Jeff: Ok, so it seems that there is some pretty good data to support a rapid fluid challenge of at least 30 cc/kg. But how do we determine who needs more fluids and how much more they need. There must be an endpoint to all of this? Jeremy: Another million dollar question. 30cc/kg is probably a good place to start. How much is too much? I think we need to be smart about our fluids. Some patients will need less and some will need much more. So, I remind my resident’s to be smart about fluids. Sono an IVC, trend a lactate, follow a urine output, do a passive leg raise, even check JVP. I mean just because you haven’t seen a unicorn doesns’t mean they’re not real. Do something to monitor volume status. Nachi: Very important. Put your ultrasound skills to work here. They’ll only improve as you practice more. Jeff, let’s get started on the ever important topic of antibiotics. Jeff: Sounds good. Current guidelines recommend that broad spectrum antibiotics be administered within the first hour of presentation for those with sepsis or septic shock, ideally with blood cultures being drawn beforehand. In one study, every hour of delayed abx administration was associated with an 8% increase in mortality. Since this 2006 study, other studies have had mixed results - with studies showing increased odds of death with delays in abx administration and others showing only a benefit in those with septic shock with or without hypotension with no benefit to those without shock. Nachi: In terms of antibiotic coverage - you need to consider the site of infection, local resistance patterns, the presence of immunosuppression, and the patient’s age and comorbidities. Table 5 of the article is very thorough and should be kept as a quick reference. Jeremy do you have any specific recommendations for our listeners on how we should approach antibiotic usage in the septic patient? Jeremy: I like to think about antibiotics a little more simply than referencing a table. I ask a couple questions. Does my patient need MRSA coverage ? Does my patient need Pseudomonal coverage? If the answer is no and no, then narrow your coverage. You don’t necessarily have to use a bunch of Vanco, or a big gun antipseudomonal like Pip/tazo. Also, have a look at your local antibiogram. I can’t tell you how many times this changes prescribing habits for even things like simple UTIs. I’m going to stray into some controversial territory here. The benefits of sepsis protocols are measured one patient at a time, but the harms are only measured in the aggregate. What does that mean? CMS metrics have caused us to use to use more broad spectrum antibiotics. As a result, we’re seeing more resistance. My resident’s tell me to make it easy, give em VZ (that’s vanco/zosyn) and it kills me. Every time you put a Z-pack into the world a pneumococcus gets it’s wings. So think more about your antibiotics, and know your local biograms. Jeff: That’s a great way to think about it, I fear I’ve given a lot of pneumococci wings during my training… Next we’re on to vasopressors. The data is pretty clear on this one - norepinephrine is the recommended first line vasopressor for septic shock. In numerous trials comparing Norepi to dopamine, NE was far superior, with dopamine increasing arrhythmias in one trial and associated with an increased risk of death as compared to NE in another trial. Jeremy: So here’s a question I get all the time: How can I give Norepi without a central line. Let’s use Dopamine, its safe peripherally. Ok, so follow that through. We’re going to give a drug to increase blood pressure by constricting blood vessels, but don’t worry, it’s safe peripherally. What does that mean? It means it doesn’t work!! It doesn’t give much blood pressaure. Dopamine is a lousy pressor. It causes a lot of tachycardia, which is not what you want in failing septic hearts. So what do we do if we don’t have a central line? We start norepi peripherally into a large bore IV for the time it takes us to get a central line. That’s where the evidence is. There’s a mortality benefit to NE over dopaine in septic shock. Jeff: Right, this month’s authors note peripheral pressors may be safe for brief periods in settings with close monitoring. While this is commonplace in some hospitals, others haven’t yet jumped on that bandwagon. I think it’s important to mention that this is becoming more and more commonplace, even in the prehospital realm. With the service I fly for, we routinely start peripheral vasopressors without hesitation. But this isn’t limited to the air. Many ground 911 services have also adopted peripheral vasopressors in a variety of settings. Nachi: I’m sure there are many trials to come in the future documenting their safety profile, but moving on to the next pressor to discuss... vasopressin. This should be your second line vasopressor for septic shock. In the VASST trial, low-dose vasopressin was found to be noninferior to NE. In other trials, vasopressin also appeared to show a potential benefit in those with AKI and sepsis, although the subsequent VANISH trial (perhaps the best name for a clinical trial so far) failed to demonstrate a benefit to vasopressin titration with regard to renal outcomes in septic shock. Vasopressin has also been shown to reduce NE dosing when administered at a fixed dose of 0.03-0.04 units/min. Jeff: Next we have epinephrine. In one study epinephrine and NE were equivalent in achieving MAP goals in ICU patients with shock, however several of those receiving epi developed marked tachycardia, lactic acidosis, or an increased insulin requirement. The increasing lactic acidosis could confound the trending of lactates, so in those requiring inotropy in addition to some peripheral squeeze - the authors recommend adding dobutamine to norepinephrine instead of starting epinephrine. Although, keep in mind, this can lead to some hypotension so remember to start at low doses. Nachi: Phenylephrine, a pure alpha adrenergic agent, is next and should be considered neither first nor second line, but it may have a role as a push dose agent while preparing other vasoactive agents. Jeff: And lastly, we have angiotensin 2. One recent 2017 study examining the role of angiotensin 2 in those with septic shock already on 0.2 mcg/kg/min of NE found that those receiving AT2 had significant improvements in MAPs as well as cardiovascular SOFA score at 48h with no difference in mortality. Unfortunately, these benefits do not come without risk as AT2 may increase risk of arterial and venous thrombosis and potentially thromboembolism. Clearly, one study isn’t enough to change practice, but it’s certainly food for thought. Nachi: So that wraps up vasopressors. Jeremy, we’re on to corticosteroids -- another hotly debated topic. When do you give steroids in sepsis? Jeremy: Hmmm steroids, this is an age old question. No study has clearly supported the blanket use of steroids in septic shock. Several like CORTICUS and ADRENAL showed no difference. I will use hydrocortisone for pressor refractory shock. Meaning, you’ve tried everything else, so you might as well try. Also, I do tend to avoid Etomidate, given the possibility of adrenal suppression and that there are several other induction agents, notably Ketamine that don’t have this problem. Jeff: Those trials are certainly important, thanks for bringing them up - Especially with all the FOAM content out there, it’s incredibly important to look back at the data to understand where certain recommendations are coming from. Anyway… one quick note on blood transfusions before we move on to special populations - Although part of the original early goal directed therapy, thanks to data from the TRISS trial which showed no difference in outcomes with a transfusion goal of 7 vs 9, transfusions are reserved for those with a hbg of less than 7. Jeremy: One population we should make sure to mention and be careful with is end stage liver disease. In the ER, we tend to miss SBP alot. Mostly because these patients have lots of reasons to be sick and they already have elevated lactate because of their deceased clearance. My practice is to give a dose of Ceftriaxone and sent a diagnostic tap to patients who are sick and have ascites. Nachi: Alright Jeremy, let’s talk controversies in sepsis. We’re giving you all the big questions this month! Jeremy: We’ve already talked about fluids and how much to give. Just a reminder that a history of CHF doesn’t preclude proper fluid resuscitation. I think broad spectrum antibiotics for relatively well patients is a big controversy. Our national rates of antibiotic resistance are terrible, and yet we’re using more antibiotics all the time. There are very few if any antibiotics coming down the pharma pipeline and we’re going to have to face the music eventually. Finally, we need national metrics that mirror clinical evidnece. Protocols should be a tool and not a crutch. You know what’s best for the patient in front of you, so don’t let metrics or protocols make you do things you think are not in your patient’s best interest. Nachi: So how do you escape the hospital protocols and CMS and do what’s best for your patient without “getting in trouble”? Jeremy: Here’s how I deal with it as the one who reads and QI’s all of our sepsis charts. I tell my colleagues to do what’s right, and if you need to deviate from the protocol tell me why. As long as you can explain your decision, I’ll support it. Explaining your thinking is good clinical practice and is good medico-legal practice. CMS has been unable to link these metric to payment, simply because no hospital can meet them with any regularity. It’s important that we advocate for our patients or nothing will change. Make them respect you for the highly educated professional that you are, and your patients will ultimately benefit. Jeff: Preach!! And before we close out with disposition, there are a few new therapies and trials on the horizon to keep a lookout for. The RACE trail examined the role of L-carinitine. The VICTAS trial is looking at vitamin C, thiamine, and steroids in sepsis. The CLOVERS trial is looking at early vasopressors vs a crystalloid liberal strategy. And lastly, IL-7 is also being investigated. All really cool stuff that could change how we manage sepsis in the future.. Nachi A few quick notes on disposition before we close this episode out. Certainly not all patients meeting SIRS require admission, but many do. Those with qSOFA of 2 or higher represent a sick population and an ICU admission should be considered. Even for those with a qSOFA of 1 but a lacate over 2 -- they have a mortality approaching that of patients with a qSOFA of 2. Be careful just sending a patient who is on the fence to the floor because several studies have demonstrated that patients who are later upgraded have worse outcomes. Jeff: That’s in line with the general themes we’ve laid out today - definitely better to start early with aggressive care rather than play catch up later. Jeremy - in 30 seconds or less, what are the most salient points in the management of sepsis that you would like our listeners to take with them from this episode. Jeremy: Here are my take aways: qSOFA, RR, AMS SBP < 100 Norepi, not Dopamine - it doesn’t work! Be smart about fluids!! Be smarter about antibiotic use! You are the best advocate for your patient, despite what anyone else says! Jeff: Excellent, so that wraps up the October 2018 episode of Emplify. A big thanks to Jeremy Rose for joining us. Jeremy: Thank you for having me!!! It was great talking with you. Nachi: For our listeners -- additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credits. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. Jeff: And the address for this month’s credit is ebmedicine.net/E1018, so head over there to get your CME credit. As always, the ding sound you heard throughout the episode corresponds to the answers to the CME questions. Nachi: Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!
Dr. Centor interviews Dr. Rachael A. Lee to try to help listeners untangle the confusion around qSOFA and SIRS, 2 tools to help clinicians decide if a patient has sepsis.
Dr. Centor interviews Dr. Rachael A. Lee to try to help listeners untangle the confusion around qSOFA and SIRS, 2 tools to help clinicians decide if a patient has sepsis.
Shree Basu is joined by Marino Festa to discuss sepsis. They cover epidemiology, challenges in diagnosing sepsis, SEPSIS 3 guidelines and what it means in paediatrics, and some clinical tips on the assessment and management of children with sepsis. Here's a useful articleon the prognostic accuracy of age-adapted SOFA, SIRS, PELOD-2, and qSOFA for in-hospital mortality among children with suspected infection admitted to the intensive care unit. From www.IntensiveCareNetwork.com
Simon Carley, Associate Editor of EMJ, talks through the highlights of the June 2018 edition of the Emergency Medicine Journal, this month, chosen by Associate Editor, Edward Carlton. Read the primary survey here: emj.bmj.com/content/35/6/341 Details of the papers mentioned in this podcast can be found below: Editor's choice: Comparison of qSOFA with current emergency department tools for screening of patients with sepsis for critical illness - emj.bmj.com/content/35/6/350 Editor's choice: qSOFA, SIRS and NEWS for predicting inhospital mortality and ICU admission in emergency admissions treated as sepsis - emj.bmj.com/content/35/6/345 Editor's choice: Sepsis-3 and simple rules - emj.bmj.com/content/35/6/343 MRSA nares swab is a more accurate predictor of MRSA wound infection compared with clinical risk factors in emergency department patients with skin and soft tissue infections - emj.bmj.com/content/35/6/357 Outpatient management of children at low risk for bacterial meningitis - emj.bmj.com/content/35/6/361 Gender and survival from out-of-hospital cardiac arrest: a New Zealand registry study - emj.bmj.com/content/35/6/367 Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan - emj.bmj.com/content/35/6/379 Validity of the Japan Acuity and Triage Scale in adults: a cohort study - emj.bmj.com/content/35/6/384 Marauding terrorist attack (MTA): prehospital considerations -emj.bmj.com/content/35/6/389 Read the full June issue of EMJ here: emj.bmj.com/content/35/6
Editor's Summary by Howard Bauchner, MD, Editor in Chief of JAMA, the Journal of the American Medical Association, for the June 05, 2018 issue
With special guest Trey La Charité, MD, FACP, SFHM, CCS, CCDS, the medical director for CDI and coding at the University of Tennessee Medical Center (UTMC) in Knoxville, Tennessee. Co-hosted by Laurie Prescott, MSN, RN, CCDS, CDIP, CRC, the CDI Education Director for ACDIS in Middleton, MA. To read "SIRS beats qSOFA for sepsis screening" as featured on In the News, please click here. To view the new 2018 ACDIS Advisory Board members as featured on ACDIS Update, please click here.
So the three of us are back together and going to take on Sepsis! It's vital to have a sound understanding of sepsis. It has a huge morbidity and mortality but importantly there is so much that we can do both prehospital and in hospital to improve patient outcomes. In the podcast we cover the following; Definitions Scale of problem Different bodies; NICE/Sepsis Trust/3rd international consensus definition including qSOFA Handover and pre alerts Treatment; Sepsis 6 The evidence base behind treatment Contentious areas Prehospital abx Fever control Steroids ETCO2 We hope the podcast helps refresh your knowledge on the topic and brings about some clarity on some contentious points. As always don't just take our word for it, go and have a look at the primary literature referenced below. Enjoy! Simon, Rob & James References & Further Reading Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Kumar. Critical Care Medicine. 2006 Prognostic value of timing of antibiotic administration in patientswith septic shock treated with early quantitative resuscitation. Ryoo SM. Am J Med Sci. 2015 The association between time to antibiotics and relevant clinicaloutcomes in emergency department patients with various stages of sepsis: a prospective multi-center study. de Groot B. Crit Care. 2015 Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Puskarich MA. Crit Care Med. 2011 Early goal-directed therapy in the treatment of severe sepsis and septic shock. Rivers E. N Engl J Med. 2001 Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Nguyen HB. Crit Care Med. 2004 The prognostic value of blood lactate levels relative to that of vitalsigns in the pre-hospital setting: a pilot study. Jansen TC Crit Care. 2008 Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. Jones AE. JAMA. 2010 Lower versus higher hemoglobin threshold for transfusion in septic shock. Holst LB. N Engl J Med. 2014 A randomized trial of protocol-based care for early septic shock. ProCESS Investigators. N Engl J Med. 2014 Trial of early, goal-directed resuscitation for septic shock. Mouncey PR. N Engl J Med. 2015 Goal-directed resuscitation for patients with early septic shock. ARISE Investigators. N Engl J Med. 2014 Acetaminophen for Fever in Critically Ill Patients with SuspectedInfection. Young P. N Engl J Med. 2015 NICE; Sepsis: recognition, diagnosis and early management The Sepsis Trust The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Singer M. JAMA. 2016 NHS E; Improving outcomes for patients with sepsis. A cross-system action plan Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. Alam N. Lancet Respir Med. 2018 Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. Venkatesh B. N Engl J Med. 2018 PHEMCAST; End Tidal Carbon Dioxide Current clinical controversies in the management of sepsis. Cohen J. J R Coll Physicians Edinb. 2016 St Emlyns; qSOFA RCEM; Severe Sepsis and Septic Shock Clinical Audit 2016/2017 National report RCEM & UK Sepsis Trust; Toolkit: Emergency Department management of Sepsis in adults and young people over 12 years- 2016
Podcast summary of articles from the May 2017 edition of Journal of Emergency Medicine from the American Academy of Emergency Medicine. Topics include Ketamine for acute pain, qSOFA vs SIRS for sepsis, hypokalemia in Cushing Syndrome, elevated liver enzymes, outpatient management of pulmonary embolisms, FEIBA for anticoagulation reversal, and board review on concussions. Guest speakers include Dr. Courtney Smalley of the Cleveland Clinic Emergency Services Institute, and Dr. Allison Lane of the Banner University Medical Center in Tucson, Arizona
HelixTalk - Rosalind Franklin University's College of Pharmacy Podcast
In this episode, we discuss the newest definition of sepsis and septic shock according to the Sepsis-3 criteria and the 2016 Surviving Sepsis guidelines. We also review the scoring systems of “qSOFA” and “SOFA” and use a patient case to help demonstrate the new definitions.
The Surviving Sepsis Campaign Guidelines were updated, reflecting some changes carried forward from Sepsis 3.0 that was released in 2016. In this podcast we go over some of the updates, many of the recommendations that stayed the same. As a bonus we cover a new study on validation of qSOFA. Show notes at FOAMcast.org Thanks for listening! Jeremy Faust and Lauren Westafer
Editor's Audio Summary by Howard Bauchner, MD, Editor in Chief of JAMA, the Journal of the American Medical Association, for the January 17, 2016 issue
Episode 81: NEWS vs. QSOFA
A lot of good literature came out in 2016 so we wanted to mention a couple of our favorite articles of the year. Sepsis 3.0 Singer M, Deutschman CS, Seymour CW, et al: The Sepsis Definitions Task Force The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The quick SOFA score (qSOFA) also came out in hopes it "provides simple bedside criteria to identify adult patients with suspected infection who are likely to have poor outcomes." It is not part of the sepsis definition Back Up Head Elevated Intubation Khandelwal et al. Head-elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesthesia and Analgesia. Apr 2016. Ketorolac Dose Motov, S, Yasavolian, M, Likourezos, A, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department. .Ann Emerg Med. 2016 Dec 16. Out of Hospital Cardiac Arrest Prognostication Jabre et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Intern Med. 2016 Dec 6;165(11):770-778 Thanks for listening! Jeremy Faust and Lauren Westafer
En este episodio discutimos la definición de shock séptico dentro de la nueva definición de sepsis. Si no lo ha visto todavía, vea y escuche el episodio anterior del ECCpodcast sobre sepsis. Evolución de un problema Como he discutido en episodios anteriores, el cambio en la definición de sepsis intenta reflejar el conocimiento actual de la condición y lo que significa en términos de mortalidad. El problema siempre ha sido el mismo, pero nuestro entendimiento del problema ha cambiado en los últimos 25 años... es más, ha cambiado en los últimos 15 años desde que Emmanuel Rivers publicó su famoso protocolo en el 2001. Esta es la parte 3 de una serie sobre sepsis, en donde se discute la evolución de la definición, comenzando por la sepsis y seguido ahora por el shock séptico. Evolución de un problema, parte 2 El shock séptico se define como el subgrupo de pacientes con sepsis cuyas anomalías circulatorias y de metabolismo celular son tan profundas que aumentan la mortalidad substancialmente. Los pacientes en shock séptico son pacientes sépticos que tienen hipotensión persistente la cual requiere de vasopresores para mantener una presión arterial media ≥65 mm Hg y que tienen un nivel de lactato > 2 mmol/L (18 mg/dL) a pesar de una resucitación adecuada de fluidos. Combinación mortal Un paciente en shock séptico tiene una mortalidad estimada en exceso de un 40%, según los autores de las guías. La mayor mortalidad ocurre en pacientes que tienen los tres criterios de shock séptico: hipotensión, uso de vasopresores, lactato > 2 mmol. La mortalidad fue disminuyendo en pacientes que solo tenían hipotensión solamente, o lactato elevado solamente, o sepsis solamente. ¿Demasiado tarde? En mi opinión personal, medir el lactato tiene 2 beneficios importantes: Identificar el paciente que tiene pobre perfusión ANTES de que tenga manifestaciones de fallo orgánico. Medir el esfuerzo de resucitación El hecho de que la definición de sepsis no incluya el uso de lactato sino hasta el punto de definir shock séptico no significa que no haga sentido medirlo desde el principio. La razón, según los autores, por la cual no la incluyeron como parte de la definición original, es porque no aumentó el valor predictivo luego de haber identifiado que habían dos, o más, criterios de qSOFA. PERO...por otro lado, el mismo artículo dice (exáctamente dos párrafos antes) que el no cumplir con dos o más criterios de qSOFA no sugiere que el paciente no deba recibir el cuidado médico adecuado inmediatamente. Es sentido común. La solución es obvia cuando conocemos el problema. Entonces, como he dicho anteriormente, en mi humilde opinión, aunque me gusta la nueva definición, mueve las definiciones (y eventuales recomendaciones) específicas un poco más a la derecha en la cronología lineal del diagnóstico y tratamiento. Aumentó la especificidad, pero no la sensitividad En el ámbito de medicina de emergencias (tanto prehospitalaria como intrahospitalaria), la prioridad está en la detección temprana. Por lo tanto, todas las herramientas que permitan la detección temprana, tales como el lactato y la capnografía, deben seguir siendo ampliamente recomendadas y difundidas. Criterios para protocolos Otro aspecto importante a tener en cuenta en el manejo de estos pacientes es que la nueva definición servirá como base para la activación de protocolos. Los protocolos no son más que nuestra forma actual de evitar desastres en el manejo de situaciones difíciles. El protocolo debe servir como la guía de seguridad, pero no necesariamente significa el cielo en el estándar de cuidado. El hecho de que un paciente no cumpla con cierto criterio no significa que no requiera el cuidado que merece en el momento adecuado (probablemente "ahora mismo")... y si para lograr eso significa que hay que activar un "protocolo", pues que así sea. Conclusión Sepsis es la principal causa de muerte en todas las unidades de cuidados intensivos. El reconocimiento temprano de la sepsis y de las fases de su evolución nos permitirá activar los protocolos suficientes para prevenir un resultado desastroso. Referencias http://jama.jamanetwork.com/article.aspx?articleid=2492881 http://jama.jamanetwork.com/article.aspx?articleid=2492875 http://jama.jamanetwork.com/article.aspx?articleid=2492876 http://jama.jamanetwork.com/article.aspx?articleid=2492871 http://jamasepsis.com/ http://www.qsofa.org/ http://www.medscape.com/viewarticle/845532 http://jama.jamanetwork.com/multimediaplayer.aspx?mediaid=12478968#.VuOBu9RFU9Y.link Merv Singer: http://emcrit.org/podcasts/sepsis-3/ Cliff Deutschman: http://emcrit.org/wee/wee-cliff-deutschman-additional-thoughts-sepsis-3-0/
Es la primera vez en 25 años que las definiciones cambian. ¿Por qué redefinirlo? No había, hasta ahora, suficientes elementos objetivos para que se midiera igualmente. Necesitamos uniformidad para poder comparar resultados de estudios. Sigue siendo la principal causa de muerte en todas las unidades de cuidados intensivos en el mundo entero. Todavía no lo detectamos a tiempo y todavía no lo atendemos adecuadamente (y a tiempo). En resumen: 1991 vs. 2016 Definición del 1991: Sepsis = Infección + Síndrome de Respuesta Inflamatoria Sistémica (SIRS, por sus siglas en inglés) Sepsis severa = Sepsis + fallo orgánico Enlace episodio anterior del ECCpodcast sobre sepsis. Definición del 2016: Sepsis = fallo orgánico que amenaza la vida, causado por una respuesta desregulada del organismo ante una infección. El problema, en términos sencillos No ha cambiado el hecho de que sabemos que una simple infección NO es sepsis. Sepsis es el resultado de una infección que ha provocado una respuesta desregulada del cuerpo, combinado con disfunción organica. Sepsis es la causa primaria de muerte debido a una infección. Sepsis es la principal causa de muerte en todas las unidades de cuidados intensivos en el mundo. Cuando los pacientes con sepsis se complican y transicionan a shock séptico y fallo multiorgánico, la muerte está cada vez más cerca. Redefinir el problema es un paso importante, pero no necesariamente es la única solución al problema. Sepsis es una condición que amenaza la vida, que ocurre cuando la respuesta desregulada del cuerpo a una infección causa más daño aún a sus propios tejidos y órganos. El problema de la sepsis se compone de tres elementos separados: infección, respuesta desregulada del cuerpo humano y fallo orgánico. Un ejemplo de una respuesta desregulada ante un insulto es la anafilaxis. La respuesta del cuerpo ante un alergeno es un mecanismo de defensa, pero en una reacción anafiláctica, la respuesta del cuerpo le causa daño al mismo organismo. Cómo identificar signos de infección y de respuesta del organismo Ante una infección, el cuerpo humano monta una respuesta de defensa. Esta respuesta de defensa tiene el objetivo de detener el insulto y repararse a sí mismo. Esta respuesta de defensa la conocemos como inflamación, o respuesta inflamatoria. La antigua definición de sepsis, elaborada en el 1991, aprovechó este conocimiento para definir el síndrome de respuesta inflamatoria sistémica (SIRS) como un marcador de que la infección está provocando una respuesta sistémica del organismo. Ya sabemos que una simple infección no significa sepsis. Sepsis implica infección más fallo orgánico. Sepsis implica un desorden en la respuesta del paciente. Para esto usábamos como referencia el Síndrome de Respuesta Inflamatoria Sistémica (SIRS). SIRS nos ayudó por mucho tiempo. Los criterios de SIRS fueron instrumentales durante los pasados 25 años en ayudar a crear una lista de criterios para comenzar a definir consistentemente los pacientes que tienen sepsis...con un problema: no todos los pacientes con sepsis tienen criterios de SIRS, y no todos los pacientes con SIRS tienen sepsis. El problema con los signos de SIRS es que es muy sensitivo, pero no es específico. SIRS no es específico de la sepsis. SIRS denota la respuesta del organismo ante un insulto. Podemos ver esta misma respuesta en otros eventos tales como trauma, cirugías y enfermedades tales como la pancreatitis. El primer paso tiene que ser sospechar una infección. La fiebre es un signo comúnmente utilizado para sospechar que hay una infección. Algunos pacientes no tienen un sistema inmune competente debido a edad avanzada, enfermedades crónicas que lo han debilitado (cáncer, diabetes, y SIDA entre otros) y/o medicamentos que lo han suprimido. Por lo tanto, es posible que NO se observe una respuesta inflamatoria muy pronunciada. Por ejemplo, en estos pacientes es posible que la respuesta del organismo ante la infección no sea lo suficiente como para producir inclusive fiebre. Algunos expertos consideran que en estos pacientes una temperatura corporal de 38ºC es suficiente para considerar que hay fiebre. Por esta razón SIRS fue eliminado de la nueva definición. No significa que no pueda ser útil. Significa que su presencia o ausencia no confirmia ni descarta sepsis, por lo tanto, requiere que un clínico tome la decisión. Ya sabemos que la medicina no es un proceso de "recetas" y que los protocolos no dictan el estándar, sino que evitan desastres, pero criterios como estos ayudan a facilitar la aplicación de protocolos por otros profesionales de la salud, estandarizar los pronósticos, y ayuda a entender mejor la data de los estudios ya que la nomenclatura significa lo mismo a lo largo y ancho. Según este estudio del 2015 publicado en el NEJM, uno de cada 8 pacientes (~12%) con sepsis no tiene signos de SIRS. Queremos crear criterios que puedan ser utilizados por todos y que puedan ser consistentemente aplicados para la toma de decisiones así como para los estudios. La definición de SIRS no deberá usarse para activar protocolos, o para estratificar riesgos, pero no deja de ser un elemento para el personal clínico. La fiebre, el aumento en los glóbulos blancos, y los demás signos de SIRS son parte de una respuesta normal ante una infección. El hecho de que ya no exista una categoría de sepsis severa, y que los pacientes que tienen sepsis ya tienen fallo orgánico, hace que el criterio de sepsis tenga mayor peso que simplemente la activación de la respuesta inflamatoria. Otros signos permiten especificar el foco de la infección a un punto anatómico. Algunos ejemplos de signos que ayudan a especificar el sitio de la infección puede ser edema, rash, consolidación en pulmones, disuria o peritonitis, entre otros. Cómo identificar signos de fallo orgánico JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287 SOFA significa Sequential (Sepsis-Related) Organ Failure Assessment. Es una puntuación de fallo orgánico. Se asume que todo paciente comienza con una puntuación de 0 (a no ser que se conozca desde antes que ya tenía un grado de fallo orgánico). Un aumento de 2 puntos sobre el nivel de base es significativo para fallo orgánico. Los pacientes con una puntuación de SOFA de 2 tienen un 10% de mortalidad. Para poner la magnitud del problema en perspectiva, el estudio cita que esto es mayor que el 8.1% de mortalidad asociada al infarto al miocardio con elevación del segmento ST. Debido a que la puntuación de SOFA requiere laboratorios, una versión más simple resultó tener validez fuera de la unidad de cuidados intensivos. Esta versión más simple, denominada QuickSOFA (qSOFA) permite identificar pacientes, con sospecha de infección, que están en riesgo elevado de estadía prolongada en la Unidad de Cuidados Intensivos y riesgo elevado de muerte. Los criterios de qSOFA son alteración en estatus mental, presión sistólica < 100 mmHg, o frecuencia respiratoria > 22/min El problema es darnos cuenta que tenemos un problema. Si no lo piensas, no lo diagnosticas. Los signos de respuesta inflamatoria sistémica no deben ser ignorados, si en efecto sospechamos que hay una infección. Estos signos son las banderas rojas porque estos paciente, aunque no tienen un riesgo de muerte elevado como los que tienen qSOFA positivo, de todos modos requieren atención médica adecuada. Rol del lactato El lactato tiene un rol importante en el diagnóstico del paciente y como guía en la evaluación continua durante el tratamiento. Se ha establecido que los pacientes con lactato > 4 mmol están teniendo pobre perfusión. Sin embargo, no todos los pacientes que tienen lactato elevado tienen sepsis. Usándolo en el contexto apropiado, el lactato puede alertar acerca de un paciente que tiene pobre perfusión asociada a una infección severa. El lactato puede ser usado como una herramienta sensitiva, pero no específica, para captar los pacientes en riesgo de sepsis. La determinación de fallo a órganos usando la escala de qSOFA será entonces la manera oficial de determinar sepsis, según la nueva definición. La disminución en el nivel de lactato podrá ser utilizada también como una herramienta para guiar la efectividad de la resucitación. Conclusión En pacientes con sepsis, los signos de fallo orgánico a veces pueden estar ocultos, por lo que hay que sospecharlos (y evaluarlos) siempre. Por otro lado, un paciente que presente signos iniciales de fallo orgánico puede tener sepsis, pero no tener signos evidentes de infección. Referencias http://jama.jamanetwork.com/article.aspx?articleid=2492881 http://jama.jamanetwork.com/article.aspx?articleid=2492875 http://jama.jamanetwork.com/article.aspx?articleid=2492876 http://jama.jamanetwork.com/article.aspx?articleid=2492871 http://jamasepsis.com/ http://www.qsofa.org/ http://www.medscape.com/viewarticle/845532 http://jama.jamanetwork.com/multimediaplayer.aspx?mediaid=12478968#.VuOBu9RFU9Y.link Merv Singer:http://emcrit.org/podcasts/sepsis-3/ Cliff Deutschman:http://emcrit.org/wee/wee-cliff-deutschman-additional-thoughts-sepsis-3-0/ JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287 Bone RC, Balk RA, Cerra FB, et al. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med. 1992;20(6):864-874.
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