Management of Adult Fever and Sepsis MLP EM Education Curriculum Dave Markel September 15, 2015

What will be covered Basic concepts and definitions Initial management Septic shock Pearls and pitfalls

What will not be covered Pediatric fever (Scheduled for May 2017, Dr. Justice) Febrile seizures Hyperthermia Environmental Drug-induced

Basic concepts and definitions Fever: temp > 37.8 C = 100 F (CDC definition) Not “I’m usually at 96 degrees so 98.6 is a fever for me” Not “It feels kinda warm in here” Not “I had a chill the other day” Most reliable way of checking the temperature? No axillary temps, please!

Basic concepts and definitions Systemic inflammatory response syndrome (SIRS) At least 2 of the following: Oral temperature > 38 or < 35 C Respiratory rate > 20 or PaCO 2 < 32 mmHg (requires ABG) Heart rate > 90 Leukocytes > 12,000 or 10% bands Sepsis: + microbial source Severe sepsis: + organ dysfunction Septic shock: + hypotension unresponsive to fluids Multiple organ dysfunction syndrome (MODS)

Sick vs Not Sick Patients with any of the following need IMMEDIATE intervention Altered mental status Respiratory distress Cardiovascular instability Prolonged temp > 41 C = F

Most aren’t critically ill… take a history! Localizing symptoms Atypical symptoms Fever patterns Tubes, lines, drains (incl. pacemakers, heart valves, PICC lines, etc) Living situation (nursing home, dorm, jail, etc) Recent hospitalizations

Never trust the elderly Symptoms are often atypical May not even mount a fever response Abdominal exam often deceptively benign 3 critical things to do when evaluating fever in the elderly Completely undress and examine skin Chest x-ray (2-view if possible) Urinalysis (straight cath if possible)

Sepsis: a problem with perfusion For MIS: sepsis is caused by a complex disarray of pro-inflammatory and anti-inflammatory mediators which are triggered by infection, leading to tissue ischemia, direct tissue injury, alterations in apoptosis For us: sepsis = poor perfusion… fix it Hypotension Elevated lactate Tachycardia Decreased urine output

How to fix the perfusion problem IV fluids Initial choice: 0.9% NS Optimal volume unknown… usually will get 3-5 liters over first 6 hours Watch for pulmonary edema Vasopressors Initial choice: norepinephrine (Levophed) Consider phenylephrine if tachycardia or dysrhythmias

Targets: first 6 hours

ProCESS, 2014: “In a multicenter trial conducted in the tertiary care setting, protocol-based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes.” ARISE, 2014: “In critically ill patients presenting to the emergency department with early septic shock, EGDT did not reduce all-cause mortality at 90 days.” ProMISe, 2015: “In patients with septic shock who were identified early and received intravenous antibiotics and adequate fluid resuscitation, hemodynamic management according to a strict EGDT protocol did not lead to an improvement in outcome.”

Bonus: empiric abx (if source unknown) Gram-positives and MRSA: vancomycin Gram-negatives: 3 rd - or 4 th generation cephalosporin (eg, ceftriaxone) Pseudomonas: zosyn, ceftazidime

Bonus: Vasopressors