Sepsis Updates Cameron Berg, MD, FACEP, FAAEM

Sepsis Matters Highest mortality of any DRG (NMMC and MGH)

Sepsis Old Days (pre-2001) Antibiotics and hope

Sepsis 2001 - EGDT Early antibiotics Aggressive IV fluids CVC for CVP and SCVO2 Vasopressors for refractory hypotension (MAP < 65) Blood transfusions for anemia (Hgb < 10) Inotropes for low SCVO2

Sepsis Now Lactate screening Early antibiotics Aggressive empiric fluids CVC and vasopressors only for shock Lactate clearance

Downsides of CVP Poorly predictive of volume status Poorly correlated with fluid responsiveness Invasive

Downsides of Transfusion Highly immunologic Correlated negatively with LOS, organ injury, and mortality Hgb > 10 is seldom needed

Downsides of Inotropes Highly arrhythmogenic

Lactate

Antibiotics For severe sepsis broad spectrum For uncomplicated sepsis – target source Give rapidly (bolus when able) ASAP

Empiric Fluid Load 2L, 3L, or 4L Consider lactate, age, and history of systolic HF Do not worry about volume ARDS is not hypervolemia

Sepsis Prior Current LOS 6.3 days Mortality 9.1% Collections 29.1%

Sepsis Prior Current No lactate 6.5% Normal 3.8% Intermediate 9.3% High 23.1% Prior No 4.7% Normal 3.1% Intermediate 8.7% High 22.3% (non-sig) Current

Sepsis Prior Current Initial IV fluids 1.8L Central line 48.7% Critical care 54% Initial IV fluids 2.6L Central line 27.8% Critical care 44.5% Prior Current

Intro to Cost Accounting What, when, where, by whom, for how long…

Sepsis Cost of Care

Sepsis LOS by Severity Low Medium High

Recognizing Sepsis Modified SIRS Temp >100.4 or < 96.8 HR > 90 RR > 20 SP02 < 90% MAP < 65 New ALOC Suspected Clinical Infection

If Sepsis Suspected Advocate (labs, fluids, antibiotics) Check lactate Culture source

Sepsis 2016 Core Measure Very problematic definitions 3hr bundle Lactate, fluid bolus, blood cultures, antibiotics 6hr bundle Repeat lactate (if elevated), vasopressors for shock, assessment of tissue perfusion

Advanced Sepsis Which antibiotic first? Which fluid? Which vasopressor? When to give steroids? Which electrolytes matter? Which method of volume assessment? When get an echo? When transfuse?