1. Sepsis Management and the Role of Venous Lactate Values
Ivan A. Mustafa
EMT/P, MSN, ARNP-C, CMO, EFO
Division Chief, EMS

2. Ready To Respond  Willing to Care  Trained to Make a Difference
Introduction
Sepsis is a time sensitive progressive illness responsible for a 30-50% mortality within 30 days of onset. There were an estimated one million cases of sepsis treated in the US in The Medical Director, Seminole County EMS and Central Florida Regional Hospital recognize the important role EMS providers play in the management of sepsis and have worked hard to provide you the tools to make an accurate evaluation and notification to the receiving hospitals.
Ready To Respond  Willing to Care  Trained to Make a Difference

3. Ready To Respond  Willing to Care  Trained to Make a Difference
Background
Since 2009, SCEMS Practice Parameters have had a sepsis worksheet to help providers identify patients who are potentially septic. This parameter underwent several revisions as well as fine tuning the worksheet to bring it in alignment with what hospitals use to screen septic patients.
Ready To Respond  Willing to Care  Trained to Make a Difference

4. Ready To Respond  Willing to Care  Trained to Make a Difference
So what is Sepsis?
Sepsis is an infection accompanied by an acute inflammatory reaction with systemic manifestations associated with a release into the bloodstream of numerous endogenous mediators of inflammation
It triggers a systemic response that causes circulatory dysfunction from an overactive immune system
Categorized as Sepsis, Severe Sepsis or Septic Shock
Ready To Respond  Willing to Care  Trained to Make a Difference

5. Severe Sepsis and Septic Shock
So, what’s the difference between these two?
Severe sepsis - is accompanied by signs of failure in at least one organ
These may include:
Cardiovascular failure with hypotension
Respiratory failure – hypoxemia
Renal failure – oliguria
Hematologic failure – coagulopathy
Septic Shock – includes organ hypoperfusion and hypotension with poor response to fluid resuscitation
Ready To Respond  Willing to Care  Trained to Make a Difference

6. What is SIRS? SIRS – Systemic Inflammatory Response Syndrome
Defines a clinical response to a nonspecific insult of either infectious or noninfectious origin
Defined as 2 or more of the following variables:
Temp of more than 38˚C or less than 36°C ( >100.4˚ F – <96.8˚ F)
Heart rate of more than 90 beats per minute
Respiratory rate of more than 20 breaths per minute or a PaCO2 level of less than 32 mm/Hg
Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10% bands)

7. Sepsis – A rapidly developing process
Originally sepsis thought to be the body’s response to infection
The process is not quite that simple
Frequently septic patients die even when the underlying triggering infection has been controlled
The immune response mounted from the infection continues causing a rapid deterioration of the patient’s condition

8. The continuum of Sepsis

9. SIRS
The nucleus of sepsis and associated SIRS revolves around a circulatory dysfunction
A massive release of pro-inflammatory mediators creates an uncontrolled response
Causes impaired fibrinolysis
Interrupts the normal clotting cascade
Circulatory microvasculature is clogged with thrombus and fails
Inflammation results in vasodilation and fluid leakage
Turns into hypotension and end-organ hypoxia

10. A Time Sensitive Event
Survival from sepsis, severe sepsis or septic shock is time dependent
Its no different than treating strokes or AMI, time is tissue
The longer time it takes to initiate therapy, the higher likelihood of mortality
Antibiotic treatment
For every hour delay in the administration of initial antibiotics there is a 7.6% increase in mortality

11. Risk Factors Extremes of age Indwelling lines/catheters
Immunocompromised states
Malnutrition
Alcoholism
Malignancy
Diabetes
Cirrhosis
Male sex
HIV+
Genetic predisposition?

12. Triggering Events Recent chemotherapy
Recent pneumonia, cellulitis, UTI
Admitted to hospital in last 30 days
Surgery in last month
Organ transplant patient
Immunocompromised
Long term indwelling catheter
Long term steroid use
Resident in long term care facility

13. Hypothermia in a suspected septic patient is an ominous sign!
Signs and Symptoms
Sepsis
Recent history of illness
Temperature alteration (>100.4˚ or <96.8˚ F)
Tachycardia (HR >90)
Tachypnea (RR >20)
Severe Sepsis
Altered mental status
Drop in blood pressure
Blood glucose alterations
Decreased urinary output (oliguria)
Elevated lactate level
Septic Shock
Cool, pale skin
Peripheral cyanosis
Mottling
Severe hypotension
Hypoperfusion
Hypothermia in a suspected septic patient is an ominous sign!

14. Evaluation and Management
Managing septic patients is not significantly different from other patients we normally care for:
CAB’s (ABC’s for us old-timers)
Airway management and O2 supplementation
Vital signs – including
An accurate temperature
Blood Glucose Level
IV access - Fluid resuscitation
Temperature regulation
Frequent reassessments

15. What are the Hospitals Doing?
Their priority is to develop a rapid screening and intervention process using EGDT

16. Early Goal Directed Therapy
Dr. Emanuel Rivers
Lead researcher and developer of EGDT
Published in the NEJM – 2001
Uses an algorithmic resuscitation strategy
Systemically measures and corrects central venous pressure
Fluid replacement therapy
Corrects the oxygen deficiency between delivery and demand
EGDT results in 16% absolute reduction in in-hospital mortality

17. SCFD screening form Sepsis score SIRS criteria checked
Severe sepsis factors
Thorough medical history obtained
Sepsis score

18. Introducing a new tool to help identify truly septic patients
Until now, all we could do was to guess if the patient is indeed septic…
Introducing a new tool to help identify truly septic patients

19. Venous Lactate Levels
Venous lactate is a reliable indicator of metabolic distress in shock and end-organ failure
Elevated lactate levels helps confirm shock in classic sepsis presentations
Its greatest advantage will be in helping identify cryptic (hidden) septic shock
Levels greater than 4 mmol/L are indicative of metabolic shock
Think of venous lactate as the biochemical vital sign for hypoperfusion

20. Venous Lactate Monitors
The Lactate Pro blood lactate analyzer is fully approved by the FDA
CLIA Waived monitor (Clinical Laboratory Improvement Amendment)
The Lactate Pro portable lactate analyzer is the only handheld lactate analyzer to be validated for medical use in the USA
Provide highly accurate venous lactate readings in 1 minute
Similar in operation as a blood glucose meter

21. Monitor Preparation Check Strip
The monitor is provided with a check strip to test the device is working correctly
The monitor is tested when new and monthly thereafter
You may also test the device anytime there is a concern of proper function
The check strip is yellow in color

22. Monitor Preparation Check Strip - To test the monitor
Insert the check strip in the inlet with the word “Check” reading correctly on the strip and green dot facing the front of the monitor
The monitor will beep and a display of “888” will show on the screen
In 2 seconds the monitor will display a value
The check strip paperwork included with the strip will provide the acceptable test range (usually mmol/L)

23. Monitor Preparation Check Strip
Complete the test by removing the check strip and placing it back in its plastic bag – store for future tests

24. Monitor Preparation Calibration Strip
For the monitor to provide correct measurements it must be calibrated to the strips
Every time a new pack of strips is opened – confirm the calibration of the monitor with the enclosed strip
The “F” number must match the ones printed in the box and on the back of each test strip
The calibration ranges from F-0 through F-12

25. Monitor Use
No difference in procedure compared to a blood glucose meter
Prep the site – MAKE SURE THE SITE IS COMPLETELY DRY!
Place the test strip on the monitor
Avoid touching the end of the strip with your fingers
Use a safety lancet to obtain a drop of blood from the patient’s finger
Wipe the first drop of blood with a gauze and use the second drop obtained for the test
Draw the blood sample - let the monitor perform the test
Record the monitor reading
Notify the hospital
Blood glucose test strips or monitors and venous lactate test strips/monitor are not interchangeable!

26. Monitor Maintenance Cleaning Testing
Wipe clean with approved disinfecting solution
DO NOT IMMERSE IN WATER!
Testing
This monitor is CLIA waived for daily testing
It only needs to be checked once per month with the check strip and calibrated when new strips are added to the kit for use

27. Seminole County Practice Parameters
5.17
Sepsis, Severe Sepsis
and Septic Shock

28. Treatment Support and monitor the airway Airway patency and management
Supplemental oxygenation to keep O2 sats at >95%
Obtain a baseline blood glucose level
Administer D50W when blood glucose level ≤ 50 mg/dl
Consider half dose of D50W if blood glucose is ≥ 50 mg/dl but ≤ 100 mg/dl

29. Treatment Obtain an accurate temperature reading
Passive cooling measures if temperature is greater than 101⁰ F
Warming measures if patient is hypothermic
Remember hypothermia is a late sign in septic shock and associated with high mortality
Obtain a VENOUS LACTATE level
Greater than 4 mmol/L is positive

30. Treatment Complete the Sepsis Screening Tool
Address the abnormal vital signs and/or shock
Fluid therapy – IV Boluses via two IV lines if possible at 20 ml/kg boluses
Dopamine as needed to maintain BP systolic greater than 90 mm/Hg
Complete the Sepsis Screening Tool
This tool is invaluable to the ED doctor!
It helps complete the history along with serial Venous Lactate Levels and lactate clearance which guides the treatment
Issue Sepsis Alert if indicated and Rapid transport

31. Take Home Points
Sepsis, Severe Sepsis and Septic Shock are identifiable disease processes by EMS personnel
Its responsible for 1 million admissions each year with a mortality between 25-50% at a cost of $15.4 billion
Sepsis is a timed event just like STEMI or CVA
For every 1 hr delay in treatment there is a 7.6% increase in mortality
EMS providers have the tools on hand to identify these patients early, establish EGDT and reduce the morbidity and mortality of these patients

32. Please contact DC Mustafa Or your agency’s EMS Chief
Any questions?
Please contact DC Mustafa
Or your agency’s EMS Chief