1. Phil Ukrainetz Thursday, May 7, 2009

2. Objective  Are we adequately identifying septic patients in the ED?  Are we optimally managing septic patients in the ED?  How can we better manage the septic patient in the ED?  What are our next steps if any?

3. “Straight forward patient”  Hx: 76 F, sent from Cardiac Function Clinic, precarious CHF, new bilateral leg cellulitis with heel ulcers  PMHx: Aortic Valve Replacement, CHF, bilateral leg DVT’s, DDR pacemaker, RA, hypothyroid, Afib  Meds: ASA, Amiodarone, Candesartan, Lasix, Imdur, Nitro patch, Losec, Coumadin, K-Dur, Metoprolol, Prednisone, Adalimumab  Jehovah Witness – No blood products

4. And by the way…  BP 80/50 (normal as per pt SBP 90), P 78, T 37.1, Sat 94% on 3L NP  Already juicy and Cr rising as per function clinic – so please avoid saline infusions  Over next 2 hrs – SBP’s as low as 58/38  Positive urine

5. Patient c/o:  Little “dizzy”  Swollen warm legs  No chest pain, no SOB on 3L NP – 92%  NAD

6. EP Mngmt:  Foley  Antibiotics  250 NS boluses  Dopamine after 750 NS  Central line and then norepi  MTU/ICU/CCU consults

7. Patient outcome – did fine admit to CCU  Mentated throughout 20 hr stay – vague, nonclinically helpful complaints  Vitals of approx SBP 80/50 and Sats of 92% maintained throughout  ICU 5 hrs to assess – gave fluid/norepi/?ccu  CCU 5 hrs to assess- chf/minor infection - admit

8. Non-Fatal Harm Morbidity Case  Patient was felt by CCU to be more CHF then sepsis  Worried about excessive fluids given  Couldn’t get off pressor – never changed urine output or oxygenation with mngmt  Admitted

9. Long and short of it  Pt given 3L fluids/20 hrs but never had incr O2 needs  Patient did well  Most of us would manage similarly  Lets learn from this difficult case

10. Sepsis Priorities  Identify sepsis early  Early antibiotics  Early “liberal” fluids  Monitor frequently, accurately and “fly ahead of the plane”

11. Sepsis Management  EGDT – Emmanuel Rivers 2001  U/S??  Arterial Line Tracing Interpretation??  Early Sepsis Hotline??

12. EGDT – Hard to Deny  “Golden hours” means ED must be involved  Who is best suited to do CVP placement monitoring? Detroit Model??  Will it aid and abet longer ED stays?  What if it were your mom?

13. Ultrasound CVP Equivalent?  Looks promising – train our own  Non-invasive – don’t add to nurse burden  Longer ED stays?  Do we see enough to be true experts?

14. Arterial Line Tracing Interpretation  RTs are now putting in arterial lines  Promising but promotes long ED stays??  Will we truly have the expertise?

15. Sepsis Hotline  We identify the patient  Stroke team like “swoop down” – glorious!  If central line/CVP needed patient is fast- tracked  No beds then CVP placed/ICU manages in ED or in ICU depending on bedspace

16. Objective  Are we adequately identifying septic patients in the ED? - yes  Are we optimally managing septic patients in the ED? – no – CVP’s should be utilized  How can we better manage the septic patient in the ED? – open dialogue with ICU  What are our next steps if any? -who else is doing ED CVPs in Alberta or Canada? what does ICU think of EGDT team? identify a champion/Jason for the cause

17. Thanks  Shawn Dowling  Jason Lord  Rob Hall  Gavin Greenfield  Tom Rich  My mom