1. Sepsis Updates
Cameron Berg, MD, FACEP, FAAEM

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

3. Sepsis Old Days (pre-2001)
Antibiotics and hope

4. 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

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

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

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

8. Downsides of Inotropes
Highly arrhythmogenic

11. Lactate

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

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

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

15. 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

16. 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

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

18. Sepsis Cost of Care

19. Sepsis LOS by Severity
Low
Medium
High

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

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

22. 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

23. 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?