ESSEX COUNTY FIRE CHIEFS ASSOCIATION

SEPSIS SPECIAL PROJECT WAIVER

SepsisHow sick is your patient?

Objectives

Understand the causes and risk factors of sepsis.

Be able to indentify a septic patient.

Understand and follow the components of the Special Project Waiver

Why is this important?

Mortality*

More than 750,000 severe sepsis cases are reported annually in the U.S. and, of those, 215,000 patients die.

Why is this important?

SepsisAccording to the most recent CDC statistics: Sepsis is the

11th leading cause of death in the United States.

Cost!

The present annual cost is estimated at $16.7 billion

SIRS

Systemic Inflammatory Response Syndrome-It’s the first step in the path to sepsis

Causes: Trauma Severe Burns Pancreatitis Ischemia Infection (Can Lead to Sepsis)

SIRS – Signs & Symptoms

Two or More White Blood Cell (Leukocyte) Count

> 12,000 or < 4,000 Respiratory Rate:

> 20 breaths.min or mechanically ventilated Heart Rate:

> 90 beats/min Temperature:

> 38 C (100.4 F) or < 36 C (96.8 F)

Sepsis is Defined as:

Sepsis is SIRS with documented or suspected infection. Bacterial Viral Fungal Protozoa

Sepsis

Common Causes Pneumonia Urinary Tract Infection Abdominal Surgery Cellulitis IV Drug Users Ear Infections

Sepsis – High Risk Factors

Higher Risk Extremes of Age Multiple Co-morbidities Recent Hospitalization

2 million Hospital Acquired Infections per year.

Sepsis – High Risk Factors

Cough PresentIndwelling Foley/IVWounds/InjuriesPara/QuadriplegicBedriddenRecent Antibiotic Use

Sepsis – High Risk Factors

Immune Compromise Diabetic Cancer HIV Systemic Steroids Anti-rejection Medications Powerful Anti-inflammatory Medications

Severe Sepsis/Septic Shock

Septic Shock = Sepsis + Hypoperfusion

Systolic Less than 90 mm Hg

Pathophysiology

Immune and inflammatory response causes vasodilation, and so reduces venous return and cardiac output.

The immune response is where bacteria invade phagocytes, causing damage or even death to the cell. This leads to the release of histamine and proteolytic enzymes leading to vasodilatation

Also can cause poor tissue perfusion and tissue death (necrosis).

All of this increases cellular metabolism which causes the cells to switch to anerobic metabolism.

MODS

Multiple Organ Dysfunction Syndrome (MODS) Presence of altered organ dysfunction in the septic

patient. Last stop before death.

How can we help????

Early recognition and treatment are the key to better patient outcomes. Good thorough assessment including measure of lactate

Identifying these patients and notifying hospital staff early, has shown to decrease mortality 30%.

The main goal of our assessment of the patient is to identify the septic patient to facilitate transition to goal directed therapy at the hospital.

What is Lactate???

It is a measure of tissue perfusion, it can tell you how well cells are being oxygenated regardless of blood pressure.

When cells do not receive enough oxygen, they convert to anaerobic metabolism

The byproduct of anaerobic metabolism are lactate and hydrogen ions.

Unit of Measurement is mmol/l (millimoles per liter)

EMS Lactate Levels

Pre-Hospital Lactate MetersDeveloped for Endurance AthletesWorks just like a Glucometer

EMS Treatment

Early Recognition KeyHistoryPhysical exam

Look for Infection

Strict Aseptic Practices Patient already compromised

EMS Treatment

Fluid Resuscitation Large Bore IVs 30 ml/kg bolus if no signs or history of CHF* Or CRF.

20 ml/kg if signs or hx of CHF or CRF*

*This is specific to this special project

EMS Treatment

Increased Oxygen Demand Hypermetabolism Impaired Oxygen Extraction

Respiratory Failure Occurs Rapidly

EMS Treatment

Slightly Increased Rate due to cellular metabolism

Consider supplemental O2

EMS Treatment

Pharmacological SupportDopamine 2-20 mcg/kg/minMaintain SBP of 90 mm HgMay need higher doses

EMS Treatment

Place supine with feet elevated. NOT Trendelenberg May Impede Breathing

Rapid TransportOur hand off report must include the results

of assessment and suspicion of sepsis as well as our Lactate Measure.

ER Treatment

Early Goal Directed Therapy (EGDT)Goal Oriented Manipulation of:

Cardiac Preload Cardiac Afterload Contractility

Balanced between oxygen delivery and oxygen demand

EGDT - Goals

Resuscitation Bundle (< 6 hours):Serum Lactate LevelsBlood Cultures Prior to AntibioticsAntibiotic therapy within 1 hour of diagnosis

Each hour of delay during the first 6 hours of hypotension was associated with a 7.6% increase in mortality

6 Hour Resuscitation Bundle

Early IdentificationEarly Antibiotics and CulturesEarly Goal Directed Therapy

EGDT - Treatment

Mean Arterial Pressure (MAP)Maintain at 65-70 mm Hg

Vasoactive AgentsNorepinephrineDopamine

EGDT - Results

Severe Sepsis or Septic Shock after 72 hours

EGDT Standard TherapyMortality 30.5% 46.5%

ScvO2 70.4% 65.3%

Lactate 3.0 mmol/L 4.4 mmol/L

Rivers, E, Et Al. Early Goal directed Therapy in the treatment of Severe Sepsis and Septic Shock. N Engl J Med 2001; 19:1368-1377.

EGDT - Results

EGDT save livesMeeting all EGDT goals in less than 6 hours

decreases mortality Studies support even better results with

earlier intervention

EMS Sepsis Special Project

GoalIdentify Septic Shock PatientsStart Fluid Resuscitation

Start Pressors (if needed)

Transfer to closest appropriate facility Consider emergent Transport

EMS Sepsis Notification Criteria

Initiate sepsis special project waiver for patients18 years and olderNOT Pregnant

TWO or more of the below SIRS Criteria (Systemic Inflammatory Response Syndrome)

Temperature >38 C (100.4 F) or <36 C (96.8 F)Pulse >90Respiratory rate > 20

AND

EMS Sepsis Notification Criteria

Suspected or Documented Infection

AND

One of the following:Hypoperfusion evidenced by SBP < 90 Lactate ≥ 4

Treatment Flowchart

S e p s i s

Age ≥ 18

If no, follow STP

Suspected or Documented Infection

If no, follow STP

At least 2 of the Following • HR ≥ 90/min • RR ≥ 20/min • Temp <96.8f or >100.4f

If no, follow STP

AND any of the Following • SBP <90mmHg • MAP <65 • Lactate ≥4mmol/L

If patient satisfies all criteria, administer NS 30cc/kg over 1st hour unless history of or signs and symptoms of CHF/CRF in which case administer 20cc/kg NS in first hour and oxygen. Alert hospital to septic shock identification.

Case #1 – EMS Findings

56 y/o FemaleResponsive to painful stimuliWitnessed SeizureHR: 135Temp: 103.5 FBP: No Radial PulseGlucose: High

Case #1 – EMS Findings

History: Flu-like Symptoms Weakness X 2 Days Diabetes Headaches

Case #1 – EMS Findings

Allergy: Codeine

Medications: Oral hypoglycemic (prescribed to husband)

occasionally.

ER Findings

Pulse: 134BP: 75/39Resp: 8Temp: 39.8 C (103.6 F)Lactate 7.7Glucose: >1,600

ER Findings

WBC: 6.4 Jumped to >20 in 24 hours

Infection Sites: Urinary tract Infection Bacteria in blood Fungus is Blood

ER Treatment

IntubatedCentral Line Placement (CVP)DopamineNormal Saline

6 liters!!!!

ER Treatment

AntibioticsInsulinAdmitted to ICU

Diagnosis: Sepsis, DKA andBleeding Gastric Ulcer

Hospital Treatment

Nor-epi InfusionVecuronimAnd 30 others

Electrolyte Balance pH Balance Pain Control

2,400 ml Blood Products

Hospital Treatment

Normal Saline First 72 Hours – 37 liters!!! Total stay – 76 liters!!!

Intubated: 9 daysTotal stay: 28 Days

Discharged Alert to Rehab

Documentation

Lactate level should be documented in “Lactate Level” intervention

Intervention Tab

Lactate Level

Documentation

Fields should be completed

Case #2 – EMS Findings

59 y/o FemaleChief Complaint:

Altered LOC and Breathing Problems

Temp: 105.5 FPulse: 180 bpmResp: 32

Case #2 – EMS Findings

Diagnosed with: Upper Respiratory Infections Sinus Infection

BP: 102/74MAP: 83

Case #2 – EMS Findings

Lactate: 4.0

Cryptic Sepsis

ER Findings

Temp: 105 FResp: 24Pulse: 148BP 79/40MAP: 53

Hospital Treatment

IntubationCentral lineNormal Saline

First 72 hours – 22 Liters!!! Total – 51 Liters!!!!

Antibiotics

Cryptic Sepsis

Patients with severe sepsis accompanied by lactic acidosis may display global tissue hypoxia in the absence of hypotension.

Early identification and goal-directed therapy of this subgroup leads to a reduction in morbidity and mortality.

Donnino, M, Et. Al. Cryptic Septic Shock: A Sub-analysis of Early, Goal-Directed Therapy. Chest 2003; 124 (4): 90 Henry Ford Hospital, Detroit, MI

Outcome

Spent 17 days in hospital.Discharged home

Questions?

Notify your EMS director each time you use the Lactate Meter.

All cases will be reviewed by the EMS director as well as the affiliate medical director.