Eight Strategies for Managing Severe Sepsis

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Update Surviving Sepsis Campaign 2012
Emerg Med 40(9):18, 2008
Dr. Catenacci is assistant professor of emergency medicine
and medical director of the department of critical care transport
at the University of Alabama at Birmingham
Dr. King is an attending physician of emergency medicine at
Trinity Medical Center in Birmingham.

 USA:

The incidence of severe sepsis

750,000 cases/year
Annual increase of 1.5%
The rising incidence may be due to
the

aging of the U.S. population

proliferating antimicrobial resistance
more invasive procedures being performed
more prevalent immunocompromised states

 Estimates

of mortality range from 20% to

50%, depending on the stage of the
disease studied
The costs are astounding:
An

estimated $22,000 is spent on every

case
$16.7 billion is spent annually

 Emergency

department visits have also

increased over the past two decades
populations at risk for sepsis elderly
Angus noted a 100-fold increased incidence of
sepsis in the elderly compared with other age
groups
Higher patient volume has been associated
with an increase in the severity of illness
Lambe reported a 59% increase in critically ill
patients presenting to emergency departments
between 1990 and 1999.

 In

addition to higher patient volumes and

acuity levels, the emergency department
physician is challenged by overcrowding from
the boarding of patients awaiting admission
National data from 2001 to 2004, Wang
recorded
a mean emergency department length of stay of 4.7
hours for severely septic patients
with 20.4% of patients staying longer than six
hours.

Position EM Practitioners in fight

against Sepsis
The rising incidence of severe sepsis
2. Increased emergency department visits
by high-risk population
3. Protracted time spent in the emergency
department awaiting admission
1.

WHAT IS SEPSIS?
Greek

word sepein to putrefy or make

rotten
1992, the American College of Chest
Physicians and the Society of Critical
Care Medicine established some
common ground

 Consensus

statement defining the systemic

inflammatory response syndrome (SIRS) as:

The bodys physiologic response to a variety of

clinical insults or multiple stressors:
Infectious
Toxicologic
Traumatic
Ischemic
Immunologic

 The
a

syndrome is manifested by:

temperature above 100.5F

Heart rate greater than 90
Respiratory rate of more than 20 or a
PaCO2 below 32
and a white blood cell count above 12,000,
below 4000, or more than 10% bands

Sepsis
SIRS

resulting from a documented or

presumed infection

Infection
pathologic

process caused by the

invasion of normally sterile tissues by
pathogenic organisms

Severe sepsis
Sepsis

complicated by either:

hypotension

before a fluid challenge

organ dysfunction
a lactate level equal to or above 4 mmol/L

Septic shock
Sepsis

with persistent hypotension

The definition of persistent hypotension
was:
a

systolic blood pressure below 90 mm Hg

or more than 40 mm Hg below baseline
A mean arterial pressure below 70 mm Hg
despite adequate fluid resuscitation

Eight strategies to help improve the

outcomes of patients with sepsis
1.
2.
3.
4.
5.
6.
7.
8.

Increased provider awareness

Early antibiotic administration
Source control
Early goal-directed therapy
Use of corticosteroids
Lung-protective ventilation
Intensive glycemic control
Recombinant human activated protein c

NO. 1: INCREASED PROVIDER

AWARENESS
Surviving

sepsis campaign

Society

of Critical Care Medicine

European Society of Intensive Care
Medicine
International Sepsis Forum

eight more organizations have joined the

effort, including the American College
of Emergency Physicians.

 Phase

1: 2002
Phase 2: 2003 guidelines 2004
Phase 3: 2005 guidelines 2008
The

aim is to create a focused plan to

help clinicians apply the guidelines at the
bedside

NO. 2: EARLY ANTIBIOTIC

ADMINISTRATION
If

targeted antibiotics are given early

pathogenic organisms will be destroyed
faster
toxin production will be limited
the detrimental effects of a robust
inflammatory response may be curbed

 Giving

antibiotics within the first hour of the

onset of hypotension resulted in an overall
survival rate of 79.9%
For each hour that antibiotics were delayed,
mortality increased an average of 7.6%
Larche noted a 7-fold increase in mortality in
patients who received antibiotics more than
two hours after admission.

 inappropriate

empiric antibiotic therapy was

associated with increased mortality (odds ratio
1.8)
Ibrahim conducted a prospective study of 492
patients with bacteremia who were admitted to
the ICU, mortality rates for those treated with
inappropriate antibiotics was 61.9%
compared to 28.4% for appropriately treated
patients.

Adult life-threatening sepsis with an

unclear source.

NO. 3: SOURCE CONTROL

Infected

prosthetic devices may need to

be removed in the emergency
department
Immediate surgical consultation for
operative debridement is indicated if
suspicion of a necrotizing skin infection
exists

NO. 4: EARLY GOAL-DIRECTED

THERAPY
This

study
commenced before
ICU admission,
within six hours of
the patients arrival
at a busy urban
emergency
department

NO. 5: USE OF
CORTICOSTEROIDS
Further

studies with larger numbers of

patients are required to truly define the
role of steroid replacement therapy in
septic patients

 For

now, the 2008 SSC guidelines emphasize

the use of intravenous hydrocortisone in adult
septic shock patients only if their blood
pressure is poorly responsive to fluid
resuscitation and vasopressor therapy
The guidelines also recommend against
routinely using steroids in septic patients
without shock, unless warranted by the
patients history of endocrine or corticosteroid
use

NO. 6: LUNG-PROTECTIVE
VENTILATION

 Lower

tidal volumes (6 ml/kg of ideal

body weight) tolerate a degree of
hypoventilation and permissive
hypercapnea (pH 7.3 to 7.45)
Use positive end-expiratory pressure to
improve oxygenation and maintain
plateau pressures less than 30 cm H2O.

NO. 7: INTENSIVE GLYCEMIC

CONTROL
Why

septic patients seem to benefit

more from intensive glycemic control
with prolonged ICU stays is not clear at
this time
Additional large, multicenter studies are
needed to reveal the best strategy for
glycemic control in sepsis

 The

2008 SSC guidelines:

reduction in morbidity and mortality of
intensive glycemic control with longer
ICU stays
recommend that patients with severe
sepsis and hyperglycemia receive
intravenous insulin therapy to a targeted
glucose level of less than 150 mg/dl

NO. 8: RECOMBINANT HUMAN

ACTIVATED PROTEIN C
Indications

for rHAPC use in the

emergency department are limited
As demonstrated by the ENHANCE
data, there may be a role for early
therapy

 However,

based on the risks of bleeding

and cost, rHAPC should probably be
considered only:
after

hemodynamic optimization is achieved

appropriate antibiotics are given
if there is significant delay in admission to
the ICU