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Thoughts From A Clinician

Thoughts from a Clinician: Current Thoughts and Trends on Sepsis Management, Sepsis Treatment: Part 2

 

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Hopefully we have all survived the holidays, had a chance to digest our holiday food and part one of this series on sepsis.  The next item to review is clinical care in sepsis management.  The main player in this is the Surviving Sepsis Campaign (1).  This campaign is aimed at clinical care of sepsis patients and has been around for quite some time. In early 2012 when sepsis became a prioritized focus in Emergency Medicine and Critical Care, they introduced sepsis treatment bundles.  Providers involved in the care of these patients, including myself, were excited to read them.  Much to my disappointment, the first line pressor agent suggested by these guidelines was Dopamine.  This remained, until early 2015 when the Surviving Sepsis Campaign released new guidelines.  In the suggested updates Dopamine has since been demoted and replaced with Levophed, as the first line pressor. In addition to addition of Levophed and the demotion of Dopamine, the SSC is also recommending push dose pressors for hemodynamic support in the sepsis patient.  Let’s take a more detailed look at the current Surviving Sepsis Campaign treatment bundle.

The “time of presentation” is defined as the time of triage in the emergency department [in which the patient presented] or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review. ** Of note, the 6-hour bundle has been updated; the 3-hour SSC bundle is not affected (1).

Within three hours of the time of presentation, it is recommended that the sepsis patient have the following interventions performed:

1) Measure lactate level (via point of care testing or lab)
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥ 4mmol/L

Additionally, after six hours from time of presentation, the patient should have these interventions performed, in sequence, following the first set of interventions.  These include:

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg
6) In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings.
7) Re-measure lactate if initial lactate elevated.

In order to adequately document the reassessment of the septic patient’s volume status and tissue perfusion, the provider should “repeat focused exam (after initial fluid resuscitation) including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings”.  If this is not feasible or is inconclusive, the provider can perform two of the following studies:

• Measure CVP

• Measure ScvO2

• Bedside cardiovascular ultrasound

• Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

This treatment bundle is the most widely used therapy in the care of the septic patient.  Most important in this treatment bundle is the timeline.  Things have to be done with in a certain timeline with regards to sepsis care.  Understandably, this pushes the treatment to start in the prehospital setting.  Training prehospital care personnel to identify sepsis and initiate treatment is highly imperative.  Suffice it to say, it can make a huge difference in patient outcomes.  When training these individuals, it is important for them to at least start IV fluids hydration for sepsis care.  Some agencies are implementing the use of antibiotics in the field, however, this remains controversial.  Until we can use point of care testing to look at lactate and other things in the field, antibiotic therapy for the septic patient will remain a debated topic. The use of antibiotic therapy in critical care transport is warranted based upon a reliable set of labs drawn at a referring facility.  This can help to guide therapy during transport.

In addition to the Surviving Sepsis Campaign, another popular treatment standard that is widely available is the Loma Linda STOP SEPSIS Bundle Toolkit (2).  This is available on their website and can be downloaded by anyone, including the general public.  The suggestions are similar to the Surviving Sepsis Campaign bundles, however, the Loma Linda Bundles are more detailed.  Loma Linda looks at sepsis in different stages and different treatments, respectively.  Treatment is aimed at early, goal-directed therapy with advanced hemodynamic monitoring, lactate measurement, and strict intake and output.  Of interest, there is not much mentioned about treating the temperature.  Perhaps is is that temperature is not all that important because it is part of the natural body’s defense system?  Included in this guideline is a recommendation to treat a febrile status if there is the potential for neurological injury due to the high temperature.

Recently, the HEAT trial results were released with much anticipation.  This trial looked at the use of Acetaminophen as an early treatment for fever.  The thought was that the early administration of Tylenol would correlate with the number of ICU free days (3).  The outcome of the trial did not support that hypothesis.  Early treatment with acetaminophen did not affect ICU free days.  This treatment was given to any patient with a fever.  Treating a temperature in sepsis has been a hotly debated topic in sepsis care and treatment.  The opinion of most ICU intensivists that have been spoken to say that treating the fever should only be done if it gets dangerously high.  What is dangerously high?  Well, anything that is known to cause brain damage is known as dangerously high.  Patients who have a temperature of at least 103 degrees Fahrenheit should definitely be treated with antipyretics, but otherwise it should just be monitored.  If we are adequately treating the disease process, the temperature should correct itself.  This treatment modality is always a controversial topic.  We do not want to completely forget about it, but we definitely want to make sure we know where it is in the treatment priorities.  Another good argument for not treating the temperature aggressively is to give us a trend to see if our treatment is helping the patient. 

In review this is a great look at the standards of sepsis care in the emergent and critical care settings.  Within these guidelines are several ways to apply them to the care of sepsis patients.  It is the position of FlightbridgeED that individuals follow their local protocols, procedures, guidelines, and stances of their medical directors.  As we may all believe in the idea and use of push dose pressors, it may not be something that all individual services can perform.  All of the staff at FlightbridgeED are driven to provide the very best evidence-based medicine and care available.  That said, please take the sepsis bundles presented here and draw your own conclusions to the care you and your service should provide.  Until next time, think logically, strive to be better, and always think like a clinician.

References:

1. http://lomalindahealth.org/common/legacy/llumc/emergency/patientcare/documents/patientcare-sepsis.pdf

2. http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf

3. New England Journal of Medicine 10/5/2015; 373:2215-24 - DOI: 10.1056/NEJMoa1508375

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Klint is a United States trained Critical Care Paramedic, who hold specialty certifications in neonatal and pediatric transport as well as being Flight Paramedic certified (FP-C).  He is currently pursuing a Baccalaureate degree in EMS Management through Western Carolina University.  Klint works full time as Flight Paramedic in the Midwest, USA.  He is also an EMS / Critical Care instructor with DistanceCME.  In addition, Klint is FlightBridgeED’s newest blog author and is heavily involved in Free Open Access Medication Education and EMS Education.  Klint can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it. or on Twitter at @NoDesat

 

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