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Sepsis Decision Pathway: Treatment

Cameron Berg, MD FAAEM and Rob Orman, MD
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EM:RAP 2015 August Summary 1 MB - PDF

Managing sepsis has become simpler over the past year, but early aggressive intervention is still essential.

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David R. -

Hey, this is not the notes for Sepsis. :)

Rob O -

Hey David! Thanks for pointing this out. Remedy in the works ASAP!

Eric A. -

Curious as to how Cam's hospital will change their protocol to comply with Sepsis Core Measures to roll out in October...

c. berg -

Very little will need to be changed. We need to automate some of the assessment/documentation tools, but the core components are met by our protocol.

That said, the elements of this core measure seem to be a big backslide...

Best,
Cameron

John K. -

As an IM resident who just completed a month of ID in downtown Detroit I have to humbly disagree with the assertion that blood cultures lack potential utility in Sepsis secondary to a SSI, CAP, or upper urinary tract infection. First, bacteremia changes the duration of therapy. What's the recommended duration of therapy for CAP vs. Gram positive Bacteremia? Are there any well designed studies looking at treatment failure (I suppose we'd have to operationalize treatment failure first?) in patients with "CAP" v. CAP with bacteremia? What about similar clinical scenarios in SSI and upper urinary tract infections? To my knowledge, these topics have not been studied. So we should probably all be cognizant of and defer to the IDSA guidelines with regard to these matters.

IDSA, at least for CAP, states the benefits of blood cultures for patients with CAP are "minor" not nonexistent. But again even simple statements such as this merely scratch the surface. What about the potential downstream effects? What about de-esclation of antibiotics in patient with CAP in the face of increasing Macrolide resistance? Antibiotic stewardship anyone? Though Blood cultures prior to antibiotic therapy are yield a measly 4-15% positive result, CAP has high incidence and therefore it's difficult to presume such a low yield equates to zero potential benefit.

At the end of the day, IDSA still recommends Blood Cultures for patient with "severe CAP." What the exact definition of severe CAP is, is anyone's guess, but I would posit that if you think someone is sick enough that you will probably admit them to the hospital then you should probably still get blood cultures. Just my take still loved the review!

John

Brian N., MD -

If the patient is septic and has a UTI, blood cultures should be obtained and not presumed to be from urosepsis. Although, it is likely that the same bacteria is the culprit, patients can have fleas and ticks.....as they say. I've had many times where the blood culture showed a different pathogen than the urine. Its usually in an elderly patient with chronic UTIs who have a subclinical pneumonia that didn't show up on CXR on the initial visit. Often, their sepsis is written off to the UTI but the actual focus is somewhere else. Its not a big stretch to get blood cultures and you would be amazed sometimes that the urine culture is completely different than the blood culture.

Michelle S. PA-C -

Thank you Dr. Berg. I FINALLY have convinced my rural, critical access hospital that obtaining a lactic acid level stat, was mandatory for good patient care. (It only took me two years.) Apparently I was the only provider asking for it. Sad, but true. I will use your information to help implement a program in our ED as well.

Teresa P., M.D. -

over how much time do you all try to give the 2 l in patietns with map<65 or lactate>2

c. berg -

Bolus answer time...
John - I hear you, and I agree. In a perfect world, blood cultures have tremendous use. The perfect doctors admit the perfect patients (true disease) and we do the perfect test. Our system is too far from perfect. We tend to use tests in huge numbers or minimal numbers. And if ALL patients who qualify for Sepsis (based on CMS criteria) should receive 2 sets of blood cultures, then I think we'll end-up paradoxically harming more patients than we'll help. We'll overdiagnose and overtreat.
...it's the opposite of what cultures are supposed to do.

Brian - I typically agree with you. An older, sicker, more cormobid, more confusing case should get a broader workup (including blood cultures). A 35yo woman with unilateral flank pain, fever, tachycardia, and elevated lactate does not, in my opinion, need blood cultures.

Michelle - Great work!

Teresa - MAP <65 as fast as possible (2L in <1hr); about 2L/hr for the remaining cohorts

Steve J., M.D. -

What about I/o use instead of central line in patients needing further resuscitation?

Carene O. -

Hello!
I live and practice in Puerto Rico, where we have high rates of viral infections such as dengue and now chinkungunya and zika. Could the pathway, or a modification be used in these patients? What about fluid resuscitation for dengue patients? They can present in all the spectrum of sepsis definitions. They CDC have previously published IVF resuscitation protocols and I am wondering if they can be integrated somehow.

Carene O. -

Also, I'm sure this has been asked and answered, but I can't find a clear answer at this time. How does the administration of lactated ringer's for sepsis resuscitation (vs normal saline) affect my reevaluation of the patient in regard to repeat lactate measurements and lactate clearance. Thanks!

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Quality Review Gets Septic Full episode audio for MD edition 252:40 min - 352 MB - M4AEM:RAP 2015 Août Résumé en Francais Français 62:21 min - 57 MB - MP3EM:RAP 2015 August Canadian Edition Canadian 31:42 min - 29 MB - MP3EM:RAP 2015 August Aussie Edition Australian 58:17 min - 53 MB - MP3EM:RAP 2015 Agosto Resumen Español Español 76:59 min - 71 MB - MP3EM:RAP 2015 August MP3 306 MB - ZIPEM:RAP 2015 August Summary 1 MB - PDFEM:RAP Español Agosto 2015 2 MB - PDFEM:RAP 2015 August Board Review Questions 223 KB - PDFEM:RAP 2015 August Board Review Answers 239 KB - PDF

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