The protocols can be found here: Sepsis Protocols. Ceftriaxone and cipro is fine for pneumonia if you don't have/can't use a macrolide as it gets the atypicals. Azithromycin is better b/c it will double cover the strep pneumo. Thanks for the kind words, Patrick.
Thanks guys. Do we know the specificity of raised lactate in the ED population? There is concern in my ED that if we follow your recommendations we will be over treating a lot of well people who, say, had the tourniquet on for too long.
Recommendations for fluid loading a severe septic patient with CHF and an EF of 15% or a dialysis patient? Be ready to intubate at a minutes notice? How about the frail 86lb malnourished bedbound nursing home female who normally has a BP of 88/56 with SIRS and a catheter associated UTI that is probably colonization and a normal lactate? Should she get 4 L of fluid then pressors?
Chris- Alan Jone's and his group disproved the tourniquet time question and the sitting without ice. It is all fine. Make sure your lactates are run on blood gas machines and the specificity is pretty good, not for sepsis, but for badness. Lactate >2, I see a bunch. Lactate >4 generally there is something wrong with your pt. Confounders are use of b-agonists, seizures, and some young trauma patients (endogenous beta-agonists). If you have a pt with suspected sepsis and a lactate >4, they are at risk of badness.
Patrick--first ? in the pt you describe: Are YOUR goals of care curative? If not we do not do severe sepsis protocol. If they are then in this pt like all my patients, I would prefer a marker of fluid tolerance like IVC ultrasound rather than empiric fluid load. If empiric is all you can do, then yes 4 liters. And yes, you may wind up intubating. Old severe septic pts who you want to cure are generally going to need intubation regardless.
Scott... Excellent review of sepsis. Philosophical question for ya...
You said that EGDT was "standard of care" yet also mentioned that there are three large multicenter RCT's being conducted looking at this. Do you think this suggests that there are many unanswered questions and doubts about EGDT? Therefore, how could this be considered "standard of care?" In addition, the sepsis protocol that you discussed looks like it has evolved quite substantially from the original one proposed by Dr Rivers. It is really "standard of care" with so many changes and unanswered questions?
Scott, great lecture! I was wondering what is the common pressor you use for post-cardiac arrest patients? Especially early after ROSC and once you have given fluids?
Hope it isn't too late to ask questions on this most excellent sepsis review which you gave. 1)does it matter venous vs arterial lactic acid? 2)is it reasonable to use UOP as further evidence of adequate fluid resusitation? 3)had pt with HR 130 BP 60/40 RR 24 and afebrile in ER (with measured elevated temp at home). NO obvious source of infection after full w/u. Responded well to fluid resus with 4L and given IV abx. Lactic acid (venous) came back at 1.5. Does low lactic acid rule out sepsis?
Do you only place central line if patient needs pressors? In our community ED, we are instructed to place line if Lactate is >4 or persistently hypotensive(severe sepsis and septic shock). Any guidelines on indications/necessity for line placement in patients who are severe sepsis?
Great episode. I think it under-emphasizes the importance of ScVO2 as a marker of cardiac output and meeting the oxygen demand of the tissues. I also think that with the current data it under-emphasizes CVP, which is not perfect, but truthfully I still find usefull. It is not uncommon to find that the CVP is very low, for example 2 or 4 indicating need for more fluid in anyone's mind. It is the "at goal" CVPs in the 8-12 range where there remains the question of fluid responsiveness, which is usually after 6L or so of initial resuscitation while putting the line in.
I agree with the general concept here - forget the blood pressure and resuscitate the patient.
Oh...and I forgot lactate negative sepsis. Not all hypoperfusion presents with an elevated lactate. If they meet criteria for severe sepsis despite a negative lactate just suck it up and put in the line as you have nothing else to follow beyond ScVO2 and these people still die. Every time you see an elevated lactate run your differential...it is short and if still elevated you need to figure out why. Something is wrong.
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Constantino D. - October 1, 2012 4:57 PM
Cipro for pneumonia?
Patrick S., M.D. - October 6, 2012 10:36 AM
You did it for trauma and you did it for sepsis. Thanks Scott.
Keir S. - October 10, 2012 8:11 AM
Great review Scott! Any chance you are willing to share your triage protocols?
EMCrit - October 12, 2012 8:47 AM
The protocols can be found here: Sepsis Protocols. Ceftriaxone and cipro is fine for pneumonia if you don't have/can't use a macrolide as it gets the atypicals. Azithromycin is better b/c it will double cover the strep pneumo. Thanks for the kind words, Patrick.
Chris C., M.D. - October 16, 2012 2:00 PM
Thanks guys.
Do we know the specificity of raised lactate in the ED population? There is concern in my ED that if we follow your recommendations we will be over treating a lot of well people who, say, had the tourniquet on for too long.
Abdullah Al-Somali - October 16, 2012 4:31 PM
Great review, Thank you,
Ricky G - October 17, 2012 3:01 AM
Recommendations for fluid loading a severe septic patient with CHF and an EF of 15% or a dialysis patient? Be ready to intubate at a minutes notice?
How about the frail 86lb malnourished bedbound nursing home female who normally has a BP of 88/56 with SIRS and a catheter associated UTI that is probably colonization and a normal lactate? Should she get 4 L of fluid then pressors?
EMCrit - October 17, 2012 2:17 PM
Chris- Alan Jone's and his group disproved the tourniquet time question and the sitting without ice. It is all fine. Make sure your lactates are run on blood gas machines and the specificity is pretty good, not for sepsis, but for badness. Lactate >2, I see a bunch. Lactate >4 generally there is something wrong with your pt. Confounders are use of b-agonists, seizures, and some young trauma patients (endogenous beta-agonists). If you have a pt with suspected sepsis and a lactate >4, they are at risk of badness.
Patrick--first ? in the pt you describe: Are YOUR goals of care curative? If not we do not do severe sepsis protocol. If they are then in this pt like all my patients, I would prefer a marker of fluid tolerance like IVC ultrasound rather than empiric fluid load. If empiric is all you can do, then yes 4 liters. And yes, you may wind up intubating. Old severe septic pts who you want to cure are generally going to need intubation regardless.
Brian D. - October 24, 2012 9:30 PM
Scott... Excellent review of sepsis. Philosophical question for ya...
You said that EGDT was "standard of care" yet also mentioned that there are three large multicenter RCT's being conducted looking at this. Do you think this suggests that there are many unanswered questions and doubts about EGDT? Therefore, how could this be considered "standard of care?" In addition, the sepsis protocol that you discussed looks like it has evolved quite substantially from the original one proposed by Dr Rivers. It is really "standard of care" with so many changes and unanswered questions?
BTW... love your work and insights... keep it up!
Jose C. - October 25, 2012 11:19 AM
Scott, great lecture! I was wondering what is the common pressor you use for post-cardiac arrest patients? Especially early after ROSC and once you have given fluids?
Thx!
J
Chris C., M.D. - November 4, 2012 5:33 AM
Thx Scott
steve r. - December 23, 2012 3:49 PM
HI Scott
Hope it isn't too late to ask questions on this most excellent sepsis review which you gave.
1)does it matter venous vs arterial lactic acid?
2)is it reasonable to use UOP as further evidence of adequate fluid resusitation?
3)had pt with HR 130 BP 60/40 RR 24 and afebrile in ER (with measured elevated temp at home). NO obvious source of infection after full w/u. Responded well to fluid resus with 4L and given IV abx. Lactic acid (venous) came back at 1.5. Does low lactic acid rule out sepsis?
thanks steve
JCM, M.D. - January 4, 2013 5:06 AM
Great review! How fast do you put in those 2-4 liters?
Thomas D. - January 26, 2013 12:14 PM
Do you only place central line if patient needs pressors? In our community ED, we are instructed to place line if Lactate is >4 or persistently hypotensive(severe sepsis and septic shock). Any guidelines on indications/necessity for line placement in patients who are severe sepsis?
Cameron - March 13, 2013 12:11 AM
Great episode. I think it under-emphasizes the importance of ScVO2 as a marker of cardiac output and meeting the oxygen demand of the tissues. I also think that with the current data it under-emphasizes CVP, which is not perfect, but truthfully I still find usefull. It is not uncommon to find that the CVP is very low, for example 2 or 4 indicating need for more fluid in anyone's mind. It is the "at goal" CVPs in the 8-12 range where there remains the question of fluid responsiveness, which is usually after 6L or so of initial resuscitation while putting the line in.
I agree with the general concept here - forget the blood pressure and resuscitate the patient.
Cameron - March 13, 2013 12:16 AM
Oh...and I forgot lactate negative sepsis. Not all hypoperfusion presents with an elevated lactate. If they meet criteria for severe sepsis despite a negative lactate just suck it up and put in the line as you have nothing else to follow beyond ScVO2 and these people still die. Every time you see an elevated lactate run your differential...it is short and if still elevated you need to figure out why. Something is wrong.