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Shyam Murali
Fellow in Trauma and Surgical Critical Care - University of Pennsylvania,
Senior Editor - CriticalCareNow.com,
Writer - RebelEM.com,
Saxophonist, EDM remixer, husband, puppy father, and new human father
The Pre-brief
The Surviving Sepsis Guidelines were released in 2016 to assist clinicians with taking care of sick patients with severe infections. I condensed the 67 page document into this summary on my residency educational blog, and I also covered the 2018 update to the guidelines here on CCN. These guidelines have been extremely controversial for a few reasons, not the least of which is that the Centers for Medicaid and Medicare Services (CMS) mandated certain aspects of the guidelines. Over time, new evidence emerged, giving us more insight into how to better treat our sepsis patients.
Enter the Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report: in 2019, ACEP convened a multispecialty task force (with an alphabet soup of acronym societies; see below) to address the controversies and areas for improvement of sepsis patients. The task force published a report in the Annals of Emergency Medicine practical consensus-based approaches to certain parts of ED sepsis management. The guidelines had input from the following societies: ACEP, AAEM, ACOEP, ABEM, AOBEM, AACEM, CORD, EMRA, ENA, NAEMSP, SAEM, SHM, SCCM, ATS, and IDSA.
Here is our summary of this manuscript (our editorials in italics):
Recognizing Sepsis and Septic Shock in the First Minutes to Hours of Care
Principles of Sepsis Recognition
- Sepsis = confirmed or suspected infection + new or worsening organ dysfunction + dysregulated host response to infection. It is not defined by a single datum or finding.
- Sepsis is COMPLEX! It is a spectrum and can be tough to diagnose, especially in the immunocompromised, elderly, and those who present early in illness.
- Guidelines or care pathways must take into consideration that diagnosis can be difficult.
- Septic Shock = Sepsis + Cardiovascular effects (typically ranging from hypotension alone to hypotension + elevated lactate requiring pressors, i.e. evidence of end organ damage) (something about end organ damage)
- A singular episode of hypotension portends a worse outcome
- Anchoring on a diagnosis of sepsis early in the illness can result in missing other diagnoses that present similarly (cardiogenic shock, overdose, pulmonary embolism, etc.)
Early Screening and Detection of Those With Sepsis
- Standardized early sepsis screening tools may improve sepsis recognition and care. However, there is no validated evidence-based tool or strategy to reliably accomplish this goal in the ED or out-of-hospital setting.
- You may have seen the EMR yell at you with a sepsis alert as soon as you open a patient’s chart. We are trying to find ways to help clinicians recognize sepsis early, and while they may improve timeliness of care, we don’t have much information about patient-oriented outcomes.
Initial Care Steps in the Emergency Department and the Out-of-Hospital Environment
Principles of Early Sepsis Management
- History and physical examination may help to detect infection and organ dysfunction.
- Very obvious point, but cannot be emphasized enough! Your physical exam skills still matter!
- Once sepsis is recognized, prompt action to treat infection and reverse or prevent hypotension and hypoperfusion is important.
- Resuscitate first → Fluids, IV antibiotics, Vasopressor support, and Source Control
- Early goal-directed therapy (EGDT) relied on a protocolized approach to sepsis treatment, which improved outcomes, but this was not demonstrated in 3 subsequent large multicenter trials (PROCESS, PROMISE, ARISE).
- While the actual study may not have reflected this, the spirit/ethos of EGDT is truly about being appropriately aggressive with the initial care and management of sick, sepsis patients.
Out-of-Hospital Care
- EMS providers can help by getting a focused history and obtaining corroborating data prior to transport.
- Ask the patient about their symptoms and identify any potential signs of infection. Briefly examine the environment, collect medications if possible, and speak with family or caregivers if they are immediately available.
- Rapidly transport sepsis patients to an ED capable of providing early sepsis care.
- Prehospital antibiotics are still being evaluated but may have the potential to improve outcomes.
Evaluation for Source of Infection
- Obtain blood cultures in the ED without delaying care
- In patients who do not have an identified source, obtain a chest x-ray and urinalysis in the ED
- Pneumonia and UTI are the 2 most common infection sources in sepsis
- Sample possible infection sources based on history and physical exam (CSF, peritoneal fluid, wounds, medical devices, etc.)
- Targeted CT is preferred to routine whole-body imaging
Severity Assessment
- Clinicians should use multiple clinical and laboratory findings to detect sepsis and guide care.
- Measure lactate level in the ED, and repeat it if the initial measurement is above 4mmol/L or if there is suspicion of clinical deterioration.
- This topic has been one of the most controversial aspects of the SSC guidelines, because of people’s misinterpretation to manage patients based on lactate levels after the initial two. However, we agree with this statement and believe this seems to be a reasonable approach. As always, use additional methods to assess patients (e.g. peripheral perfusion, mental status, urine output, etc.)
- Consider using a scoring system (e.g. SOFA), to stratify individual sepsis patient risk at early stages of care.
- SOFA score assesses 6 organ systems: respiratory, coagulation, liver, cardiovascular, central nervous, and renal.
- Consider using the qSOFA as well (RR > 22/min, AMS, SBP < 100mmHg)
- The authors do not advocate performing an ABG for the sole purpose of obtaining PaO2 for P/F ratio.
Intravenous Fluid and Timing of Vasopressors
- Deliver an IV fluid bolus during initial management of patients who have hypotension or findings of hypoperfusion absent signs of fluid overload
- The guidelines do not support a prespecified volume or body-mass adjusted volume for all patients; however, the authors recognize many patients benefit from 30 mL/kg of crystalloid. Patient response may serve as the best indicator of the appropriateness of fluid resuscitation volume, rather than the delivery of a prespecified volume.
- Every patient is different and requires a personalized approach to fluid administration. Use the many tools at your disposal to determine how much crystalloid you should give your patient.
- They specifically state:
“We do not believe data support a singular body mass-based volume for all or most patients, although we recognize that many will receive and respond to certain targets like 30 mL/kg. We believe any new guidelines should incorporate titration and response assessment along with defined aliquots, including body mass-based, to optimally improve care.”
- The authors do not recognize a specific minimum fluid amount before starting vasopressor support.
- However, they do recognize that vasopressors may be coupled with fluid resuscitation to prevent cardiovascular collapse in those with severe hypotension or life-threatening hypoperfusion.
- Use serial exams
- Keep a close eye on your patients. These are usually very sick patients and need frequent reassessment and reconsideration of therapies.
- The guidelines support using balanced crystalloid solutions (LR or Plasmalyte) as the primary resuscitation fluid, especially if volumes of more than 1L are used.
- Saline can cause hyperchloremic metabolic acidosis that may impair renal performance.
- The data does not currently support the use of colloids in sepsis despite the theoretical physiologic benefits.
- Be on the lookout for abdominal compartment syndrome and major adverse kidney events
Vasopressors
- Norepinephrine is an excellent first-line vasopressor for patients with septic shock.
- Consider adding vasopressin to reduce norepinephrine requirements.
- Use epinephrine as a second-line vasopressor
- Titrating vasopressors to maintain a MAP of at least 65 mmHg in most patients is a common target.
- A practice that hasn’t really been studied yet is using vasopressors concurrently with the initial 30mL/kg fluid bolus to help augment severe hypotension. While there’s not enough research to recommend that as a standard practice, it may help certain patients who are extremely ill.
- Early vasopressors can be administered through a well-secured nondistal peripheral IV catheter.
- There’s a lot of important language in this statement: well-secured (don’t let the tip of the catheter get dislodged and come out of the vein) and nondistal (make sure the IV is proximal to the wrist or ankle). Make sure to monitor the site closely for any signs of extravasation. I am particularly a fan of ultrasound-guided peripheral IV placement and these may help improve the quality and integrity of IVs.
- They posit that because central venous access was historically required for vasopressors, the delay in obtaining central venous access may increase the volume of fluid administration.
Antimicrobials
- We support early antibiotics once sepsis is diagnosed or deemed likely
- Shorter time is preferred, but the precise time frame still remains to be defined. The current data does not support a singular time target.
- Antivirals are less clearly time sensitive in the earliest phases of disease
- For sepsis patients without an identified pathogen, we recommend initiation of broad-spectrum antibiotics with activity against gram-negative and gram-positive bacteria according to local susceptibility patterns.
- Choose your antimicrobials based on the most likely and most harmful potential pathogens rather than targeting a specific pathogen, unless the clinical presentation directs such a focused approach.
- Avoid narrow-spectrum therapy.
- Consider viral and fungal pathogens and use appropriate additional antimicrobials if necessary.
Infection Source Control
- Identify infections requiring source control early and perform the appropriate interventions.
- Here are some examples included in their guidelines:
- tunneled vascular catheters
- hemodialysis lines
- vascular ports
- implanted devices
- infected ureteral stones
- biliary ductal obstruction with cholangitis
- deep space or body cavity abscesses
- intestinal perforation or obstruction with ischemia
- necrotizing soft tissue infection → Do not miss! Get their clothes off and examine thoroughly!
- complications of infections such as those related to Clostridium difficile colitis
- Here are some examples included in their guidelines:
- No specific timing thresholds for achieving source control currently exist.
- Again, the sooner, the better.
Titration of Care
Ongoing Fluid Administration
- Fluid administration after an initial bolus should be based on serial assessments of the patient and response to therapy.
- No singular assessment approach is superior
- Clinical evaluation: changes in vital signs, physical examination findings, and urinary output (less reliable on shorter ED stays)
- Quantitative evaluation: dynamic measures > static measures (eg. CVP, isolated vital signs)
- Dynamic measures: pulse pressure variation, stroke volume variation, passive leg raise measurement with continuous stroke volume or cardiac output measurement, inferior vena cava collapsibility on ultrasound, aortic valve velocity time integral
- Up to half of septic shock patients fail to increase cardiac output or have a transient response in cardiac output to fluid administration.
Vascular Access and Invasive Monitoring
- Vasopressor administration through peripheral IV or IO catheters is acceptable for short-term use.
- See above for our views on this.
- Invasive hemodynamic devices (e.g. arterial catheters, CVP) may aid but are not routinely needed in early sepsis care.
Subsequent Doses of Antibiotics
- Give additional doses of antibiotics according to the optimal dosing schedule
- This is extremely important for our patients who board in the emergency department.
Adjunctive Early Sepsis Therapies
- Routine corticosteroid therapy does not benefit sepsis patients
- However, if a patient chronically takes corticosteroids or has preexisting adrenal insufficiency, they should receive stress-dose hydrocortisone.
- Consider adding stress dose steroids if the pressor requirement keeps rising despite appropriate fluid resuscitation.
- Other adjuncts, including angiotensin II, vitamin C, vitamin D, and thiamine lack strong evidence supporting benefit and are not recommended.
Role of Interhospital Transfer, Inpatient Boarding, and Care Transitions in Sepsis Management
- ED boarding presents risk for sepsis patients
- Rapidly stabilize and transfer patients out of facilities that do not have the capabilities to promptly care for critically ill patients
- Each institution should develop a plan that defines explicit accountability for sepsis patients receiving prolonged ED care.
- Get your patients to the ICU quickly and if that can’t happen, figure out why and fix it.
Related Controversies
- We support recommendations and quality assessment tools required by government or regulatory bodies as important ways to improve the outcomes of those with sepsis, and we believe these should be based on the best available evidence and should undergo regular reevaluation.
- The creation of recommendations, guidelines, and quality assessment tools must include input from all relevant stakeholders engaged at each phase of care and must incorporate assessment of impact on both targeted patients and others receiving care.
- Care must be modified for those providers in low-resource settings based on the available options. Some studies demonstrate that lower volumes of IV fluid administration may lead to better patient outcomes in settings where advanced critical care capabilities were uncommon.
The Debrief
- The care of our septic shock patients is extremely complex, and the first few hours matter the most
- Identify sepsis early
- Once sepsis is recognized, prompt action to treat infection and reverse or prevent hypotension and hypoperfusion is important
- Give fluids, but personalize the volume of fluid administration to the needs of your patient. Use dynamic measures of assessment, instead of static measures, to determine which patients need more IV crystalloid.
- Monitor your patients closely and adjust the treatments based on the patient’s response
- Give antibiotics early, but there is not enough data to support a specific time frame in which to give it
- Vasopressors can be given through a good peripheral IV for short periods
References
- Yealy DM, Mohr NM, Shapiro NI, Venkatesh A, Jones AE, Self WH. Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report. Ann Emerg Med. 2021 Apr 9:S0196-0644(21)00117-7. doi: 10.1016/j.annemergmed.2021.02.006. Epub ahead of print. PMID: 33840511.
- Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017 Mar;43(3):304-377. doi: 10.1007/s00134-017-4683-6. Epub 2017 Jan 18. PMID: 28101605.
- Marchick MR, Kline JA, Jones AE. The significance of non-sustained hypotension in emergency department patients with sepsis. Intensive Care Med. 2009 Jul;35(7):1261-4. doi: 10.1007/s00134-009-1448-x. Epub 2009 Feb 24. PMID: 19238354; PMCID: PMC2923927.
- Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019 Feb 19;321(7):654-664. doi: 10.1001/jama.2019.0071. PMID: 30772908; PMCID: PMC6439620.
