Sepsis Protocols in the Emergency Department

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Sepsis Protocols in the Emergency Department 

• E2E March 12, 2009
• Dennis Djogovic MD, FRCPC
• Emergency Medicine and Critical Care
• University of Alberta

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Objectives

• Where should the focus be?
• Who is with you?
• The Edmonton Experience

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• Why is sepsis so important NOW?
• Push to earlier identification, earlier treatment
• Most useful therapies are not necessarily most
  expensive
• ED has taken the forefront, ICU the backup role

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Life in the ER?
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Lactate

• it should be recognized that systemic
  hypo-perfusion usually precedes hypotension,
  especially in patients with sepsis
• Rackow, JAMA 1991
• Lactate elevation means cells are dying

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• GOAL rapid lactate value
• If you dont have access to lactate values,
  pressure your admin to obtain a way of measuring
  them
• In my opinion, lactate use is the most
  significant change in sepsis identification I
  have seen

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Antibiotics

• Suggestion
• Talk to your IM, ID, pharmacy folks
• Goal Determine what are reasonable empiric
  choices for first abx dose
• For chest sepsis
• For abdo/GU sepsis
• For skin sepsis
• For CNS sepsis

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Fluids

• Only rate of administration is wide open
• Forget maintenance rates, that is for stable
  patients
• Central lines dont save lives, big IVs save
  lives
• Ideally, fluids and resus are guided by EGDT
• However without upper limb central lines, central
  venous gases and CVP this is not possible

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Fluid resus

• Suggest 2 streams of resus
• 1) if you are able to consistently obtain CVP
  and CVsO2 values
• Either by ER or by rapid ICU
• A la Rivers EGDT
• 2) if you cannot
• Focus on heavy fluids, vasopressors if SBPlt90,
  MAPlt70

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Vasopressors

• Need more vessel squeeze than heart pump
• Dopamine
• Norepinephrine (levophed)
• But dont forget about the fluid!

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Steroids

• Unclear after many studies
• If they are on steroids, give them steroids
• If they have been on steroids, give them steroids
• If they are not responsing to fluids and
  pressors
• Probably give them steroids
• Goal What does your local ICU prefer?

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Consult ICU

• Old days
• Patients needed pressors and ventilator to get
  into ICU
• Now
• ICU should get involved sooner
• Having ICU involved and the patient eventually
  goes to Medicine ward is a success, not a failure
• Discuss it with your local ICU
• Goal When do you want to be called?

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Who is with you?

• Cant do it alone
• Just like a bad trauma or bad AMI
• RT
• RN
• ID
• ICU
• Admin
• pharmacy

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Sepsis Protocols

• Paper vs computer?
• We have tried both
• Both are effective

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Paper

• Pocket cards for all MDs, residents
• Posters in your acute care areas
• On the wall of your resus room

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University of AlbertaSevere Sepsis Protocol
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In Summary

• Setting up a sepsis protocol can help your
  patients
• Must be multidisciplinary
• But it does not have to be difficult
• Adopt an existing strategy
• Simple posters in your resus rooms
• Lactate!
• Dont be afraid to ask for help

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Thank You !djogovic_at_ualberta.ca
Questions?