Sepsis

Read on for a conference review written by Zach Adams

Oh, sepsis.  We discuss the topic constantly and we see the impact of the disease on a daily basis in the ED.  The Sepsis III guidelines (Sepsis III) define some new criteria for diagnosis, though currently ACEP has not quite bought in.  In the meantime, utilization of either criteria (qSOFA, SIRS) can be utilized with similar efficacy, though there are problems with both definitions (Problems with Sepsis III).  Given the ongoing debate, I think we can all agree that rapid identification and initiation of IV fluids, broad spectrum antibiotics based on likely source, and vasopressors if needed are a must.  And we do a great job of this at Ohio State.  Some finer points:

  • Volume resuscitation is key, but over-resuscitation is no good (Early Vasopressor Use)
  • Norepinephrine is the vasopressor of choice for sepsis (Pressors in Sepsis)
    • Add on vasopressin secondarily
      • If you’re adding on a second pressor, you should be considering stress dose steroids
    • Forget dopamine
    • Consider dobutamine if ionotropic support is needed
    • Phenylephrine is probably in the “don’t use” category unless norepinephrine has been known to cause an intolerable tachyarrhythmia or there is a known high output cardiac state
    • Don’t forget epinephrine as a second line pressor (Epinephrine)
  • Lactate measurement is useful for identifying sick patients, while serial measurements are of unknown utility (Lactate)
  • Ultrasound is awesome, don’t forget your RUSH Exam (RUSH Exam)
  • Goal directed therapy is out (The Death of Goal Directed Therapy)

Bottomline, whether you’re using SIRS or qSOFA for identifying patients with sepsis, rapid identification is critical – start IVF, broad spectrum antibiotics, early vasopressors when required (MAP goal >65 in most), find the source and control the source.

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