Superbugs and SepsisSuperbugs and SepsisOverview:Overview:
MRSA in your Ambulance!MRSA in your Ambulance!Sepsis: Definitions and Sepsis: Definitions and PathophysiologyPathophysiologyRole of the EMS Provider in Early Role of the EMS Provider in Early Goal Goal Directed Therapy for Severe Directed Therapy for Severe Sepsis and Sepsis and Septic Shock Septic Shock
Prehospital Testing of LactatePrehospital Testing of Lactate
Faculty Faculty
Michael Schmitz, DO, MSMichael Schmitz, DO, MSDepartment of Emergency MedicineDepartment of Emergency Medicine
Southern Maine Medical CenterSouthern Maine Medical Center
Andrew Turcotte, RN, BS, NREMT-P/CCEMT-PAndrew Turcotte, RN, BS, NREMT-P/CCEMT-PKennebunk Fire RescueKennebunk Fire Rescue
Thank youThank you Cynthia Pernice, MPA, Maine HealthCynthia Pernice, MPA, Maine Health Jennifer Granata, RN SMMCJennifer Granata, RN SMMC Christopher Pare, EMT-PChristopher Pare, EMT-P Matthew Sholl, MD, MPH, FACEPMatthew Sholl, MD, MPH, FACEP
MRSA in Your Ambulance!MRSA in Your Ambulance!
ObjectivesObjectives Describe the basic characteristics of the Describe the basic characteristics of the
bacteria, bacteria, Staphylococcus aureusStaphylococcus aureus Discuss the history of drug-resistant Discuss the history of drug-resistant
Staphylococcus aureusStaphylococcus aureus in the hospital and the in the hospital and the communitycommunity
Discuss the types of infections associated with Discuss the types of infections associated with MRSAMRSA
Present current research describing the Present current research describing the prevalence of MRSA in the prehospital prevalence of MRSA in the prehospital environmentenvironment
Describe best Infection Control practicesDescribe best Infection Control practices
What is MRSA?What is MRSA?
MM ethicillinethicillinRR esistantesistantSS
taphylococcustaphylococcusAA ureusureus
DefinitionDefinition Bacteria commonly carried on the skin or in theBacteria commonly carried on the skin or in the
nose of healthy peoplenose of healthy people MRSA may be present without causing MRSA may be present without causing
infectioninfection 25% to 30% of the population is “colonized”25% to 30% of the population is “colonized” ““Staph” bacteria are one of the most commonStaph” bacteria are one of the most common
causes of skin infections in the U.S.causes of skin infections in the U.S.
History - MRSAHistory - MRSA First described in 1961 in the United KingdomFirst described in 1961 in the United Kingdom
First recognized in the 1970’s causing epidemics in healthcare First recognized in the 1970’s causing epidemics in healthcare settings. These strains are referred to as (HCA-MRSA)settings. These strains are referred to as (HCA-MRSA)
Generally resistant to most antibiotics: all beta-lactams, usually Generally resistant to most antibiotics: all beta-lactams, usually macrolides, clindamycin, quinolones, and tetracyclinesmacrolides, clindamycin, quinolones, and tetracyclines
Risk factors for HCA-MRSA:Risk factors for HCA-MRSA:– – prolonged hospitalizationprolonged hospitalization– – care in an intensive care unitcare in an intensive care unit– – prolonged antimicrobial therapyprolonged antimicrobial therapy– – surgical proceduressurgical procedures– – close proximity to an infected/colonized patientclose proximity to an infected/colonized patient
Usually considered an infection of chronically ill, hospitalized Usually considered an infection of chronically ill, hospitalized patientspatients
Community-Acquired Methicillin-ResistantCommunity-Acquired Methicillin-ResistantStaphylococcus aureusStaphylococcus aureus (CA-MRSA) (CA-MRSA)
A new strain of MRSA presenting from the A new strain of MRSA presenting from the community in persons without traditional risk community in persons without traditional risk factors for MRSAfactors for MRSA
First known CA infection reported in 1980First known CA infection reported in 1980 Differing from HCA-MRSA in terms ofDiffering from HCA-MRSA in terms of
– – EpidemiologyEpidemiology– – Antibiotic sensitivity patternsAntibiotic sensitivity patterns– – VirulenceVirulence– – PresentationPresentation– – TreatmentTreatment
Thought to have evolved separately in the Thought to have evolved separately in the community based on genetic differences community based on genetic differences
CA-MRSA- PrevalenceCA-MRSA- Prevalence Infection rates are increasingInfection rates are increasing
A recent meta-analysis found CA-MRSA to account for 30%-A recent meta-analysis found CA-MRSA to account for 30%-37% of all hospitalized MRSA patients37% of all hospitalized MRSA patients
In Los Angeles, a study demonstrated that CA-MRSA was the In Los Angeles, a study demonstrated that CA-MRSA was the most common cause of community-acquired skin/soft tissue most common cause of community-acquired skin/soft tissue infections presenting to emergency rooms infections presenting to emergency rooms
A Houston study demonstrated that CA-MRSA accounted for A Houston study demonstrated that CA-MRSA accounted for 56% in 2000-2001, 57% in 2002 and 78% in 2003 of 56% in 2000-2001, 57% in 2002 and 78% in 2003 of community-associatedcommunity-associatedStaph aureus infections in hospitalized pediatric patients Staph aureus infections in hospitalized pediatric patients
A Rhode Island study has demonstrated that up to 40% of A Rhode Island study has demonstrated that up to 40% of children with MRSA have community acquired strains children with MRSA have community acquired strains
MRSA-associated DiseasesMRSA-associated Diseases Skin/soft tissue 1,266 Skin/soft tissue 1,266 (77%)(77%) Wound (Traumatic) 157 Wound (Traumatic) 157 (10%)(10%) Urinary Tract Infection 64 Urinary Tract Infection 64 (4%)(4%) Sinusitis 61 Sinusitis 61 (4%)(4%) Bacteremia 43 Bacteremia 43 (3%)(3%) Pneumonia 31 Pneumonia 31 (2%)(2%)
Fridkin et al NEJM 2005;352:1436-44
CA-MRSA Risk FactorsCA-MRSA Risk Factors CA-MRSA appears to spread by close contactCA-MRSA appears to spread by close contact
In one study 26% of CA hand infections were MRSA-In one study 26% of CA hand infections were MRSA-positivepositive
Factors conducive to spread of the bacteria include:Factors conducive to spread of the bacteria include:– – Close skin to skin contactClose skin to skin contact– – Cuts or abrasionsCuts or abrasions– – Shared contaminated items or surfacesShared contaminated items or surfaces– – Poor hygienePoor hygiene– – Crowded living conditionsCrowded living conditions
CA-MRSA: Signs/SymptomsCA-MRSA: Signs/Symptoms CA-MRSA most often causes severe skin and soft CA-MRSA most often causes severe skin and soft
tissue infections.tissue infections. Skin and soft tissue infections often present as Skin and soft tissue infections often present as
cellulitis, boils, or furuncles often in the thighs cellulitis, boils, or furuncles often in the thighs and buttocks. and buttocks.
Patients may think they have been bitten by a Patients may think they have been bitten by a spider.spider.
Children may present with a severe necrotizing Children may present with a severe necrotizing pneumonia.pneumonia.
More serious infections like blood stream More serious infections like blood stream infections, septic arthritis, osteomyelitis, septic infections, septic arthritis, osteomyelitis, septic arthritis, and endocarditis are possiblearthritis, and endocarditis are possible
EMS and MRSAEMS and MRSA A 2007 study tested five A 2007 study tested five
specific areas in a fleet of specific areas in a fleet of 21 ambulances for MRSA 21 ambulances for MRSA contaminationcontamination– Steering wheel, left patient Steering wheel, left patient
handrail, stretcher cushion, handrail, stretcher cushion, work area to the patient’s work area to the patient’s right, yankauer suction tipright, yankauer suction tip
Thirteen samples isolated Thirteen samples isolated from 10 of the 21 from 10 of the 21 ambulances tested were ambulances tested were positive (47.6%).positive (47.6%).– 7/13 samples from the 7/13 samples from the
work area to the right of work area to the right of the patient tested positivethe patient tested positive
--Prehospital Emergency Care 2007;11:241-Prehospital Emergency Care 2007;11:241-244244
EMS and MRSAEMS and MRSA
A 2009 study examined the prevalence of MRSA on A 2009 study examined the prevalence of MRSA on the stethoscopes of EMS providersthe stethoscopes of EMS providers– Stethoscopes, like doctor’s ties, are known fomites for MRSAStethoscopes, like doctor’s ties, are known fomites for MRSA
Of 50 stethoscopes that were swabbed, 16 (32%) Of 50 stethoscopes that were swabbed, 16 (32%) were colonized with MRSAwere colonized with MRSA
LTTE in subsequent issue challenges this paper’s lab protocolLTTE in subsequent issue challenges this paper’s lab protocolPrehospital Emergency Care 2009;13:71-74
PREVALENCE OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUSIN AMBULANCES IN SOUTHERN MAINE
Robert Brown, OMS-IV, Julianne Minnon, OMS-IV, Stephanie Schneider, OMS-IV,James Vaughn, PhD
•Study published in 2010
•Lead author UNE MS-IV
•Obtained samples from specified areas in 51 ambulances in southern Maine
•25 (49%) had at least one area that was positive for MRSA
•No statistical difference between fire-based vs. non-fire based services or based on call-volume
•Statistically different lower rate of contamination among services providing paid, 24-hour coverage vs. those that did not
PREVALENCE OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS
IN AMBULANCES IN SOUTHERN MAINE
PREVALENCE OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUSIN AMBULANCES IN SOUTHERN MAINE
PREVALENCE OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUSIN AMBULANCES IN SOUTHERN MAINE
Why is EMS at risk?Why is EMS at risk? Fast turn-around timesFast turn-around times
– Difficult to clean thoroughly following a Difficult to clean thoroughly following a callcall
Working quickly in a confined spaceWorking quickly in a confined space Patient’s isolation status may not be Patient’s isolation status may not be
shared at time of transfer or be shared at time of transfer or be “buried” in the chart“buried” in the chart
PreventionPrevention CDC’s “Five C’s”CDC’s “Five C’s”
– CrowdingCrowding– Skin to skin contactSkin to skin contact– Compromised SkinCompromised Skin– Contaminated Items and SurfacesContaminated Items and Surfaces– Lack of CleanlinessLack of Cleanliness
PreventionPrevention Keep hands clean by washing thoroughly Keep hands clean by washing thoroughly
with soap and water or using an alcohol-with soap and water or using an alcohol-based hand sanitizerbased hand sanitizer
Keep cuts and scrapes clean and covered Keep cuts and scrapes clean and covered with a bandage until healedwith a bandage until healed
Avoid contact with other people’s wounds Avoid contact with other people’s wounds or bandagesor bandages
Avoid sharing personal items such as Avoid sharing personal items such as towels or razorstowels or razors
If skin is dry, use a moisturizer to prevent If skin is dry, use a moisturizer to prevent crackingcracking
HandwashingHandwashing Without question, Without question,
the most effective the most effective way to prevent way to prevent transmissiontransmission
Alcohol based hand Alcohol based hand sanitizers are sanitizers are effective against effective against MRSA, must be at MRSA, must be at least 60% alcohol least 60% alcohol (CDC)(CDC)
HandwashingHandwashing
HandwashingHandwashing
HandwashingHandwashing
Celebrity Endorsement?Celebrity Endorsement?
Objectives:Objectives: Discuss the prevalence of sepsis in the United Discuss the prevalence of sepsis in the United
StatesStates Define systemic inflammatory response Define systemic inflammatory response
syndrome, sepsis and septic shocksyndrome, sepsis and septic shock Briefly discuss the pathophysiology of this Briefly discuss the pathophysiology of this
complex problemcomplex problem Discuss the presentation of the septic patientDiscuss the presentation of the septic patient Why is this important?Why is this important?
Sepsis is….Sepsis is…. COMMONCOMMON
LETHALLETHAL
EXPENSIVEEXPENSIVE
Sepsis By the NumbersSepsis By the Numbers More than 750,000 cases of severe sepsis in More than 750,000 cases of severe sepsis in
the US each yearthe US each year Mortality about 20% (recent decline)Mortality about 20% (recent decline) Economic cost of $17 billion each yearEconomic cost of $17 billion each year Incidence is projected to increase by 1.5% Incidence is projected to increase by 1.5%
yearlyyearly Although prognosis has improved, because of Although prognosis has improved, because of
increased incidence, actual deaths per year will increased incidence, actual deaths per year will increaseincrease
What is Sepsis?What is Sepsis?
The Sepsis ContinuumThe Sepsis Continuum
A clinical response arising from A clinical response arising from a nonspecific insult, with a nonspecific insult, with 2 of 2 of the following:the following: T >38T >38ooC or <36C or <36ooCC HR >90 beats/minHR >90 beats/min RR >20/minRR >20/min WBC >12,000/mmWBC >12,000/mm33 or or
<4,000/mm<4,000/mm33 or >10% bands or >10% bands
SIRS = systemic inflammatory response syndrome
SIRS with a presumed or confirmed infectious process
Chest 1992;101:1644.
SepsisSIRSSevere Sepsis
SepticShock
Sepsis with organ failure
Refractoryhypotension
SEPSIS DEFINED:SEPSIS DEFINED:
““An inciting infectious event and host-An inciting infectious event and host-pathogen interaction leading to pathogen interaction leading to hemodynamic consequences cause by hemodynamic consequences cause by the relationship among proinflammatory, the relationship among proinflammatory, antiinflammatory and apopotic mediators”antiinflammatory and apopotic mediators”
Rackow EC, Astiz ME. JAMA 1991; 266:548-554Rackow EC, Astiz ME. JAMA 1991; 266:548-554
Sepsis: PathogenesisSepsis: Pathogenesis Systemic proinflammatory reactionSystemic proinflammatory reaction causes causes
endothelial damage, microvascular endothelial damage, microvascular dysfunction, and impaired tissue oxygenation.dysfunction, and impaired tissue oxygenation.
Excessive antiinflammatory responseExcessive antiinflammatory response triggers anergy and host immunosuppression.triggers anergy and host immunosuppression.
In addition, pro- and anti-inflammatory In addition, pro- and anti-inflammatory processes may interfere with each other, processes may interfere with each other, creating a state of destructive immunologic creating a state of destructive immunologic dissonancedissonance
Am J Physiol 1980; 239:F135.
SEPSIS: PRESENTATIONSEPSIS: PRESENTATION Pathogenesis starts before ICU admitPathogenesis starts before ICU admit Patient vital signs alone may fail to detect Patient vital signs alone may fail to detect
global tissue hypoxiaglobal tissue hypoxia Early presentation may be subtle Early presentation may be subtle
(do not rely on fever alone)(do not rely on fever alone) Early recognition is the key to successful Early recognition is the key to successful
treatmenttreatment
ROLE OF LACTATEROLE OF LACTATE Lactate is a marker of anaerobic Lactate is a marker of anaerobic
metabolism metabolism Indicates global tissue hypoxia, critical Indicates global tissue hypoxia, critical
step is recognition and aggressive step is recognition and aggressive treatmenttreatment
High lactate is associated w/ increased High lactate is associated w/ increased morbidity/mortalitymorbidity/mortality
Chest 2006;130;159-1595Chest 2006;130;159-1595
SEPSISSEPSIS
Sepsis can be thought of as “a process of Sepsis can be thought of as “a process of malignant intravascular inflammation”malignant intravascular inflammation”
End result: a potentially lethal and complex End result: a potentially lethal and complex type of distributive shocktype of distributive shock
Troubling thought: “No autopsy studies have Troubling thought: “No autopsy studies have revealed why patients with sepsis die.”revealed why patients with sepsis die.”
NEJM 2003;348:2 138-150
SO WHAT CAN BE DONE SO WHAT CAN BE DONE TO INTERVENE ? TO INTERVENE ?
EARLY GOAL-DIRECTED EARLY GOAL-DIRECTED THERAPY FOR SEVERE THERAPY FOR SEVERE
SEPSIS AND SEPTIC SHOCKSEPSIS AND SEPTIC SHOCK
Objectives:Objectives:
Define Define Early Goal-Directed TherapyEarly Goal-Directed Therapy (EGDT) (EGDT) for Severe Sepsis and Septic Shockfor Severe Sepsis and Septic ShockReview the literature evaluating EGDTReview the literature evaluating EGDTDiscuss the impact of EGDT for treating sepsisDiscuss the impact of EGDT for treating sepsisDiscuss the importance of fluid resuscitation in Discuss the importance of fluid resuscitation in this patient populationthis patient populationDiscuss how to apply EGDT in the pre-hospital Discuss how to apply EGDT in the pre-hospital environmentenvironment
NEJM 2001;345:1368
Purpose: “to evaluate the efficacy of early goal-directed therapy before admission to the intensive care unit”.
Early Goal Directed TherapyEarly Goal Directed Therapy
“ “The administration of IV fluids, pressors The administration of IV fluids, pressors and transfusion based upon targets for and transfusion based upon targets for central venous pressure, blood pressure, central venous pressure, blood pressure, urine output, mixed venous oxygen urine output, mixed venous oxygen saturation and hematocrit to reduce saturation and hematocrit to reduce mortality in patients with severe sepsis mortality in patients with severe sepsis and septic shock”and septic shock”
HistoryHistory
Physicians at Henry Ford Hospital had Physicians at Henry Ford Hospital had previously established lactate measurement as a previously established lactate measurement as a screening test for severe sepsis screening test for severe sepsis
( (Chest 1996;110:145SChest 1996;110:145S))Prevalence study estimated baseline mortality of Prevalence study estimated baseline mortality of 51% for patients with severe sepsis and septic 51% for patients with severe sepsis and septic shock at their facilityshock at their facility
((Acad Emerg Med Acad Emerg Med 1997;4:402-4031997;4:402-403))
Basis for “standard treatment” arm of protocolBasis for “standard treatment” arm of protocol
NEJM 2001;345:1368-77
CVP: central venous pressure
MAP: mean arterial pressure
ScvO2: central venous oxygen saturation
Early Goal-Early Goal-Directed TherapyDirected Therapy
NEJM 2001;345:1368-77.
49.2%
33.3%
0
10
20
30
40
50
60
Standard Therapy N=133
EGDTN=130
P = 0.01*
*Key difference was in sudden CV collapse, not MODS
Early Goal-Directed Therapy Results:Early Goal-Directed Therapy Results:28 Day Mortality28 Day Mortality
Sudden CV Collapse
MODS
21% vs 10%
p=0.02
22% vs 16%
P=0.27
NEJM 2001;345:1368-77.
Mortality
ResultsResults
Decrease in incidence of sudden Decrease in incidence of sudden cardiopulmonary complications (cardiac cardiopulmonary complications (cardiac arrest), hypotension or acute respiratory arrest), hypotension or acute respiratory failure in the EGDT group (p=0.02)failure in the EGDT group (p=0.02)
Among survivors, EGDT associated with Among survivors, EGDT associated with decreased length of stay (LOS) (p=0.04)decreased length of stay (LOS) (p=0.04)
Key Components:Key Components:
Fluid resuscitation!!Fluid resuscitation!!Appropriate cultures prior to antibiotic Appropriate cultures prior to antibiotic administrationadministrationEarly targeted antibiotics and source Early targeted antibiotics and source controlcontrolUse of vasopressors/inotropes when fluid Use of vasopressors/inotropes when fluid resuscitation optimized resuscitation optimized
The Surviving Sepsis CampaignThe Surviving Sepsis Campaign
Launched in Fall 2002 as a collaborative effort to Launched in Fall 2002 as a collaborative effort to condense management guidelines for sepsis. condense management guidelines for sepsis. Goal: complete “resuscitation bundle” within 6 hoursGoal: complete “resuscitation bundle” within 6 hoursEGDT is the earliest step in the implementation of the EGDT is the earliest step in the implementation of the guidelinesguidelinesGoal: reduce sepsis mortality by 25% in the next 5 yearsGoal: reduce sepsis mortality by 25% in the next 5 yearsGuidelines revealed at SCCM in Feb 2004Guidelines revealed at SCCM in Feb 2004
Critical Care MedicineCritical Care Medicine March 2004 32(3):858-87. March 2004 32(3):858-87. Website: survivingsepsisWebsite: survivingsepsis .. orgorg
Chest 1992;101:1644..
SepsisSIRSSevere Sepsis
SepticShock
Early Goal Directed Therapy
Antibiotics and Source Control
*
The Campaign was associated with The Campaign was associated with sustained, continuous quality improvement sustained, continuous quality improvement in sepsis care.in sepsis care.Although Although not necessarilynot necessarily cause and effect, cause and effect, a reduction in reported hospital mortality a reduction in reported hospital mortality rates was associated with participation. rates was associated with participation. The implications of this study can serve as The implications of this study can serve as an impetus for similar improvement efforts. an impetus for similar improvement efforts.
CONCLUSIONS:
Example:Example:
Cooper Hospital (NJ)Cooper Hospital (NJ)No additional staffingNo additional staffingNo change in physical No change in physical structurestructure+ Close cooperation+ Close cooperationAll targets achieved in All targets achieved in under 6 hoursunder 6 hoursMortality decreased Mortality decreased from 43.8 to 18.2%from 43.8 to 18.2%
Chest 2006;129:225-32
Example:Example:
Carolinas Medical Carolinas Medical Center:Center:9% absolute mortality 9% absolute mortality reduction (33% relative reduction (33% relative risk reduction) after risk reduction) after implementation of implementation of EGDT in their EDEGDT in their ED
((Chest 2007; 132:425-432)Chest 2007; 132:425-432)
EGDT Follow-up Studies:EGDT Follow-up Studies:
Survey of centers in 2006 using EGDT:Survey of centers in 2006 using EGDT:1,298 patient charts reviewed1,298 patient charts reviewedMean mortality pre-EGDT: 44.8 +/- 7.8%Mean mortality pre-EGDT: 44.8 +/- 7.8%Mean mortality post-EGDT: 24.5% +/- 5.5%Mean mortality post-EGDT: 24.5% +/- 5.5%Average reduction in mortality 20.3%Average reduction in mortality 20.3%
(Chest Otero 2006)(Chest Otero 2006)
Cost effectiveness: 23.4% reduction in hospital Cost effectiveness: 23.4% reduction in hospital costs for patients w/severe sepsis/shock costs for patients w/severe sepsis/shock
(Crit Care 2003;7(suppl):S116)(Crit Care 2003;7(suppl):S116)
Q: How does EGDT compare to Q: How does EGDT compare to other emergency interventions?other emergency interventions?
A: It’s HUGE!A: It’s HUGE!
Number Needed to Treat:Number Needed to Treat:
The reciprocal of the absolute risk reduction The reciprocal of the absolute risk reduction between two treatment options in a studybetween two treatment options in a study
NNT = 100 / Absolute Risk ReductionNNT = 100 / Absolute Risk Reduction
NNT for EGDT = 5NNT for EGDT = 5
Other NNT examples*:Other NNT examples*:Aspirin, 12-Lead and PCI with ECG to balloon < 90 minutes Aspirin, 12-Lead and PCI with ECG to balloon < 90 minutes
(NNT = 15)(NNT = 15)ARDS protocol (hospital) ARDS protocol (hospital) (NNT = 12)(NNT = 12)NIPPV for APE NIPPV for APE (NNT = 6)(NNT = 6)
BiPAP for COPD (ED) BiPAP for COPD (ED) (NNT = 10)(NNT = 10)
Clinical hypothermia for cardiac arrest (hospital) Clinical hypothermia for cardiac arrest (hospital) (NNT = 6)(NNT = 6)
Defib on scene < 5 minutes vs. < 8 minutes Defib on scene < 5 minutes vs. < 8 minutes (NNT = 8)(NNT = 8)
Early identification and defibrillation for v. fib Early identification and defibrillation for v. fib (NNT = 3)(NNT = 3)
NNT is a statistic that is meant to be taken in context !!!
Prehospital Emergency Care 2008, Vol 12 (2) 141-151
SummarySummary
24 peer reviewed publications24 peer reviewed publications 2,000 patients2,000 patients
28 published abstracts28 published abstracts 10,000 patients10,000 patients
All cite significant mortality benefit after All cite significant mortality benefit after implementing EGDTimplementing EGDTProven in both the community and Proven in both the community and academic settingacademic setting
Universal Acceptance?Universal Acceptance?
NO, not without it’s critics:NO, not without it’s critics:““Certain components may be more effective”Certain components may be more effective”““Original study only examines 6 hours of a total Original study only examines 6 hours of a total
hospitalization that lasted on avg. 13 days”hospitalization that lasted on avg. 13 days”““Some components impractical in ED” (SvO2)Some components impractical in ED” (SvO2)““Too much work, ties up the nurses”Too much work, ties up the nurses” “ “Better outcomes through more monitoring”Better outcomes through more monitoring”
Crystalloid fluid resuscitation rated as Crystalloid fluid resuscitation rated as “strongly recommended” and supported by “strongly recommended” and supported by “moderate quality of evidence” in SSC “moderate quality of evidence” in SSC literatureliterature
(Intensive care med 2008 Jan;34(1):17-(Intensive care med 2008 Jan;34(1):17-60)60)
In other words:In other words: EARLYEARLY and and AGGRESSIVEAGGRESSIVE
Fluid resuscitation is Fluid resuscitation is
CRITICAL !CRITICAL !
Meta-analysis suggests that early, but not Meta-analysis suggests that early, but not late, hemodynamic optimization reduced late, hemodynamic optimization reduced mortality in patients with sepsis. All mortality in patients with sepsis. All patients received EGDT prior to ICU patients received EGDT prior to ICU arrivalarrival
Crit Care Med Crit Care Med 2002;30:1686-16922002;30:1686-1692
First 6 hours are important both for diagnosis First 6 hours are important both for diagnosis and evaluating effects of therapyand evaluating effects of therapy
Study did not account for EMS interventionStudy did not account for EMS intervention
Has early intervention for the patient with Has early intervention for the patient with severe sepsis or septic shock ever been severe sepsis or septic shock ever been studied in the prehospital environment?studied in the prehospital environment?
Should it be?Should it be?
OUT-OF-HOSPITAL FLUID IN SEVERE SEPSIS: EFFECT ON EARLY RESUSCITATIONOUT-OF-HOSPITAL FLUID IN SEVERE SEPSIS: EFFECT ON EARLY RESUSCITATIONIN THE EMERGENCY DEPARTMENTIN THE EMERGENCY DEPARTMENT
Christopher W. Seymour, MD, Colin R. Cooke, MD, MSCE, Mark E. Mikkelsen,Christopher W. Seymour, MD, Colin R. Cooke, MD, MSCE, Mark E. Mikkelsen,Julie Hylton, BS, Tom D. Rea, MD, MPH, Christopher H. Goss, MD, MSc,Julie Hylton, BS, Tom D. Rea, MD, MPH, Christopher H. Goss, MD, MSc,
David F. Gaieski, MD, Roger A. Band, MDDavid F. Gaieski, MD, Roger A. Band, MD
Objective: “to determine if the delivery of out-of-hospital Objective: “to determine if the delivery of out-of-hospital fluid in patients with severe sepsis is associated with fluid in patients with severe sepsis is associated with reduced time to achievement of goal-oriented reduced time to achievement of goal-oriented resuscitation in the emergency department.”resuscitation in the emergency department.”
Type: Secondary analysis of a retrospective, cohort Type: Secondary analysis of a retrospective, cohort study in a metropolitan setting (Philadelphia) with a two-study in a metropolitan setting (Philadelphia) with a two-tier EMS responsetier EMS response.. Note: the original study evaluated use of EGDT in Note: the original study evaluated use of EGDT in
their Emergency Departmenttheir Emergency Department
Prehospital Emergency Care 14(2) 2010 145-152
Key Question:Key Question:
Is there an association between delivery of Is there an association between delivery of out-of-hospital fluid by advanced life out-of-hospital fluid by advanced life support providers and the achievement of support providers and the achievement of (EGDT) resuscitation endpoints within 6 (EGDT) resuscitation endpoints within 6 hours after triage in the Emergency hours after triage in the Emergency Department?Department?
Twenty-five (48%) of 52 patients Twenty-five (48%) of 52 patients transported by ALS with severe sepsis transported by ALS with severe sepsis received “prehospital fluid”received “prehospital fluid”((note: note: quotations added for sarcastic emphasisquotations added for sarcastic emphasis))
Patients receiving these fluids had lower Patients receiving these fluids had lower mean blood pressure and higher SOFA mean blood pressure and higher SOFA scoresscores
Conclusion:Conclusion:
Pt receiving prehospital IVF “approached” Pt receiving prehospital IVF “approached” but did not attain a statistically significant but did not attain a statistically significant increase in the likelihood of achieving goal increase in the likelihood of achieving goal for MAP w/in 6 hours and showed no for MAP w/in 6 hours and showed no difference in achieving goal of CVP or difference in achieving goal of CVP or ScvO2 while in the emergency ScvO2 while in the emergency department.department.
Is this a good (strong) study?Is this a good (strong) study?How many patients needed to be enrolled in order to How many patients needed to be enrolled in order to show a statistically significant difference between the two show a statistically significant difference between the two groups?groups?
Were the patients in the two groups “equally sick”?Were the patients in the two groups “equally sick”?
Why was it retrospective? Why was it retrospective? Does this help or hurt the study?Does this help or hurt the study?
Reminder: What was the endpoint in the original EGDT Reminder: What was the endpoint in the original EGDT paper? (not the goal)paper? (not the goal)
Why did the authors choose a different endpoint?Why did the authors choose a different endpoint?
Fluid ResuscitationFluid Resuscitation “ “the early, hypovolemic, the early, hypovolemic,
hypodynamic phase of hypodynamic phase of sepsis is treated by sepsis is treated by providing appropriate, providing appropriate, high volume fluid high volume fluid resuscitation… resuscitation… crystalloid solutions crystalloid solutions (6 to 10 L)(6 to 10 L) are are usually required during usually required during the initial resuscitation”the initial resuscitation”Crit Care Med1999;27:639-660Crit Care Med1999;27:639-660
FACT:FACT:One liter of normal One liter of normal saline adds saline adds 275 ml275 ml to the patient’s to the patient’s plasma volumeplasma volume
A Reminder….A Reminder….Gauge Gauge Length Length Flow RateFlow Rate
Minutes/LiterMinutes/Liter2424 0.75" 0.75" 17 mL/min.17 mL/min. 60 6022 22 1.00" 1.00" 28 mL/min28 mL/min 35 352020 1.88" 1.88" 42 mL/min42 mL/min 25 2518 18 1.88" 1.88" 79 mL/min79 mL/min 12.5 12.51616 1.88" 1.88" 147 mL/min147 mL/min 6.8 6.816 16 3.25" 3.25" 127 mL/min 127 mL/min 7.8 7.816 16 5.25“5.25“ 108 mL/min108 mL/min 9.2 9.214 14 1.88" 1.88" 277 mL/min277 mL/min 3.6 3.614 14 3.25" 3.25" 249 mL/min249 mL/min 4.04.014 14 5.25" 5.25" 219 mL/min219 mL/min 4.5 4.512 12 3.00" 3.00" 449 mL/min449 mL/min 2.2 2.210 10 3.00" 3.00" 609 mL/min609 mL/min 1.6 1.6
Indications:Indications:
Appropriate when patient is Appropriate when patient is hemodynamically unstablehemodynamically unstableGoal: Optimize cardiac outputGoal: Optimize cardiac output Increases tissue oxygen deliveryIncreases tissue oxygen delivery Improves tissue oxygenationImproves tissue oxygenation Increases arterial pressure and renal Increases arterial pressure and renal
perfusionperfusion Decreased lacate levelsDecreased lacate levels Improve systemic acidosisImprove systemic acidosis
QUESTIONS:QUESTIONS:
Will I harm my patient?Will I harm my patient?
What about the dialysis patient?What about the dialysis patient?
Back to RiversBack to Rivers
Q: In the EGDT study, which group had a Q: In the EGDT study, which group had a higher rate of intubation and use of higher rate of intubation and use of mechanical ventilation?mechanical ventilation?
A: The Standard care group!A: The Standard care group!
No significant difference in rate of intubation and No significant difference in rate of intubation and MV in first 6 hours in standard care group MV in first 6 hours in standard care group (53.8%) vs. EGDT (53%)(53.8%) vs. EGDT (53%)
From 7 to 72 hours, 16.8% standard care From 7 to 72 hours, 16.8% standard care needed ET/MV vs. 2.6% in EGDT (p < 0.001)needed ET/MV vs. 2.6% in EGDT (p < 0.001)
Intubation at any point during hospitalization: Intubation at any point during hospitalization: 70.6% standard care vs. 55.6% in EGDT70.6% standard care vs. 55.6% in EGDT
(p < 0.02)(p < 0.02)
Back to RiversBack to Rivers
Suggests that the need for ET/MV has Suggests that the need for ET/MV has more to do with failure to resolve SHOCK more to do with failure to resolve SHOCK w/in the first 24 hours rather than w/in the first 24 hours rather than respiratory decompensation later.respiratory decompensation later.
Timing matters!Timing matters!
The Dialysis PatientThe Dialysis Patient
Study in subset EGDT patientsStudy in subset EGDT patients10 standard care, 8 EGDT10 standard care, 8 EGDTET 50% vs. 29% ( p < 0.01)ET 50% vs. 29% ( p < 0.01)Mortality 70% vs. 14% (p < 0.01)Mortality 70% vs. 14% (p < 0.01)Standard care patients received LESS Standard care patients received LESS fluid overall compared to EGDT patientsfluid overall compared to EGDT patients
(Crit Care Med 2004; 8 (Crit Care Med 2004; 8 (suppl)P163(suppl)P163
DON’T WITHOLD IV FLUIDS FROM THEDON’T WITHOLD IV FLUIDS FROM THE
HYPOTENSIVE, SYMPTOMATIC HYPOTENSIVE, SYMPTOMATIC
DIALYSIS PATIENT!!!!DIALYSIS PATIENT!!!!
WarningsWarnings::
Maine EMS has not Maine EMS has not authorized or authorized or endorsed an Early endorsed an Early Goal Directed Goal Directed Therapy or Severe Therapy or Severe Sepsis protocol for Sepsis protocol for EMS providersEMS providers
The Road AheadThe Road Ahead
Why is this important?Why is this important?
Closing ThoughtsClosing Thoughts- The care of the critically ill - The care of the critically ill patient traverses patient patient traverses patient location and depends on (the location and depends on (the timing of) critical actions by timing of) critical actions by multiple health care providers multiple health care providers and must bridge care between and must bridge care between specialties, departments and specialties, departments and facilitiesfacilities
- Sepsis is not an “ICU”-limited - Sepsis is not an “ICU”-limited illnessillness
- Peter Safar, - Peter Safar, MDMD
(1924-2003)(1924-2003)
Dr. Safar’s Roadmap for Dr. Safar’s Roadmap for Performance ImprovementPerformance Improvement
Must have a pre-determined, objective and Must have a pre-determined, objective and comprehensive strategycomprehensive strategyIdentify high risk patients based on early Identify high risk patients based on early signs and symptomssigns and symptomsMobilize resources to interveneMobilize resources to interveneExecute protocol based on best evidenceExecute protocol based on best evidenceContinually assess complianceContinually assess complianceContinually assess outcomeContinually assess outcome
Does this concept of a “bundle of care” Does this concept of a “bundle of care” sound familiar?sound familiar?
AMI, stroke and trauma have all seen AMI, stroke and trauma have all seen improvements in outcome after application improvements in outcome after application of time-sensitive therapies.of time-sensitive therapies.
(as well as teamwork)(as well as teamwork)
ALL HAVE MULTIPLE CRITICAL ALL HAVE MULTIPLE CRITICAL PREHOSPITAL INTERVENTIONS!!PREHOSPITAL INTERVENTIONS!!
Closing ThoughtsClosing Thoughts- Patient care is improved when - Patient care is improved when key interventions are initiated in key interventions are initiated in the pre-hospital setting for a the pre-hospital setting for a variety of time-dependent variety of time-dependent emergenciesemergencies
- Evidence-based medicine is - Evidence-based medicine is going to shape how the practice going to shape how the practice of emergency medicine in the of emergency medicine in the pre-hospital setting evolvespre-hospital setting evolves
- A preponderance of high quality, - A preponderance of high quality, peer-reviewed medical literature peer-reviewed medical literature proves that EGDT improves proves that EGDT improves patient mortality and is cost and patient mortality and is cost and time-efficienttime-efficient
- Photo courtesy of Dan Limmer, used with permission
Closing ThoughtsClosing Thoughts- Early and aggressive fluid - Early and aggressive fluid resuscitation for the symptomatic, resuscitation for the symptomatic, hypotensive septic patient is hypotensive septic patient is CRITICAL!CRITICAL!- This strategy is well-supported - This strategy is well-supported by a wide body of peer-reviewed by a wide body of peer-reviewed literatureliterature- There is still ample ground for - There is still ample ground for improvement and research improvement and research concerning the benefit of concerning the benefit of prehospital intervention for the prehospital intervention for the septic patientseptic patient
VISION OF CRITICAL CAREVISION OF CRITICAL CARE““Critical care is a concept, Critical care is a concept, not a location, which not a location, which frequently begins with ED frequently begins with ED intervention and intervention and culminates in intensive culminates in intensive care unit admission and care unit admission and continued management.”continued management.”
Peter Safar, MDPeter Safar, MD (1924-2003)(1924-2003)
Clin Anesth 1974; 10:65-125
Questions?Questions?
