Sepsis Prehospital Care

Hey guys,

This is the second half of sepsis blogs. Go to the first blog “Defining Sepsis”

While experts are still working on the definition and better screening tools to give us the guidelines for the management of sepsis and septic shock, how do we actually apply the current best evidence to our practice in the prehospital environment?

Protocolised care vs. personalised care

Quick history…
There was no standard management for sepsis in ED till 2001. A protocol based approach called “Early Goal Directed Therapy (TGDT)” was first introduced in 2001 (Rivers et al., 2001). Multiple studies reconfirmed the benefit of this approach that resulted in EGDT largely adopted in the SSC guidelines. However, a trio of more recent studies (ProCESS, ARISE, and ProMISe) did not show any benefit of protocolised care compared to empiric care. Along with findings of protocalised care may be harmful to some patients, experts are calling for the importance of personalised sepsis management.

To reflect this statement, one of the most popular quotes at SMACC conference was by Dr Paul Marik stating;

“Algorithms makes stupid people even stupider, and algorithms makes even experts stupid.”

You MUST check out this amazing debate by the world experts.

 

However….

While the importance of personalised care is strongly highlighted within the expert group, it may not be directly applicable to us. This point was also raised by one of the panels of discussion from Brazil questioning the safety of not having the algorithm or protocalised care in the less developed countries or communities where there is no expert skill or equipment available.

Paramedics need a guidelines that allows the right level of autonomy while gives enough guidance. As mentioned last week our current CPG is actually very good!

The real message here is t;

“Look at the patient instead of looking at the monitors”

We don’t have blood analysis, CVP monitoring, CT, ultrasound, etc, however, novice paramedics still do tend to rely too much on findings such as SPO2, ECG.

This teaching is not new to us, and this is a good reminder for any assessment that we do.

Treatment

Antibiotics
Consensus agreement still indicates the early use of broad-spectrum antibiotics.
I understand St John is replacing ceftriaxone with ABs targeting more common microorganisms in the next CPG update. Although paramedics also need to play a responsible role in the prevention of unnecessary AB resistance, we need to be aggressive in giving ABs for septic shock patients.

Fluid therapy
Fluid Expansion as Supportive Therapy (FEAST) study (Maitland et al., 2011) showed aggressive fluid resuscitation, although resolving shock more frequently, was associated with a significant increase in mortality. As a result, giving 6~8l of fluid had become the thing of the past, and this part of the world down under is a strong advocate for the restricted use of fluid.
Discussions for the use of different types of fluid and adverse effects, such as acidosis, with the use of normal saline are ongoing, and its implication for us in the prehospital environment is still largely unknown.

Vasopressors
Although noradrenaline is the recommend first line vasopressor, adrenaline is found to be just as effective and is a good alternative or addition to noradrenaline. As we should be mindful of the fluid overload, it’s no brainer for the clever use of adrenaline infusion to maintain minimum end-organ perfusion (MAP>65mmHg or higher for chronic HTN).
Peripheral administration of vasopressors appears safe but we still need to be mindful of extravasation causing ischaemic injury, and make sure the IV access is patent. I would do my best to avoid IV access for the purpose of vasopressor administration in the back of hands or ACF if possible.

See my reference below for the basic understanding of vasopressors, but if you have a good understanding on vasopressors, check out;

http://emcrit.org/pulmcrit/epinephrine-challenge-septic-shock/

We must remember the severe sepsis and septic shock management requires expert care, and we are blessed with relatively short transport time to the expert help in Canterbury.

My thoughts in summary are;

Important take home points

  • Early (and correct) recognition
  • Early antibiotics when appropriate
  • Early delivery to expert care

Management principle

  • Look at the patient instead of looking at the monitors and numbers.
  • Use our CPG criteria but also consider qSOFA, MEWS if additinal tools are required.
  • Be aggressive with AB if septic shock, but hold off if mild sepsis * Exactly what our current CPG say – aggressive but no blanket, prophylactic approach.
  • Use fluid and vasopressor (adrenaline infusion) as per CPG but avoid excessive fluid overload (aiming for MAP>65mmHg after the initial resus = 500ml challenges and total 2l for adults)
  • If unsure, call back up or consult the clinical desk early.

………………………………………………

If you are yet to explore this fascinating subject, I hope this is thought provoking and give you somewhere to start to deepen the understanding of sepsis/septic shock.

 

Reference

Fantastic series of sepsis related podcasts (EMCrit)

Arrigo, M., & Mebazaa, A. (2015). Understanding the differences among inotropes. Intensive Care Medicine, 41(5), 912–915. http://doi.org/10.1007/s00134-015-3659-7

Avni, T., Lador, A., Lev, S., Leibovici, L., Paul, M., & Grossman, A. (2015). Vasopressors for the Treatment of Septic Shock: Systematic Review and Meta-Analysis. PLoS ONE, 10(8), e0129305. http://doi.org/10.1371/journal.pone.0129305

Dellinger, R. P., Jaeschke, R., Osborn, T. M., Nunnally, M. E., Townsend, S. R., Reinhart, K., … Douglas, I. S. (2013). Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Medicine, 39(2), 165–228. http://doi.org/10.1007/s00134-012-2769-8

Head, L. W., & Coopersmith, C. M. (2016). Evolution of Sepsis Management: From Early Goal-Directed Therapy to Personalized Care. Advances in Surgery. http://doi.org/10.1016/j.yasu.2016.04.002

Kaukonen K, Bailey M, Suzuki S, Pilcher D, & Bellomo R. (2014). Mortality related to severe sepsis and septic shock among critically ill patients in australia and new zealand, 2000-2012. JAMA, 311(13), 1308–1316. http://doi.org/10.1001/jama.2014.2637

Leone, M., Asfar, P., Radermacher, P., Vincent, J.-L., & Martin, C. (2015). Optimizing mean arterial pressure in septic shock: a critical reappraisal of the literature. Critical Care, 19(1), 101. http://doi.org/10.1186/s13054-015-0794-z

Levy, M. M., Fink, M. P., Marshall, J. C., Abraham, E., Angus, D., Cook, D., … Ramsay, G. (2003). 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Medicine, 29(4), 530–538. http://doi.org/10.1007/s00134-003-1662-x

Maitland, K., Kiguli, S., Opoka, R. O., Engoru, C., Olupot-Olupot, P., Akech, S. O., … Gibb, D. M. (2011). Mortality after Fluid Bolus in African Children with Severe Infection. New England Journal of Medicine, 364(26), 2483–2495. http://doi.org/10.1056/NEJMoa1101549

Marik, P. E. (2014). Early Management of Severe Sepsis: Concepts and Controversies. Chest, 145(6), 1407–1418. http://doi.org/10.1378/chest.13-2104

Mouncey, P. R., Osborn, T. M., Power, G. S., Harrison, D. A., Sadique, M. Z., Grieve, R. D., … Rowan, K. M. (2015). Protocolised Management In Sepsis (ProMISe): a multicentre randomised controlled  trial of the clinical effectiveness and cost-effectiveness of early, goal-directed, protocolised resuscitation for emerging septic shock. Health Technology Assessment (Winchester, England), 19(97), i–xxv, 1-150. http://doi.org/10.3310/hta19970

Myburgh, J. A., Higgins, A., Jovanovska, A., Lipman, J., Ramakrishnan, N., Santamaria, J., … the CAT Study investigators. (2008). A comparison of epinephrine and norepinephrine in critically ill patients. Intensive Care Medicine, 34(12), 2226–2234. http://doi.org/10.1007/s00134-008-1219-0

Nguyen, H. B., Jaehne, A. K., Jayaprakash, N., Semler, M. W., Hegab, S., Yataco, A. C., … Rivers, E. P. (2016). Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE. Critical Care (London, England), 20(1), 160–160. http://doi.org/10.1186/s13054-016-1288-3

Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., … Tomlanovich, M. (2001). Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. New England Journal of Medicine, 345(19), 1368–1377. http://doi.org/10.1056/NEJMoa010307

Semler, M. W., & Rice, T. W. (2016). Sepsis Resuscitation: Fluid Choice and Dose. Sepsis, 37(2), 241–250. http://doi.org/10.1016/j.ccm.2016.01.007

Shankar-Hari M, Phillips GS, Levy ML, & et al. (2016). Developing a new definition and assessing new clinical criteria for septic shock: For the third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA, 315(8), 775–787. http://doi.org/10.1001/jama.2016.0289

Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., … Angus, D. C. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA: Journal of the American Medical Association, 315(8), 801–810. http://doi.org/10.1001/jama.2016.0287

The ARISE Investigators and the ANZICS Clinical Trials Group. (2014). Goal-Directed Resuscitation for Patients with Early Septic Shock. New England Journal of Medicine, 371(16), 1496–1506. http://doi.org/10.1056/NEJMoa1404380

The ProCESS Investigators. (2014). A Randomized Trial of Protocol-Based Care for Early Septic Shock. New England Journal of Medicine, 370(18), 1683–1693. http://doi.org/10.1056/NEJMoa1401602

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