Sepsis

EM Clerkship

Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD

Health & Fitness, Science, Education, Medicine, Life Sciences

4.9 • 816 Ratings

🗓️ 1 April 2018

⏱️ 8 minutes

🔗️ Recording | iTunes | RSS

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Summary

Sepsis guidelines are constantly changing. Refer to your national guidelines or institutional protocol for most up to date treatment information.

Introduction

* Sepsis is bad and needs to be treated aggressively* Confusion around multiple conflicting guidelines and requirements* Surviving Sepsis Campaign recommendations* CMS requirements* Sepsis-3* SOFA/SIRS/qSOFA* Institutional protocols

Sepsis-3 Proposed Recommendations

* Screen for sepsis by applying qSOFA instead of SIRS criteria* qSOFA criteria* Altered mental status* Tachypnea* Hypotension* SIRS criteria* Tachycardia* Tachypnea* Leukocytosis* Hyper/hypothermia* qSOFA criteria miss cases of sepsis (too specific)* SIRS calls everything “sepsis” even if the patient is fine (too sensitive)* Change definition of “Sepsis” (no more SIRS plus source)* New definition* Source of infection* PLUS* Organ disfunction* Determined by SOFA score (different purpose than qSOFA)* Eliminate the term “severe sepsis” completely* Redefine “septic shock”* Persistent hypotension* OR * Lactic acid >4

Current Approach to Sepsis

* Step 1- If the patient has SIRS plus source* Get labs including a lactic acid* Step 2- If the patient has organ dysfunction* Diagnose sepsis* Step 3- If the patient has sepsis* Order broad spectrum antibiotics* Order blood cultures* Needs to be completed in <3 hours* Step 4- If the patient has persistent hypotension or lactate >4* Diagnose septic shock* Step 5- If they have septic shock* Give 30ml/kg crystalloid bolus* Start vasopressers if hypotension doesn’t improve with bolus

Additional Reading

* CMS Sepsis Core Measures (ACEP)* Sepsis-3 Recommendations (EMJ)* Surviving Sepsis Campaign (SCCM)

Transcript

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0:00.0	Hello, med students. My name is Zach Olson and thank you for downloading this week's episode of the EM
0:06.5	Clerkship Podcast. When I put out my last sepsis episode, it was right around the time of
0:15.8	sepsis three and a new set of surviving sepsis recommendations. And my episode was just a little bit outdated.
0:24.4	I left some of that new stuff out on purpose, actually, because I wanted to see how things
0:28.6	settled out. But I think it's time to go over everything again. I'm starting to get confused on
0:33.6	my shifts. It turns out in the end, not a lot had changed really from the last episode,
0:40.1	but when you talk about this with your attending now, after listening to this today, you're
0:44.9	going to sound much more knowledgeable and updated. So I do think this is valuable for you to hear,
0:50.7	even though not a lot has changed as far as management.
0:59.7	What you need to know, everybody still agrees that sepsis is bad.
1:07.0	But the current problem, and it is a problem, is you have CMS with their rules,
1:12.8	you have surviving sepsis campaign with their rules, you have sepsis three with their rules. And then you have each hospital now with their take on things. And it's all different.
1:17.4	It's a disaster. It's a complete disaster. It's super confusing. There's no standard of care.
1:23.9	It started with sepsis three. Spsis three was a new set of proposed recommendations, and sepsis three proposed four things.
1:39.1	First, sepsis three wanted to completely get rid of SERS for sepsis screening and replace it with something
1:46.5	called Q SOFA. Those SERS criteria you learned, they wanted to eliminate them, make it so they
1:54.2	have no place in ED triage ever again, with the argument being that too many people had SERS who didn't have
2:02.7	sepsis, that SERS was way too sensitive and bringing in too many false positives.
2:10.5	So they recommended screening with something called Q Sofa, a different score instead.
2:17.7	Q Sofa was much more specific.
2:21.2	And QSofa was only three things.
2:23.1	Altered mental status, tachypnea, and hypotension.
	...

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