Sepsis in the Emergency Department: Improvements in Rapid Assessment and Treatment

Topics: Intensive care medicine, Systemic inflammatory response syndrome, Sepsis Pages: 7 (2243 words) Published: December 5, 2013
Abstract
Sepsis remains one of the most deadly diseases in the country. According to the literature, a majority of sepsis cases filter though the Emergency department. The diagnosis and treatment of sepsis are complex and the barriers to improving these things are even more intricate but the fact remains that improvement of sepsis care begins in the ED. Early recognition of sepsis using the SIRS criteria followed by multidisciplinary rapid response diagnostic testing and treatment are the keys to improvement of sepsis care in the ED.

Introduction
Sepsis is defined by the Surviving Sepsis Campaign (SSC) as “the presence (probable or documented) of infection together with systemic manifestations of infection” (Dellinger et al., 2013). Severe sepsis is defined by the SSC as “sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion” (Dellinger et al., 2013). Despite advances in treatment modalities, the current literature reports mortality for severe sepsis and septic shock ranges from 20% to 60% (Burney et al., 2012; Dickinson & Kellef, 2011; Turi & Von, 2011) making it the 10th leading cause of death in the United States. The prevalence of sepsis is markedly higher among the elderly population and rises exponentially after the age of 65 (Gaieski et al., 2010). With the baby boomer generation now approaching this age, systematic and effective treatment of sepsis has never been more important. Severe sepsis until the last decade was a grossly under recognized and undertreated illness. Although treatment protocols have improved impart due to the Surviving Sepsis Campaign, there exists an urgent need for improvement of prompt, methodical and aggressive care of severe sepsis and septic shock. More than 500,000 cases of severe sepsis are initially managed in US emergency departments annually with an average ED length of stay for these patients of 5 hours (Wang et al., 2007). The SSC strongly recommends seven, time sensitive, initiatives. Within three hours of suspected, or diagnosed sepsis, the clinical team must measure lactate level, obtain blood cultures, administer broad spectrum antibiotics, and correct any hypotension or lactic acidosis with the administration of 30mL/kg crystalloid. Within 6 hours, the SSC recommends applying vasopressors for sustained hypotension, measuring central venous pressure (CVP) and central venous oxygen saturation (Scvo2) and remeasuring lactate if initial lactate was elevated (Dellinger et al., 2013). What is not obviously evident in these recommendations is the workload associated with completing these tasks, which for nurses, includes inserting multiple large bore IV’s, multiple blood draws, assisting with invasive procedures and for physicians includes inserting invasive lines and managing a critically ill patient. This puts a huge emphasis as well as a burden on the ED, for the improvement in recognition and initial management of sepsis. Definitions of Sepsis

Sepsis is a physiologic response to an infection that begins with the systemic inflammatory response syndrome (SIRS). SIRS, originally defined in 1992, is characterized by a presence of two of the following five physiologic changes: 1.Body Temperature < 98.6° F or > 100.4° F

2.Heart rate > 90/min
3.Respiratory Rate >20/min
4.Hyperventilation, indicated by a PaCO2 of 12,000/uL or the presence of >10% immature neutrophils (Simpson & Pitts, 2010)
Severe sepsis is the presence of sepsis with the presence of organ failure separate from the site of infection. The hallmark signs of organ failure summarized by the American College of Chest Physicians includes: 1.Hypotension

2.Renal failure that manifests as a creatinine value increase > 0.5 mg/dL, poor urine output (defined as < 0.5 mL/kg for ≥ 1 h), or the need for renal replacement therapy 3.Altered mental status (from individual patient baseline)

4.Thrombocytopenia (< 100,000 platelets/mL)
5.Respiratory failure that manifests by arterial...

References: Dellinger, R., Levy, M., Rhodes, A., Annane, D., Gerlach, H., Opal, S., & ... Moreno, R. (2013). Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Medicine, 39(2), 165-228.
Dickinson, J., & Kollef, M. (2011). Early and adequate antibiotic therapy in the treatment of severe sepsis and septic shock. Current Infectious Disease Reports, 13(5), 399-405.
Miano, T. A., Powell, E., Schweickert, W. D., Morgan, S., Binkley, S., & Sarani, B. (2012). Effect of an antibiotic algorithm on the adequacy of empiric antibiotic therapy given by a medical emergency team. Journal Of Critical Care, 27(1), 45-50.
Simpson, S., & Pitts, L. (2012). Rapid treatment of severe sepsis. Pulmonary Critical Care Sleep Update, 25(26).
Wang, H., Shapiro, N., Angus, D., & Yealy, D. (2007). National estimates of severe sepsis in United States emergency departments. Critical Care Medicine, 35(8), 1928-1936.
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