Sepsis: the first “Golden” hour
Last post we looked at trying to sort the sick patients from the rest in ED – the goal is to identify them early. Great – but why is this important?
The evidence from the huge trials all over the world has come up with a lot of data supporting the concept that Early Goal Directed Therapy (EGDT), early appropriate antibiotics and source control are the keys to improving the outcomes for these sick patients. If you work in a remote place – then early evacuation to a larger centre would seem prudent – as these people need 24 hour monitoring and this is hard to do in a small hospital.
The Surviving Sepsis Campaign has produced a nice single page set of Guidelines (click). Ithink there are a number of strategies that come out of this that need to be done in the ED. NB: Xigris (rec Act protein C) has been withdrawn from the market – cos it didn’t work….
The concept of a single set of cultures is not really good enough if you want to identify the cause.
Source control probably makes more difference than any other intervention over the next few days.
If you are in a remote location and have a possible abscess somewhere that needs surgical drainage – then early evacuation is key – do’t rely on the IV ABs. As they say: “if there’s pus about, cut it out!”
- Go broad-spectrum initially – one or more ABs that you believe will cover the suspected sites in this patient.
- If you are not sure – then call your local friendly Microbiologist for advice.
- Tailor this to the scenario – is this a chemo patient? are they at risk of Melioidosis (Broome bug)
- There is some evidence that using the wrong agent can actually result in a worse outcome (Kumar, in Chest 2009)
- Aggressive initial fluid resuscitation
- Goal-directed resuscitation – target therapy to MAP, CVP, SVCO2, lactate clearance
- Transfusion to optimise Hb / oxygen carriage
OK that is the thumbnail sketch of the strategies for the early management of sepsis. Will add some flow diagrams when I get around to it
Casey
Any Place for Race on the Coalface?
Clinical case 067: awake intubation procrastination.
First10EM Journal Club: Jan 2021
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
Hi Casey,
Just one quibble – the surviving sepsis guidleines mention using Recombinant Activated Protein C (Xigris). This was recently withdrawn from the market following a trial which showed no benefit from using it. At $25000 a course it’s a pity that this wasn’t realised sooner.
Thanks Roy. As always an eye for detail and the fiscal bottom line
You will be pleased to know I never prescribe Xigris! It costs more than an intern and is proven to be inefficacious ( unlike our interns)
That’s a great summary Casey, thanks, and for the interesting blog.
I’ve just got back from the UK Intensive Care Society’s State of the Art meeting, where the lead for the Surviving Sepsis Campaign was talking about some changes to the SSG. New guidelines out next year, but they are dropping the ‘management’ bundle entirely- No Xigris, steroids out, glucose control out. Appropriate TV ventilation still in somewhere, but I think they feel that is now basic management and almost universally recognized.
In terms of what you’ve written here, all will still be right I think. The early Mx recommendations are basically unchanged- triage with lactate, early fluid bolus (crystalloid- colloid no longer recommended), Broad spectrum Abx, source control. If requires pressors, noradrenaline (have dropped the ‘or dopamine’).
I think they are planning to publish the new set early next year. Have the Australian CICM now accepted the SSC guidelines? Last I’d heard, they felt they weren’t right…