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 NB: Xigris (rec Act protein C) has been withdrawn from the market – cos it didn’t work….
This means taking multiple blood cultures, urine, sputum, line samples or pus swabs from wherever the patient needs it.
The concept of a single set of cultures is not really good enough if you want to identify the cause.
This is analogous to the Massive transfusion stuff – if you can find a site which you can treat surgically – then they should get that done ASAP. If you think it is the IDC or the PICC – then remove it ASAP.
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!”
The Guidelines recommend giving IV ABs within 1 hour of diagnosis of “sepsis”. However, then the question is – which ones? The answer is complex – but in summary:
- 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)
In case you have been living under a rock, the concept of Early Goal Directed Therapy was championed in the early 2000’s by Dr Emmanuel Rivers “game-changing” trial. The concept is simple enough, but can be harder to achieve.
- 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