This issue includes 4 hours of ACEP/AMA category 1 CME credit.
Authors: Ethan Booker, MD
Peer Reviewers: Steven J. Schwartz, MD and Amish Shah, MD, MPH
Publication Date: May 1, 2008
Excerpt from the issue… As you start your shift, you’re handed the chart of an 82-year-old nursing home patient with urosepsis who is waiting for a bed. Your colleague remarks, “She got some fluids, the antibiotics are in, she looks good, and she’s much more ‘with it’ now. The family says she’s pretty much at baseline mental status now. She’s headed to the floor in a bit.”
Later in your shift, you see a 43-year-old male with a history of well-controlled diabetes but no other medical history. He presents awake, alert, but ill appearing and short of breath. Over the next few hours he becomes febrile and confused. His respiratory status declines, and he requires intubation. His blood pressure is difficult to support despite aggressive fluid resuscitation and vasopressors. His blood glucose is greater than 600, his blood lactate level was elevated on arrival, and it further increased prior to transfer to the ICU. His creatinine is very elevated and he develops DIC. He requires 1-to-1 nursing with additional help from other staff and a considerable amount of your time, essentially grinding your ED to a halt. Upon moving the patient to the ICU, you report to the admitting intensivist, “This guy is really septic.” In following up on the patient, you discover that he expired after 48 hours in the ICU.
In reviewing the shift, it occurs to you that the same diagnostic label was applied to a disease process in which an 82-year-old nursing home patient recovered largely in the ED and went to the floor while a reasonably healthy younger person became desperately ill and expired in an ICU.
Is this really the same disease process? Are there symptoms, signs, or tests that accurately identify patients with infections that are likely to become septic? Are there interventions in the ED that could improve the chance of survival of the young man above?
Conclustion of the above case study... Returning to our initial cases: The decision to admit a nursing home patient to a medical ward after therapy in the ED was informed by the use of a MEDS score78 and a lactate level64 to determine a low risk of mortality and to identify a patient unlikely to require or benefit from more aggressive interventions and unlikely to need subsequent transfers to the ICU.
As for the second case, our ability to review pathophysiology and prognostic indicators of poor outcome reveal a patient with increasing rather than improving lactate, altered mental status, DIC, and multi-organ failure. His blood cultures return positive with a Gram-negative organism in less than 24 hours. His chance of survival is very small. The application of a goal-directed therapeutic plan with aggressive volume correction, optimized oxygen delivery, prompt delivery of antibiotics with activity against the responsible organism, support of cardiac output and function, and possibly the addition of specific medications for reversal or moderation of sepsis physiology may result in improvement. This may include a decreasing lactate4 preserved or improving cardiac performance, a normal or near normal glucose, replacement steroids for a dysfunctional adrenal gland, and replacement of depleted blood products, such as oxygen-carrying hemoglobin or even coagulation cascade products like protein C.
About this article: Application of the available evidence can have an immediate impact in reducing morbidity, mortality, and even cost in sepsis care. This issue of Emergency Medicine Practice presents a best-evidence approach to the management of sepsis. It focuses on the pathophysiology, identification, and classification of sepsis, early interventions, implementation of graded, systematic responses targeting the most aggressive care to the appropriate patients, and disposition encouraging enhanced synergy with intensivists.
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