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Emergency Management of Sepsis

Emergency Management of Sepsis
Author Information (click to view)

David N. Williams, MD

Professor of Medicine and Infectious Disease
Hennepin County Medical Center
University of Minnesota

David N. Williams, MD has indicated to Physician’s Weekly that he has no financial disclosures to report.

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David N. Williams, MD (click to view)

David N. Williams, MD

Professor of Medicine and Infectious Disease
Hennepin County Medical Center
University of Minnesota

David N. Williams, MD has indicated to Physician’s Weekly that he has no financial disclosures to report.

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Studies have shown that rates of sepsis have steadily increased over the past decade and account for 2% of all hospital admissions. Nearly half of sepsis patients are eventually managed in ICU settings and account for more than 10% of all ICU admissions overall. Today, more than 750,000 patients are seen each year for sepsis and sepsis-related conditions in the United States, accounting for 4% of all inpatient costs.

In response to increasing sepsis trends, “sepsis pathways” have been developed in hospital settings, aimed at targeting clinical, regulatory, and coding issues that are designed to ultimately improve patient outcomes. The Surviving Sepsis Campaign, for example, has enhanced the public and clinical awareness of sepsis. As a result, evidence-based guidelines have been adopted in an effort to improve severe sepsis and septic shock outcomes by facilitating early identification and evidence-based management.

Taking a Bundled Approach

“Sepsis bundles” have emerged in various forms in an effort to simplify the complex processes of care required for assessing and managing septic patients. The ultimate goals of these bundles are to use evidence-based processes, which when implemented, collectively improve outcomes beyond the effect of any single measure. Although outcomes are difficult to quantify, recent data support processes for early sepsis recognition and strategic interventions. After implementing sepsis bundles, several published studies have demonstrated decreases in mortality and hospital and ICU length of stay, with corresponding rates improving as more hospitals comply with sepsis-related bundle practices.

The Role of Blood Cultures

In addition to strategic interventions, the early collection of laboratory blood cultures is also demonstrating value in the identification and management of sepsis. One prospective study evaluated the individual components of the Surviving Sepsis Campaign and their association with survival in patients with severe sepsis/septic shock. This analysis showed that early administration of antimicrobials (120 minutes or less from sepsis identification) and early blood culture obtainment were the only interventions associated with lower mortality.

Despite its potential advantages, the use of blood cultures remains controversial in sepsis care, and questions persist as to when and how many blood cultures are needed. Recognition of the importance of obtaining blood cultures prior to administering antimicrobials remains a critical goal within sepsis guidelines and highlights the value of a timely and accurate diagnosis. To appropriately consider antimicrobial therapy, clinicians often rely on microbiological confirmation and susceptibility testing that results from positive blood cultures. As hospitals strive to implement sepsis programs and customize screening tools, blood culture obtainment should be required to further our ability to accurately diagnose patients in the fight against sepsis.

Readings & Resources (click to view)

Bone RC, Sibbald WJ, Sprung CL. The ACCP-SCCM consensus conference on sepsis and organ failure. Chest. 1992;101:1481-1483.

Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31:1250-1256.

Walraven C Van, Wong J. Independent influence of negative blood cultures and bloodstream infections on in-hospital mortality. BMC Infect Dis. 2014;14:1-11.

Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29:1303-1310.

Lagu T, Rothberg MB, Shieh M-S, Pekow PS, Steingrub JS, Lindenauer PK. Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003 to 2007. Crit Care Med. 2012;40:754-761.

Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39:165-228.

Rivers E, Nguyen B HS et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-1377.

Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34:1589-1596.

Gaieski DF, Mikkelsen ME, Band R, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med. 2010;38:1045-1053..

Levy MM, Rhodes A, Phillips GS, et al. Surviving sepsis campaign: association between performance metrics and outcomes in a 7.5-year study. Crit Care Med. 2015;43:3-12.

Parikh K, Davis AB PP. Do we need this blood culture? Hosp Pediatr. 2014;4:78-84.

Moore LJ, Jones SL, Kreiner L a, et al. Validation of a screening tool for the early identification of sepsis. J Trauma. 2009;66:1539-1546.

1 Comment

  1. Use of Blood Cultures prior to ATB Rx, and implementation of early ATB Rx is an oversimplification of the real issues that effect and lead in the actual survival chances of patients arriving to the ER with Sepsis and Septic Shock. As important is to recognize the high prevalence of Staph Aureus MRSA, with its increasing trends and incidence rates, specially among the Elderly, specially those with frequent falls, with the cause of falls likely to be a “hidden” or occult focus of infection. Instituting “Dual Mode” of empirical ATB-Rx aiming at treating Staph Aureus MRSA early on, pending results of Blood Cultures, admission to the ICU (without delay in the ER), preparing the patient with Central Lines for vascular access, institution of Vasopressors (cardiac ionotropics), and ear;y recognition of Multi-Organ System Failure, are crucial in order to achieve success rates of the survival of this Fragile & Vulnerable patient population.

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