Glenn G. Druckenbrod, M.D. Medical Director Department of Emergency Medicine Inova Fairfax Hospital

Glenn G. Druckenbrod, M.D.
Medical Director
Department of Emergency Medicine
Inova Fairfax Hospital
Best Practices, Inc.
Ponte Vedra 6/21/2012
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40 year old male
c/c – HA, abdominal pain, feels weak
PMH – HBP
Vitals – 104/68, P – 114, RR – 22, T – 98.9
PE – Looks well, AAO X 3, Mild suprapubic tenderness
Labs – WBC 9.9, BUN/Cr – 24/1.9, U/A – 5 – 10 WBCs, lactate 2.4
Treatment –One liter IV NS, IV ABX
Repeat vitals – 101/64, P – 118, RR - 24, T – 98.7
Admitted to the floor
Ponte Vedra 6/21/2012
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Four hours after admission “rapid response” called for
BP 60/p
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Eventual diagnosis: prostatitis
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Blood cultures positive for E. Coli
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Sepsis clues –
persistent tachycardia
 BP (relatively) low for a hypertensive patient
 Increasing RR
 Elevated creatinine
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Provider discounted sepsis risk because –
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The patient looked “well”
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Tachycardia noted and was the reason for admission
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Elevated creatinine thought due to dehydration
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RR on chart never noted
Ponte Vedra 6/21/2012
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60 year old female
Throat cancer, recent chemo with c/c of weakness, difficulty
eating, sore throat and no fever by history
BP - 97/52, P – 126, RR – 25 (non labored), T – 99oF
PE – looks well, mucous membranes dry
Labs – WBC 0.8, BUN/Cr 44/1.9, Lactate 2.8, CXR RLL
consolidation
Subsequent vitals – 104/56, P - 129, RR - 29 and 118/57, P – 129,
RR – 28, T – 98.7
Treatment – NS X 1 L, Zosyn and Vancomycin
Admit intermediate care (i.e., ICU step down)
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Dropped blood pressure within 4 hours
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Transferred to ICU
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Eventually succumbed
Ponte Vedra 6/21/2012
Sepsis clues –
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BP
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Pulse
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RR
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Renal insufficiency
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Immune status
Ponte Vedra 6/21/2012
Provider follow-up –
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Patient looked good despite vitals
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Recognized immune state
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Pulse felt secondary to dehydration and underlying debilitated
status
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RR noted but not processed. No evidence of distress
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Creatinine elevation caused by dehydration
Ponte Vedra 6/21/2012
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60s female BIBA difficult to arouse. PMH remarkable for recent
kidney stone, on narcotic pain medication. Denies other
symptoms.
Vitals – 77/45, P – 94, RR – 22, T – 97.1oF
PE – awake and alert, oriented X 3. Abd: min L tend, + L flank
tenderness
Labs – WBC 10.7, BUN/Cr 70/5.5, Lactate 3.4, D-dimer 4067, UA
10-15 WBC
Subsequent vitals – 82/50, P – 96 and 95/55, P – 109
Initially admitted to step down unit, ABX 4 hours after arrival.
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While boarding in ED patient suffered cardiac arrest: successfully
resuscitated
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Blood and urine cultures positive.
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Infected, obstructed kidney stone
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Sepsis clues –
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Renal insufficiency
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Hypotension
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Elevated lactate
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Elevated D-dimer
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Tachypnea
Ponte Vedra 6/21/2012
Provider follow-up
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BP felt secondary to narcotics
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Renal status from stone
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Lactate noted, uncertain of significance
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D-dimer level not understood
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Sepsis
Early goal directed therapy (EGDT)
in treatment of severe sepsis
and septic shock. *
*Rivers, et al Nov 8
th
2001 in NEJM
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Mortality:
•Standard Therapy – 46.5%
•EGDT – 30.5%
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Mortality Benefit*:
•Thromobolytics – 12%
•PCI – 7%
*Danami-2 Study 2002
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Adjusting cardiac preload, afterload and
contractility to balance oxygen delivery with
oxygen demand.
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River’s Study:
•263 patients
•130 EGDT- 30.5% mortality
•133 Standard Therapy – 46.5% mortality
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Keys to EGDT
Central Venous Catheter capable of central venous O2 sat.
6 Hours of intense treatment in the ED.
500 CC boluses q30 minutes for CVP 8-12 mm/hg.
MAP <65 mm/hg vasopressors utilized.
MAP >90 mm/hg vasodilators utilized.
Central Venous O2 sat of <70% RBC’s transfused to HCT of 30.
Optimized patients had Dobutamine begun if central venous O2 sat
remain <70.
• Mechanical ventilation and sedation for non optimized patients to
reduce O2 demand.
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Sepsis – Presence of infection in
conjunction with the systemic
inflammatory response syndrome (SIRS).
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SIRS
Two or more of the following:
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Source of infection
Lactate >4
Temperature <36C or >38C
HR >90 BPM
RR >20 or PACO2 <32
WBC >4,000 or >12,000 or bands >10%
Ponte Vedra 6/21/2012
Severe Sepsis – Sepsis with evidence of organ
dysfunction
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Altered mental status
Creatinine increase >0.5 mg/dl from baseline
Coagulation abnormalities
Thrombocytopenia
Oliguria
Arterial hypoxemia
Ponte Vedra 6/21/2012
Septic Shock
Severe sepsis and hypotension unresponsive to
20 cc/kg bolus
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Lactate – Easily available
marker of severity of illness.
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Lactate
Mortality
0-2.5
4.9%
2.6-4
9%
>4
36%
Ponte Vedra 6/21/2012
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Lack of fever
End organ dysfunction, typically increased creatinine, attributed
to dehydration
Anchoring on another diagnosis
Ignoring tachycardia or increased RR
Patients “look good”
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Septic patients look good.
Then they die.
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Institutional Response to Sepsis
Surviving Sepsis Campaign –
• Build Awareness and increase use of proper treatment saw mortality
decrease when management bundles were utilized.
•Database use has markedly decreased over time.
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CMS added sepsis to ruling
regarding hospital infection.
Goal is to shift cost to providers. (2010)
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Hours of in hospital Sepsis
meetings……..
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