"Sepsis Musings" By Steven P. LaRosa, M.D.
The data are clear that the mortality of patients who develop sepsis in the hospital is higher than those who present to the ED with sepsis. This undoubtedly is due to delayed identification. It is of critical importance to have an "Early Warning System" incorporated into the EMR to flag patients with sepsis. A review of the literature indicates that the National Early Warning Score (NEWS) has the best combination of sensitivity and specificity for this purpose. SIRS criteria are too sensitive leading to "alert fatigue"while the newly coined qSOFA has great specificity but poor sensitivity.
Of all the components of the early sepsis bundle is appears that the early administration of effective antibiotics is the most important. It is critical the ID physicians play a key role in a sepsis team.
There is an accumulating data that hyperchloremic "normal saline" is associated with worse outcomes and increased incidence of AKI than balanced salt solutions such as Lactated Ringers and Plasmalyte. Large randomized clinical trials are underway to address this issue. In the meantime, if I come in with septic shock please give me Lactated Ringers and not saline.
The data is becoming clear that flooding patients with fluids during resuscitation is not good. Positive fluid balance in the first 72 hours of sepsis is associated with poor outcomes. After the initial fluid resuscitation dynamic measures of fluid responsiveness such as passive leg raising effect on CO, SV or pulse pressure and cardiac ECHO should be used.
Beta -lactam and Carbapenem antimicrobial activity is driven by the time that the concentration is above the MIC for the organism. To maximize this I use either shortened interval dosing (q 6 hours for Cefepime and Meropenem) or extended infusions (4 hours) for Piperacillin-Tazobactam.
In young, previously healthy patient it is important to be aware of the possibility of Augmented Renal Clearance (ARC). Clues to ARC include age < 50, SOFA score 4 or less, trauma as admitting diagnosis and serum creatinine less than 0.6. Higher doses and extended infusion of antimicrobials should be used in this setting.
You can give all the antimicrobials in the formulary but if you don't achieve "source control" of infection sepsis will progress. Source control includes drainage of abscesses, relief of genitourinary obstruction, removal of dead bowel, removal of infected foreign bodies and debridement of necrotic tissue.
As the timeliness of appropriate antimicrobial therapy directly impacts outcomes we must endorse and push for rapid microbiologic assays including: Strep pneumo urine Ag, Legionella urine ag, Biofire Respiratory panel Microarray, Accelerate Pheno rapid ID of positive blood culture isolates.
There is no evidence to support routine empiric antifungal therapy in sepsis but you could consider it in patients with risk factors for Candidemia including the use of TPN and multi-focal Candida colonization.
Despite the inexpensive cost of the Vitamin C regimen (Vitamin C/corticosteroids/thiamine), there is insufficient evidence to support its adoption at this point without an adequately powered RCT
The recently completed Euphrates Trial results do no support the use of the Immobilized Polymyxin Filter for the treatment of septic shock.
The data are clear that the mortality of patients who develop sepsis in the hospital is higher than those who present to the ED with sepsis. This undoubtedly is due to delayed identification. It is of critical importance to have an "Early Warning System" incorporated into the EMR to flag patients with sepsis. A review of the literature indicates that the National Early Warning Score (NEWS) has the best combination of sensitivity and specificity for this purpose. SIRS criteria are too sensitive leading to "alert fatigue"while the newly coined qSOFA has great specificity but poor sensitivity.
Of all the components of the early sepsis bundle is appears that the early administration of effective antibiotics is the most important. It is critical the ID physicians play a key role in a sepsis team.
There is an accumulating data that hyperchloremic "normal saline" is associated with worse outcomes and increased incidence of AKI than balanced salt solutions such as Lactated Ringers and Plasmalyte. Large randomized clinical trials are underway to address this issue. In the meantime, if I come in with septic shock please give me Lactated Ringers and not saline.
The data is becoming clear that flooding patients with fluids during resuscitation is not good. Positive fluid balance in the first 72 hours of sepsis is associated with poor outcomes. After the initial fluid resuscitation dynamic measures of fluid responsiveness such as passive leg raising effect on CO, SV or pulse pressure and cardiac ECHO should be used.
Beta -lactam and Carbapenem antimicrobial activity is driven by the time that the concentration is above the MIC for the organism. To maximize this I use either shortened interval dosing (q 6 hours for Cefepime and Meropenem) or extended infusions (4 hours) for Piperacillin-Tazobactam.
In young, previously healthy patient it is important to be aware of the possibility of Augmented Renal Clearance (ARC). Clues to ARC include age < 50, SOFA score 4 or less, trauma as admitting diagnosis and serum creatinine less than 0.6. Higher doses and extended infusion of antimicrobials should be used in this setting.
You can give all the antimicrobials in the formulary but if you don't achieve "source control" of infection sepsis will progress. Source control includes drainage of abscesses, relief of genitourinary obstruction, removal of dead bowel, removal of infected foreign bodies and debridement of necrotic tissue.
As the timeliness of appropriate antimicrobial therapy directly impacts outcomes we must endorse and push for rapid microbiologic assays including: Strep pneumo urine Ag, Legionella urine ag, Biofire Respiratory panel Microarray, Accelerate Pheno rapid ID of positive blood culture isolates.
There is no evidence to support routine empiric antifungal therapy in sepsis but you could consider it in patients with risk factors for Candidemia including the use of TPN and multi-focal Candida colonization.
Despite the inexpensive cost of the Vitamin C regimen (Vitamin C/corticosteroids/thiamine), there is insufficient evidence to support its adoption at this point without an adequately powered RCT
The recently completed Euphrates Trial results do no support the use of the Immobilized Polymyxin Filter for the treatment of septic shock.
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