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Q Tips (Sepsis)

Overall Sinai is doing much better in regards to care of the septic patient in 2008.  In January, our MICU admits with sepsis had lactates drawn 100% of the time (vs. 66% in Dec 2007).  However, only 50% (5/10) of patients eligible for the EGDT protocol (lactate >4 or hypotension) went through the protocol.  The following management suggestions were culled from the 10 MICU admits with severe sepsis:
  • EGDT Eligibility: Septic patients with low BP or lactate over 4 should be considered for Early Goal Directed Therapy.  The inclusion criteria and pathway are available in copies, or at critical-care.info.  Anyone unfamiliar with our protocol, please print a copy out and check it out.
  • Pressors: Dopamine vs. Levophed.  Both remain in the surviving sepsis campaign recommendations as first line agents for hypotension in sepsis.  Levophed is the pressor of choice in our protocol.  From the SSC 2008 recommendations: Norepinephrine is more potent than dopamine and may be more effective at reversing hypotension in patients with septic shock. Dopamine may be particularly useful in patients with compromised systolic function but causes more tachycardia and may be more arrhythmogenic (78). It may also influence the endocrine response via the hypothalamic-pituitary axis and have immunosuppressive effects.
  • Initial Hypotension in Sepsis:  Our protocol flows from fluids, to pressors, to steroids, to blood products to dobutamine, to intubation, to yet more fluids.  These elements are in sequence on the protocol, and will remain as they are for clarity, however, there is one instance when they may need to be instituted in parallel.  If your patient’s MAP is very low initially, start pressors even if no fluid has been given yet.  Although there is no data to support a specific cutoff, a MAP<50 is reasonable.  Fluid resuscitation ought to begin at the same time.  Give the empiric 20 cc/kg bolus as part of the EGDT protocol.  Pressors will affect your CVP measurements, so the key is to get the CVP up to >8 while on pressors, and then titrate down as MAP stays > 65. As you titrate down, you’ll see the CVP will drop–give more fluids.  If the patient’s blood pressure is > 65 with low dose pressors and CVP > 8, turn off the pressors for a few minutes and see where the CVP goes.
  • Documentation: Please document.  HPI should be something related (not the STD HPI).  Attendings can document Critical Care time for patients requiring EGDT.  If you go through the EGDT protocol document your CVPs as they may not be recorded by the resus RN.  We are working on a more complete EGDT documentation record.
  • Steroids: Cortisol stimulation testing has gone by the wayside s/p the recent CORTICUS trial.  Our protocol has dropped Dexamethasone in favor of Hydrocortisone to be given only in patients with septic shock refractory to vasopressor therapy.
  • Lactates: Every septic patient going to the MICU had a lactate drawn.  Excellent.  Fewer had them repeated.  You should repeat a lactate (as easy as drawing a GEMM) to evaluate oxygen delivery in the prbc/dobutamine/intubation part of the EGDT protocol – and a declining lactate at 6 hours is an important prognostic marker.
  • Cardiac Biomarkers in Sepsis: Watch out for confounding +Troponins in your septic patient.  If they have no story or EKG changes, the + troponin that the lab called you about may be leak related to their sepsis, rather than a primary coronary/myocardial event.  If you still suspect severe sepsis is the prime mover, don’t forget to continue EGDT if you have a lactate over four or hypotension.

 

Written by reuben

March 23rd, 2008 at 1:55 am

Posted in Pearls,Sepsis