Sepsis Management in the Emergency Department Bryon K. Frost, MD, FACEP September 13, 2010 Medical...
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Transcript of Sepsis Management in the Emergency Department Bryon K. Frost, MD, FACEP September 13, 2010 Medical...
Sepsis Management in the
Emergency Department
Bryon K. Frost, MD, FACEPBryon K. Frost, MD, FACEP
September 13, 2010September 13, 2010
Medical Staff Meeting
1) We will discuss and define Cryptic Shock.2) Relevant literature review on Early Goal Directed Therapy in the
Emergency Department.
Lecture Agenda
MAP = SVR X CO
P<0.001
• Outcomes of Patients with a Baseline MAP > 100, Lactate >36CONTROL n = 25 and Treatment n = 23
Cryptic ShockCryptic Shock: Inadequate tissue perfusion
without hypotension.
• A clinical response arisingfrom a nonspecific insult, including 2 of the following:– Temperature 38oC or
36oC– HR 90 beats/min– WBC count 12,000/mm3 or
4,000/mm3
SIRS = systemic inflammatory response syndrome.SIRS = systemic inflammatory response syndrome.The critical factor in saving lives of patients in shock is early recognition!!!
SIRS with a presumed or confirmed infectious process
SepsisSepsisSIRSSIRSInfection/Infection/TraumaTrauma Severe SepsisSevere Sepsis
Sepsis + > 1 system organ failure.
Persistent hypotension
↓
Septic Shock
Death Death
Cryptic ShockCryptic ShockCryptic ShockCryptic Shock
Sepsis A: Disease Continuum
↓
“You should already suspect that shock could appear if the underlying disease is left undiagnosed and untreated”.“You should already suspect that shock could appear if the underlying disease is left undiagnosed and untreated”.
STAGE 1STAGE 1: Local Infection onlyLocal Infection only (AnticipationAnticipation)
“The absence of shock is due to the fact that compensatory mechanisms are at play”( SVR gives rise to Cryptic ShockCryptic Shock)“The absence of shock is due to the fact that compensatory mechanisms are at play”( SVR gives rise to Cryptic ShockCryptic Shock)
STAGE 2STAGE 2: Systemic InfectionSystemic Infection (Pre-ShockPre-Shock)
Many physicians fail to recognize this stage: “Pt does not look right"... and "I don't know what is going on, but the blood pressure is not too bad"... Many physicians fail to recognize this stage: “Pt does not look right"... and "I don't know what is going on, but the blood pressure is not too bad"...
Stage 3Stage 3: Compensated Shock-Compensated Shock- Normotensive, “Normotensive, “Cryptic ShockCryptic Shock””
“B.P. can only be restored with intravenous fluid and vasopressors. If you have not diagnosed the cause of shock by now, it will be very difficult to treat pt.”“B.P. can only be restored with intravenous fluid and vasopressors. If you have not diagnosed the cause of shock by now, it will be very difficult to treat pt.”
Stage 4Stage 4: Decompensated Shock-Decompensated Shock- ReversibleReversible
DeathDeath
Stage 5Stage 5: Decompensated Shock-Decompensated Shock- IrreversibleIrreversible
Early Goal Directed Therapy (EGDT) Early Goal Directed Therapy (EGDT) Literature Review:Literature Review:
MortalityMortality AcuteAcute 28 Day28 Day 60 Day60 Day
EGDT EGDT 30.5%30.5% 33.3%33.3% 44.3%44.3%
Standard (p) 46.5% (0.009) 49% (0.01) 56.9% (<0.001)
Rivers E. N Eng J Med. 2001; Nov8;345:1368-77 * P < 0.01
Early Goal Directed TherapyEarly Goal Directed TherapyDr. River’s Data:Dr. River’s Data:
* p < 0.02
BIG NEWS !!!BIG NEWS !!! ICUICU HospHospDecreased DaysDecreased Days 3.53.5 7.27.2
Decreased Resource Utilization - Days
EGDT vs.. Control: Survivors
Resource Utilization of SurvivorsResource Utilization of SurvivorsDr. River’s Study :Dr. River’s Study :
Health Care Resource Use - Health Care Resource Use - DaysDays
“Duration of hypotension before initiation of antimicrobial therapy is the critical determinant of survival in human septic shock” Kumer et al, Crit Care Med 2006
“Duration of hypotension before initiation of antimicrobial therapy is the critical determinant of survival in human septic shock” Kumer et al, Crit Care Med 2006
Early Goal Directed TherapyEarly Goal Directed TherapyDr. Kumer’s Data:Dr. Kumer’s Data:
Rivers E P Chest 2010;138:476-480
Literature ReviewLiterature Review of EGDT Effectiveness: of EGDT Effectiveness:
• The “BAD”:1. “Community-
acquired septic shock: early management and outcome in a nationwide study in Finland” -VARPULA
2. “Failure to implement evidence-based guidelines for sepsis at the ED” -José
•The GOOD:1.“The Surviving Sepsis Campaign: Results of an International Guideline-based Performance Improvement Program targeting severe sepsis” -Levy, MD2.“Hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis” -Thiel, MD3.“Effect of a Rapid Response System for patients in shock on time to treatment and mortality during 5 years” -Sebat,MD4.“Before–after study of a standardized hospital order set for the management of septic shock” -Micek, PharmD5.“Early Goal-Directed Therapy: Improving Mortality and Morbidity of Sepsis in the Emergency Department” –Anne Focht, RN6.“Impact of time to antibiotics on survival in patients with severe sepsis or sepsis shock in whom early goal-directed therapy was initiated in the emergency department” –Gaieski, MD
The UGLY:
“Factors Associated with Nonadherence to Early Goal-Directed Therapy in the ED” –Mikkelsen, MD
“We can’t do this here”, “The patient is not sick enough to have sepsis”
Looking at the Literature:Looking at the Literature:
$31,011/admitDecreased Admit Costs:
$26,359,350/yr
136136 per year! per year!
3,8003,800 patient days patient days saved per year !saved per year !
850 patients/yr
Decreased Hospital Costs:
Lives Saved:Lives Saved:
Decreased Hospital Days:
Septic Patients:
Henry Ford Hospital Data:Henry Ford Hospital Data:
Admitted From ED toAdmitted From ED to:: ICUICU
(n(n = 266) = 266)
HospitalHospital
(n (n = 531)= 531)
Average LOS before EGDTAverage LOS before EGDT 9.3 9.3 daysdays 18.2 18.2 daysdays
Estimated Cost/Pt/DayEstimated Cost/Pt/Day $$43594359 $$29272927
Est. Current CostEst. Current Cost (($$4359)4359)(266pt) (9.3D)(266pt) (9.3D)
$$1010..8 8 millionmillion $$2828..3 3 millionmillion
Days Days ReducedReduced with EGDT with EGDT 33..5 5 daysdays 77..2 2 daysdays
$ $ SavedSaved $$44..0 0 millionmillion $$1111..2 2 millionmillion
Potential Hospital Cost Savings Benefit at University of Virginia:
C.E.A.= Cost Effective Analysis: a form of economic analysis that compares the relative costs and outcomes (effects) of two or more courses of action.
QALY= Quality Adjusted Life Year: a measure of disease burden, including both the quality and the quantity of life lived. It is used in assessing the value, in money, of a medical intervention.
“Exploring the advantages of effectively using EGDT at McLeod; pertaining to quality, cost and lives saved”
Dr. David Huang’s Data:Dr. David Huang’s Data:
0.5 1.0 1.5 2.0-0.5
-10,000
10,000
20,000
30,000
Dif
fere
nce
in
co
sts
(US
$)
Difference in effectiveness (QALY per patient)
QALY- Quality Adjusted Life Year
1.0
More costlyLess effective
More costlyMore effective
Less costlyMore effective
Less costlyLess effective
0
0
Less EffectiveLess Effective More EffectiveMore Effective
Less CostLess Cost
More CostMore Cost$20,000/Q
ALY
$50,
000/
QA
LY
Societal perspective Cost-effective analysis:Societal perspective Cost-effective analysis:
0.5 1.0 1.5 2.0-0.5
-10,000
10,000
20,000
30,000
Dif
fere
nce
in
co
sts
(US
$)
Difference in effectiveness (QALY per patient)
1.0
$20,000/QALY
$50,
000/
QA
LY
0
0
Cost per QALY = $7,800
More costlyLess effective
More costlyMore effective
Less costlyMore effective
Less costlyLess effective
Societal perspective:Societal perspective:
EGDT
Newborn Hep B vaccine
Screening mammography
20k $40k $60k $80k $100k$120k$140k$160k$180k0
$16,000 $105,000
$32,000 $143,000
$5,000 $49,000
$8,000 $69,000
$40,000 $120,000
$24,000 $61,000
Antihypertensive
Cholesterol lowering drugs
CABG for 2V disease
Airbags
League Table: modified from Schwartz, Leonard Davis Institute
Drotrecogin-alfa
E.G.D.T.E.G.D.T.EGDT in perspective:EGDT in perspective:
Difference in survival (number of lives saved)
0
0.25 0.5-0.25-30,000
-10,000
-20,000
10,000
Dif
fere
nce
in
co
sts
(US
$)
0
Cost Savings per survivor at 60 Days = $6,500
More costlyLess effective
More costlyMore effective
Less costlyMore effective
Less costlyLess effective
Hospital perspective: