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





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





Hospital perspective:

sepsis management in the emergency department bryon k. frost, md, facep september 13, 2010 medical...

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