Chapter 22
Sepsis Response Team Emanuel P. Rivers, David Amponsah, and Victor Coba
Keywords Sepsis • Rapid • Response • System • Early • Goal-directed • Therapy
Introduction The transition from sepsis to severe life-threatening disease frequently develops well before admission to an intensive care unit (ICU), often in the pre-hospital setting, the emergency department (ED), general medical-surgical floors, operating room or the outpatient clinic setting. One would hope that as soon as possible after the sepsis syndrome occurs, treatment with resuscitation fluids, restoration of adequate oxygen delivery to the tissues, and antimicrobial therapy would begin. However, optimal care may be delayed for many reasons, including lack of recognition, ED overcrowding and long wait times for ICU beds. Delays to medical emergency teams (MET) and rapid response team involvement may further hinder the availability of expert care to prevent morbidity and mortality. For years we have recognized that delay in care negatively impacts outcome for trauma, myocardial infarction, and stroke.1–3 There is now robust evidence that treatment delay can also negatively impact outcome in sepsis.4–7 This chapter will review the evidence for early intervention in sepsis, models of delivery, and potential obstacles. While a specific team response is not required, a Rapid Response System with a trained efferent limb may provide one mechanism for providing a rapid, coordinated team response to patients presenting to the hospital with signs of sepsis.
E.P. Rivers (*) Wayne State University, Henry Ford Hospital, Emergency Medicine and Surgery, Detroit, MI, USA e-mail:
[email protected] M.A. DeVita et al. (eds.), Textbook of Rapid Response Systems: Concepts and Implementation, DOI 10.1007/978-0-387-92853-1_22, © Springer Science+Business Media, LLC 2011
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Early Goal-Directed Therapy In 2001, Rivers et al showed that Early Goal-Directed Therapy (EGDT) provided in the ED at the most proximal stages of severe sepsis and septic shock produced significant outcome benefit (Table 22.1).5 The interventions stipulated by EGDT were commonly used ICU therapies. What was novel in this report was earlier application of these therapies in the ED within 1 h of presentation. EGDT is an algorithmic approach to resuscitation designed to correct existing (and prevent the recurrence of) hemodynamic and oxygen delivery instability of severe sepsis/septic shock within the first 6 h of hospital care (Fig. 22.1). It may be especially helpful in high-risk patients. It is a “bundle-of-care” strategy based on early recognition and rapid resolution of inadequate systemic oxygen delivery and subsequent global tissue hypoxia that occurs in severe sepsis. There are a number of “triggers” to embark on EGDT; however, we favor in particular the use of a lactate greater than 4 mM/L because it has been shown to be associated with high mortality in both the pre-hospital and ED setting.8–11 EGDT targets achieving normal oxygen delivery by optimizing preload using central venous pressure monitoring, afterload using mean arterial pressure, and oxygen delivery using hemoglobin and inotropic agents guided by central venous oxygen saturation (SCVO2). The goal of these interventions is to correct high lactate levels and ameliorate global tissue hypoxia. In the Rivers et al study, patients presenting to the ED with severe sepsis and septic shock were randomized to standard therapy vs. an EGDT protocol. Mean ED length of stay was 6.3 h vs. 8.0 h, in the stangard and EGDT groups, respectively. The standard therapy group received volume resuscitation and vasoactive therapy guided by central venous pressure andt arterial pressure monitoring. The EGDT group received the same volume resuscitation and vasoactive therapy, but resuscitation in this group was guided by SCVO2 monitoring (Edwards Lifesciences, Irvine, CA) to assess global tissue hypoxia, which might occur despite normalized central venous pressure, blood pressure, and urine output. Additional fluid resuscitation, blood transfusions, ventilatory support, and inotropic therapy were used to reach a goal SCVO2 of at least 70%. All patients received the same standard of care after admission to the ICU, with no Table 22.1 Entry criteria for EGDT5 Clinical suspicion of infection Plus Two of four systemic inflammatory response syndrome (SIRS) criteria Temperature ³ 38°C or 90 beats∙min−1 Respiratory rate > 20 breaths·min−1 or PaCO2 12,000 ml−1 or 10% immature forms Plus either Hypotension (systolic blood pressure 4 mmole/liter
Antibiotics within 1 hour and Source Control
CVP
8-12 mmHg
Decrease Oxygen Consumption
MAP
90 mmHg
Vasoactive Agent(s)
>65-90 mmHg
ScvO2
70% Packed red blood cells to Hct >30%
>70% Ionotrope (s)
No
Fig. 22.1 The EGDT protocol
Goals Achieved
