Posted on May 17, 2019 by Paul
Why do we care about sepsis in prolonged field care? What can we do about septic shock with what we are normally carrying on a deployment? How do you mix an epinephrine drip? Dr. Maves lays it all out in about 20 minutes.
Here are some of the resources and pearls he mentioned in the episode:
Infection plus organ dysfunction is sepsis
Infection plus hypotension is septic shock
Q-SOFA positive with 2 of the three and suggestive of sepsis:
Systolic BP <100
RR>22 breaths per minute
Presence of delirium
Earlier intervention is better than later
Higher mortality rate than poly trauma or myocardial infarction
Something is better than nothing
Septic shock is not purely distributive. You will also see myocardial depression loss of contractility, capillary leakage, microvascular obstruction from small thrombi and concomitant hypovolemia.
Some fluids are good but more fluids mat be dangerous
If 2 or 3 liters does not work it is unlikely that 5 or 6 fix hypovolemia. At some point it will start increasing mortality.
The best vasopressor is the one you have
Delaying proper antibiotics increases risk of death by 8% every hour.
IMAI district clinician manual: Hospital care for adolescents and adults…
For more Download the World Health Organization Manual for Integrated Management of Adolescent and Adult Illness:
Download Volume 2 of the WHO IMAI:
Now on to the podcast…
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Thank you Paul, I’ll share this with our Foreign Service Colleagues.
Good Day, I noticed during the podcast a quote of Sepsis having a higher mortality rate than polytrauma or MI. I didn’t know this and would like to read more can you all point me in the direction to find this study or reference?
I’ll ask him for a reference and update the post when he gets back to me. Thanks!
It’s a great question. Obviously there is a spectrum of risk: a 25 year old healthy woman with pyelonephritis, a little hypotension, and a creatinine bump is going to have a lower mortality than a 75 year old with CML on the ventilator.
If you look at the big sepsis trials of the past few years (ProCESS, ProMISE, and ARISE being three of the biggest), the mortality rates for septic shock are around 25-30% in a modern hospital setting. Taking all comers, the in-hospital mortality of sepsis in the US is around 15% (Rhee C et al, JAMA 2017;318:1241-1249).
Conversely, the risk of death from MI in the US in 2015 was about 14% (Chatterjee P et al, JAMA Cardiology 2018;3:336-340). For patients with polytrauma, which we can define as an ISS of 16 or greater based on an older definition, the mortality in the US is about 11% (Dijkink et al, Injury 2018;49:104-109). There is a newer “Berlin definition” of polytrauma that may skew my numbers a bit, though.
I think the shorter podcast is a good idea. Attention spans usually last about 15 minutes anyway (good Mike Lauria talk). EMcrit and FlightBridgeEd Podcasts follow this model.
This was a great podcast. What I have listened to and read about managing sepsis has mostly been within the CONUS and using CONUS support. It was great to hear current best practices in the context of PFC.
Perhaps you guys can comment on this further but as the podcast was playing, my mind when to Hetastarch as a possible adjunct to crystalloids. I did a little research and found several studies advising against the use of hydroxyethyl starches (Hextend being one) and their use and the FDA issuing a black box warning against its use and possible nephrotoxicity an increased risk of bleeding. In reading these studies though, I do not see where it specifies the time period the HES’s were administered. Was it given initially to help with SBP or was it given over the course of the ICU stay (rhetorical)? I could not find this. In the PFC environment, it may be hours to days before evacuation.
What is your take on using Hextend for this short period of time for s/s of lack of organ perfusion?
Treatment with the fluid you have is always my opinion. Are there better choices than hetastarch? Umm yeah, but if that is all you have and the patient doesn’t have the mental status to drink water, or the rectal route is not an option, then I guess the patient’s best chance would be to use it. Just my opinion though.
Speaking for myself, I would avoid hetastarch if I had a choice. The issue is an increased risk of AKI compared with crystalloids (Myburgh et al, NEJM 2012; 367:1901-1911) as well as increased mortality (Perner et al, NEJM 2012; 367:124-134). If you open your pack and hetastarch is all you have…well, any port in a storm, I guess. But I would pack LR or something comparable, like PlasmaLyte, at least for fluid resuscitation in sepsis.