Once again Dr. H grabbed his orange, tackle box-like emergency kit—only containing antibiotics—and we walked out the door. But this time, we walked and chatted—with less enthusiasm and excitement than my preceding Code Blue experience. Patient B was an 80 year old female, who just arrived to the ER with slight elevation in temperature and recent drop in blood pressure. She was not mentally alert, oriented to person, place and time. After thorough inspection, the physician suspected injury related infections. The nurses jumped in with their diagnostic testing; and the phlebotomist patiently waited her turn to draw the patient’s blood for lab samples. Three tests—cTnl, Chem8+, and CG4+— were ran using Abbott Point of CARE i-STAT Systems to expedite lab results required to begin empiric antimicrobial therapy.
- cTnl—Cardiac troponin I—serum concentrations are useful in the detection of myocardial (heart tissue) damage. High concentrations will reveal a possible heart attack.
- Chem8+ cartridge tests for Na+, Cl-, K+, CO2, Ca2+, glucose, BUN, creatinine, and hematocrit.
- CG4+ cartridge tests for pH, PCO2, HCO3, and TCO2, Base Excess, PO2, O2, and lactate
Meanwhile, Dr. H and I proceed to the Pysix MedStation to prepare the empiric antimicrobial regimen that the physician ordered to start therapy immediately.
Generally, code sepsis are often called in the Emergency Department—but at times, they are used for hospitalized patients as well. The sepsis response team usually include a physician, a pharmacist, nurses, and other personnel—such as a phlebotomist.
What is sepsis? Why do many students find it confusing? The table below outlines the clinical differences between systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock.
Systemic Inflammatory Response Syndrome (SIRS) is defined as the initial response to infection, wound, or trauma. Your body alerts you when it fights off invading infections by bringing on responses such as sudden changes in temperature, heart rate, respiratory rate, and white blood cell count.
Sepsis is in the event when patients meet at least two or more of the SIRS criteria alongside with an active systemic infection but without organ dysfunction.
Severe sepsis is defined as sepsis with acute organ dysfunction—such as heart, liver, or kidney failure— secondary to the infection. So in this situation, all three criteria needs to be met in order to be classified as severe sepsis— two or more SIRS criteria, an active systemic infection, and acute organ damage.
Septic shock is the most severe and life threatening form of sepsis that is associated with circulatory failure—generally resulting in what is known as “hypotension”. Sepsis-induced hypotension are characterized by persistent hypotension despite of adequate fluid resuscitation.
The different approaches to diagnosing and management of sepsis are too extensive to cover in any one blog or article. You can refer to International Guidelines for Management of Severe Sepsis and Septic Shock (2012) for more recommendations on diagnostic criteria, goals, and treatment methods. The purpose of this blog is to discuss topics relevant to identifying biomarkers and to aid students in the process of antimicrobial selection.
The following biomarkers are essential in the identification of sepsis— with elevation of lactic acid and procalcitonin as the two most useful diagnostic tools.
- Lactic acid >2: lack of o2 delivery to tissues results in decreased cellular metabolism and an increase in cellular lactate production and subsequent diffusion into the blood stream. It indicates tissue hypoxia
- Elevated Procalcitonin levels (>2 SD above normal value): PCT will rise in response to a pro-inflammatory stimulus, usually bacterial in origin. One of the best markers used today for diagnosis of sepsis
- Leukocytosis in later stages
- Leukopenia in early stages
- Thrombocytosis in acute phase
- Thrombocytopenia in overt sepsis
- Elevated creatinine, liver functions, CRP
Understanding and becoming familiar with SEPSIS BUNDLE is crucial for institutional sepsis rounds and easily the best tool to impress your preceptor.
Antimicrobial selections are based on the site pf origin and source of infection. The SEPSIS BUNDLE may appear to be intimidating— but it really isn’t. A common approach to managing sepsis involves the use of two or more “big guns” broad spectrum antibiotics—Zosyn, meropenem, and Unasyn. Do not forget vancomycin—the most commonly add-on antibiotic to provide additional Methicillin-resistant Staphylococcus Aureus (MRSA) coverage. Vancomycin is like that third wheel friend-always there and you can count on them during tough times. Vancomycin is also your go to drug for all skin or soft tissue related infections and/or IV line-induced infections to cover staphylococcus bacteria found on your skin. Other options include the use of cephalosporins, fluoroquinolones, gentamicin, and/or metronidazole.