We have hit the 10,000 patient mark in the NYC STOP Sepsis collaborative. Here are some of the lessons learned…
Want to See the Protocols?
Recognition
- Let nurses handle recognition
Lactate
- Send lots of lactates
- Lactate turn-around 30 minutes or get Point-of-Care
- Run the lactates on a blood gas machine
- Make lactate >=4 a panic value
Treatment
- Prompt palliative vs. curative
- Non-invasive protocols have evidence and seem to be working
Want to See the Protocols?
Early appropriate antibiotics
- Empiric Abx Guidelines
- First dose of those antibiotics in the ED
- Simultaneous Infusions
Intubation
- Safe Intubation
Fluids
- Echo Assessment of Cardiac Output
- IVC ultrasound (Also check out the Stone Debate)
- If empiric fluid-loading, give
4-6 liters2-3 liters
Pressors
- Do a sterile neck line or a non-sterile femoral (which should be yanked and replaced as soon as the patient gets upstairs)
- In 2023- we would do midlines
- Norepi should be your 1st pressor choice
Check Your Work
- Mandate repeat lactates
More Sepsis Resources
- Manny Rivers on Early Goal Directed Therapy
- A tirade on Sepsis Care in the ED (And additional follow-up) Back then there was no Non-Invasive Path
- That was until Alan Jones published his lactate clearance study
- Find a ton of evidence and other good stuff on the EMCrit Severe Sepsis Deep Dive Pages
The Proposed NQF Measure
Please contact the folks in your hospital that will be voting on the measure
Additional New Information
More on EMCrit
- EMCrit 154 – Preemptive Sepsis Panel SmaccBack(Opens in a new browser tab)
- Frequently Asked Questions (FAQ) regarding Sepsis(Opens in a new browser tab)
- Podcast 241 – Sepsis Update 2019
Additional Resources
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- EMCrit 387 – Emergency Department Charting for Legal Protection and Patient Safety - November 1, 2024
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Great post as always Scott.
Why do you think the NQF is doing this? Are we seeing a 10 year knowledge translation situation where the Rivers paper from 2001 was finally adopted by all, or is this something else? Also, would something like this occurring really mean you couldn’t manage sepsis non-invasively, or is that an exaggeration?
Happy holidays,
Chris
@SOCMOBEM
The people advising NQF may have a vested interest in keeping things along the lines of the invasive path, but that is just conjecture. What I can say for sure is that if the measure goes through and is adopted by CMS that is the end of non-invasive approach for the USA–no exaggeration.
Scott,
Does the STOP Sepsis Iniative deal with ICU care, or just in the ED? I’m interested in the use of protocols to guide continuing fluid replacement/treatment upstairs as well as in the ED. I’m particularly interested in protocols that allow the ICU nurses to “titrate” fluids based on a non-invasive measurement (such as the NICOM). As I’ve been researching this topic, I encounter a lot of people who think it’s crazy to even look at non-invasive measurements, although I tend to agree with you, why put a big neck line in someone who doesn’t need pressors?
Bryan
Bryan you’ll have to clarify if they mean non-invasive measurements such as IVC UTS or they are doubting NICOM. The ongoing fluid decisions after the 1st 24 hours are actually much tougher than the first 24 hours and even the latter is already pretty tough.
Speaking from the nurse side….. (Insider tip) When physicians what fluids and antibiotics RN’s mix you vanco, zosyn, or whatever in a 1 liter bag. Yes it still must be timed (ie 1 hour 30 min etc) however while you are blasting in a liter of saline bang in your antibiotics over an hour in a liter. Firstly in a resus few people think of maintenance fluids. I need to give them normal maintenance plus what they are missing. I alway imagine a septic patient like a burn patient who comes from a po-dunk hospital that has administered insufficient fluids.… Read more »
Hey there FlyinRN. Thanks for commenting. Not sure I am crazy about the idea of fluid boluses going in under abx administration. Rather just judge what fluid the pt needs and give specific fluids accordingly. The concept of maintenance fluids doesn’t exist during the resuscitative phase of critical illness. We are assessing these patients constantly to see their status and dosing fluids accordingly.
Scott, I am a critical care transport nurse and given the given the limited resources (no POC lactate or US capabilities) and information (very little information from the sending facility about source. about half the time the physician is gone and not available to answer questions. so i am talking to an RN who has no idea what is going on with the patient. sometimes I may get one set of labs that is 4-6 hours old that includes a lactate about 25% of the time). What are the most important interventions that I can do in my limited time… Read more »
Scott, I have a related question for you and your followers: What are your ideas on taking sepsis care to the streets, onto the ambulances? I would like to involve our EMS providers in sepsis care and am considering having our paramedics start the sepsis identification process in the field and maybe even begin antibiotics before arrival. There are a lot of details to work out such as: Is it feasible for a paramedic to accurately identify sepsis? Is there a single antibiotic agent that might be carried that would be appropriate first-agent coverage in most common causes of sepsis?… Read more »
Scott, I assume you are using iStat’s as your point of care lactate monitor? I’m in the early plannig phase to see if we can do some sort of our own study and or treatment improvement from a pre-hospital standpoint. Unfortunately, many of our local services won’t be able to afford iStat’s and I am trying to figure out how to get a field lactate done. Any ideas?
There are a few options out there for prehospital lactate testing. The two I have seen most often is the lactate scout and the lactate plus. Hope that helps I know they are pretty inexpensive in comparison to an ISTAT. The biger question is however how is getting a lactate in the field really going to change the care provided by the medics. I look forward to hearing every bodies opinions on that.
Ah, crap, forgot about those. Thanks for the reminder. As for medic treatment in the field… Our transport times are an average of 15-20 minutes, we have a number of hospitals within that region. A protocol like this would be easy enough to implement. I’ll be honest, we do a poor job of identifying sepsis and testing appropriately until we are well behind the power curve and have to dump fluids in and start pressors. Some of that is our problem, some of that is the problem of the nursing home staff and or patients family to recognize how seriously… Read more »
Sorry. Forgot about the lactate. I think with a bit of effort, and proper understanding, we’d be able to shoot for a goal. If their lactate is 6, we know the patient is rather hypo-perfused and we need to load them with fluids. It’s an easy concept. Sure, that’s the bare bones, Mongo see lactate, Mongo fix lactate, way too look at it. But it works. Combining that with all of the other general cares, you really have a simple tool to improve the outcome in the field, vs. just pouring a random amount of fluid in.
Dave, Here in Canada we in EMS are the first step and primary source of early sepsis recognition. We already practice aggressive fluid administration, early hospital notification/stratification to appropriate facilities. As well some jurisdictions have regional guidelines for prehospital IV antibiotic administration and most have vassopressors(typically dopamine though we are starting to get Levo) I dont have any stats on success or out comes, as far as I know they are not kept. But atleast with the patients I deal with I have seen success. I would love to see for us to ideally carry istats but a lactate monitor… Read more »
I absoloutley love iStat, but they are not (physically) made for being out of a hospital environment. I spend at least 8 months of the year with the thing stuck down the front of my jacket (so it doesn’t get too cold) or keeping in wrapped in cold packs (so it doesn’t get too hot). The iStat has such a narrow temperature range in which it will operate that it is practically infeasible to use in the transport environment. Once it gets out of temperature range it WILL NOT WORK until it is brought back into its comfort zone by… Read more »