EM-CCM Conference: May 2014 - The Original Kings of County

EM-CCM CONFERENCE SUMMARY

PRESENTED BY DR. PIA DANIEL

SUMMARY BY DR. FRANCIS YOUN

CASE: Elderly, bedbound, nonverbal female with past history of dementia, hypothyroidism, sigmoid volvulus s/p sigmoidectomy and colostomy sent from NH for altered mental status, fever, and concern for bowel obstruction.

VS: T 103, BP 99/60, HR 125, RR 28, SpO2 88%, FS 91

PRIMARY ASSESSMENT: protecting airway, clear and bilateral breath sounds, tachypneic, hypoxic, tachycardic.

INITIAL INTERVENTIONS: IV/O2/monitor, 2L NS bolus, PR acetaminophen, foley catheterization

SECONDARY ASSESSMENT (notable findings): decreased responsiveness, dry mucous membranes, tachycardia, clear lung sounds, RUQ tenderness to palpation, no rashes or decubiti, no LE edema, moving all extremities, moans to pain

WORKING DIAGNOSIS: SIRS, presumed sepsis (UTI, colitis, diverticulitis, cholecystitis, cholangitis, pancreatitis, pneumonia, meningitis), bowel obstruction, intracranial mass/lesion/hemorrhage

FURTHER INTERVENTIONS: Broad-spectrum antibiotics (vancomycin, piperacillin/tazobactam), subclavian central venous catheter placement, norepinephrine vasopressor infusion, IV fluid boluses

LABS (notable): pH 7.3, lactate 5.4, CO2 20, Cr 1.5, WBC 6.19, AST 180, ALT 200, Alk Phos 585, Tbili 6.6, Dbili 4.6, Lipase 1,000

ECG: sinus tachycardia

CXR: no focal consolidation, unchanged from previous

CT abdomen/pelvis: choledocholithiasis (multiple with largest 7mm), intra- and extra-hepatic bile duct obstruction, CBD 15mm, CBD sludge, normal pancreas

HOSPITAL COURSE:

Additional abx added (gentamicin and metronidazole), general surgery consulted, GI consulted

Admit to SICU; emergent ERCP with stone extraction and stent placement as well as laparoscopic repair of perforated duodenum

FINAL ASSESSMENT: Septic shock secondary to acute cholangitis with biliary obstruction and duodenal perforation

DISCUSSION:

CHOLANGITIS: biliary tract infection (primary etiologies: CBD stones or medical interventions)

– Charcot’s Triad: fever, jaundice, RUQ pain

– Reynold’s Pentad: fever, jaundice, RUQ pain, shock, and AMS

– MGMT: U/S, CT, antibiotics, endoscopic biliary drainage and decompression via ERCP or PTC imaging modalities or if GI unsuccessful, surgical management comprises decompression of the biliary tree, including stone extraction, T-tube insertion, transhepatic intubation of bile duct or bilio-enteric bypass, or as an alternative, percutaneous transhepatic biliary drainage (PTBD)

SEPSIS:

– Definitions:

– SIRS: 2 or more of the following: T < 36.0 or > 38.0, HR > 90, RR > 20 or pCO2 < 32, WBC < 4,000 or > 12,000 or > 10% bands

– SEPSIS: SIRS + source of infection

– SEVERE SEPSIS: SEPSIS + evidence of end-organ dysfunction (in the ED, end-organ dysfunction cannot be immediately assessed, so lactate > 4 is used)

– SEPTIC SHOCK: SEVERE SEPSIS and hypotension (despite initial fluid resuscitation – 30cc/kg)

– Causes:

– Gram(+): S. aureus, S. pneumonia

– Gram(-): E. coli, Klebsiella, Pseudomonas

– Empiric Antimicrobial Treatment (IDSA)

– CAP: ceftriaxone + azithromycin OR resp quinolone

– CAP (High-risk): cefepime + cipro OR zosyn + cipro OR meropenem + cipro

– Intra-abdominal: metronidazole PLUS ceftriaxone OR cefepime OR quinolone; alternative: piperacillin-tazobactam

– UTI: ceftriaxone OR ciprofloxacin OR cefepime

– Unknown: vancomycin PLUS zosyn OR cefepime OR meropenem OR moxifloxacin

– Early Goal-Directed Therapy (EGDT) Management: Rivers (NEJM, 2001)

– EGDT = aggressive hemodynamic management and monitoring

– Goals: CVP 8-12, ScvO2 > 70%, MAP > 65

– 60-day mortality 50% for EGDT vs. 70% for ST (standard therapy)

– 2012 Surviving Sepsis Campaign Guidelines (variations from EGDT)

– use of alternative markers: procalcitonin (inflammatory marker but poor test characteristics), lactate (tissue perfusion marker); goals based on time windows

– Within first 3 hours for severe sepsis: crystalloid bolus 30cc/kg in 30 min using pressure bag, antibiotics within first hour of recognition, ≥2 blood cultures, source identification and control, serial lactate

– 2006 Crit Care Med: abx within 1^st hour survival rate = 79%; each hour delay = 7.6% decrease in survival rate [“the clock starts ticking when the diagnosis of severe sepsis is made”, i.e. if lactate > 4, consider likely source when choosing antibiotics, but cover broadly if source remains unclear; if lactate is < 4, you have time to possibly IDENTIFY source prior to antibiosis]

– Within first 6 hours: CVP 6-12, MAP > 65, UOP > 0.5cc/kg/hr, ScvO2 > 70, downtrending lactate

– Chest 2008: poor correlation between CVP and fluid status

– AJEM 2012: maximal IVC diameter less in hypovolemic vs. euvolemic pts

– 2014 J US Med: IVC collapse > 40% is associated with fluid responsiveness

– Intensive Care Med 2005: MAP < 65% independently associated with increased mortality

– NEJM 2014: MAP 80-85 vs. MAP 65-70 showed no significant difference in mortality at 28 and 90 days

– JAMA 2010: lactate clearance of 10% noninferior to ScvO2 > 70% with respect to in-hospital mortality

– Crit Care Med 2004: 11% decreased mortality benefit for each 10% in lactate clearance

– Additional Guidelines:

– Vasopressor: norepinephrine is 1^st-line, then epinephrine

– Inotrope: Dobutamine

– Hydrocortisone: only if patient is hypotensive despite IVF/pressors

– Blood transfusion: hgb < 7

ProCESS: Protocolized Care for Early Septic Shock: EGDT vs. Protocolized Standard Care (SC) vs. SC alone (MD discretion); primary endpoint is survival (60d, 90d, 1yr)

– Group 1: EGDT: Tight hemodynamic monitoring, CVC, 6 hour time frame

– Group 2: Protocolized SC: Tight monitoring, no CVC required, 6 hr time frame

– Group 3: SC: no guidelines

– RESULTS: Prior to randomization, all groups 2L NS bolus, 75% rec’d abx; EGDT = 21% mortality, Protocolized SC = 18% mortality, SC = 18.9% mortality

CONCLUSION: no difference in outcomes between groups, decreased emphasis on invasive monitoring; although ScvO2 has been de-emphasized, one may use it to decide on RBC transfusion – If hct is low, but not quite < 21 and ScvO2 is <70%, then consider transfusion

REFERENCES:

Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637.
Dipti A, Soucy Z, Surana A, et al. Role of inferior vena cava diameter in assessment of volume status: a meta-analysis. AJEM. 2012;30:1414-1419
Jones AE, Shapiro NI, Trzeciak S, et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;303(8):739-746
Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? Asystematic review of the literature and the tale of seven mares. Chest. 2008; 134 (): 172-1785.
Marik PE, Cavallazzi R, Vasu T, et al. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med. 2009;37:2642-2647
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-1377
Shapiro et al. A Randomized Trial of Protocol-Based Care for Early Septic Shock. N Engl J Med 2014; 370:1683-1693
Varpula M, Tallgren M, Saukkonen K, et al. Hemodynamic variables related to outcome in septic shock. Intensive Care Med. 2005 Aug;31(8):1066-71

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital