CJEM Articles: sepsis

Displaying 1-10 of 12 results

  • January 2012 14 1
    Daniel Howes, David Easton, David Lechelt, David Sweet, Dennis Djogovic, Edward Patterson, Jonathan Davidow, Jonathan Gaudet, Michael R. Kolber, Robert Green, Robert Keyes, Robert Stenstrom, Sara Gray, Shavaun MacDonald

    Objective:

    The Canadian Association of Emergency Physicians (CAEP) sepsis guidelines created by the CAEP Critical Care Practice Committee (C4) and published in the Canadian Journal of Emergency Medicine (CJEM) form the most definitive publication on Canadian emergency department (ED) sepsis care to date. Our intention was to identify which of the care items in this document are specifically necessary in the ED and then to provide these items in a tiered checklist that can be used by any Canadian ED practitioner.

    Methods:

    Practice points from the CJEM sepsis publication were identified to create a practice point list. Members of C4 then used a Delphi technique consensus process over May to October 2009 via e-mail to create a tiered checklist of sepsis care items that can or could be completed in a Canadian ED when caring for the septic shock patient. This checklist was then assessed for use by a survey of ED practitioners from varying backgrounds (rural ED, community ED, tertiary ED) from July to October 2010.

    Results:

    Twenty sepsis care items were identified in the CAEP sepsis guidelines. Fifteen items were felt to be necessary for ED care. Two levels of checklists were then created that can be used in a Canadian ED. Most ED physicians in community and tertiary care centres could complete all parts of the level I sepsis checklist. Rural centres often struggle with the ability to obtain lactate values and central venous access. Many items of the level II sepsis checklist could not be completed outside the tertiary care centre ED.

    Conclusion:

    Sepsis care continues to be an integral and major part of the ED domain. Practice points for sepsis care that require specialized monitoring and invasive techniques are often limited to larger tertiary care EDs and, although heavily emphasized by many medical bodies, cannot be reasonably expected in all centres. When the resources of a centre limit patient care, transfer may be required.

  • July 2011 13 4
    Alina Toma, Angela Stone, Robert S. Green, Sara Gray

    CLINICAL QUESTION What is the role of steroids in septic shock in the emergency department?
    ARTICLE CHOSEN Sprung CL, Annane D, Keh D, et al; CORTICUS Study Group. Hydrocortisone therapy for patients with septic shock. N Engl J Med 2008;358:111-24.
    STUDY OBJECTIVE To assess the safety and efficacy of low-dose hydrocortisone therapy for patients with septic shock and to compare outcomes based on response to corticotropin testing.

  • March 2011 13 2
    Rob Green, Sean K. Gorman

    Clinical questions

    1. In critically ill patients with septic shock, does exposure to bolus administration of etomidate increase the risk of inadequate response to corticotropin and mortality compared to no exposure?
    2. In critically ill patients with septic shock who are exposed to bolus administration of etomidate, does hydrocortisone reduce the risk of death compared to placebo?

    Article chosenCuthbertson BH, Sprung CL, Annane D, et al. The effects of etomidate on adrenal responsiveness and mortality in patients with septic shock. Intensive Care Med 2009;35:1868-76.
    Study objectiveThe authors sought to test the hypotheses that bolus doses of etomidate results in an increased proportion of nonresponders to corticotropin and an increase in mortality and that hydrocortisone treatment decreases mortality in patients receiving etomidate.

  • January 2011 13 1
    Carolyn Kelly-Smith, Corinne Hohl
  • July 2010 12 4
    Daniel Peterson, Marc Francis, Tom Rich, Tyler Williamson

    Objective: We sought to evaluate the time to antibiotics for emergency department (ED) patients meeting criteria for severe sepsis before and after the implementation of an ED sepsis protocol. Compliance with published guidelines for time to antibiotics and initial empiric therapy in sepsis was also assessed.

    Methods: A retrospective chart review was conducted. Emergency department patient encounters with International Classification of Diseases codes related to severe infections were screened during a 3-month period before and after the implementation of a sepsis protocol. Encounters meeting criteria for severe sepsis were further assessed. The time to ini­tiation of antibiotics was determined as well as the initial choice of antimicrobial therapy based on the presumed source of infection.

    Results: We reviewed 213 unique ED patient encounters meeting criteria for severe sepsis. Analysis of the period before implementation showed a median time from the time criteria for severe sepsis were met to delivery of antibiotics of 163 minutes (95% confidence interval [CI] 124 to 210 min). Analysis of the period after implementation of the protocol revealed a median time of 79 minutes (95% CI 64 to 94 min), representing an overall reduction of 84 minutes (95% CI 42 to 126 min). Before the implementation of the protocol, 47% of patients received correct antibiotic coverage for the presumed source of infection in compliance with locally published guidelines. After the initiation of the protocol, 73% received appropriate initial antibiotics, for an overall improvement of 26%.

    Conclusion: A guideline-based ED sepsis protocol for the evaluation and treatment of the septic patient appears to improve the time to administration of antibiotics as well as the appropriateness of initial antibiotic therapy in patients with severe sepsis.

  • March 2010 12 2
    Catherine Patocka, Eddy Lang, Joel Turner
  • January 2010 12 1
    L. McIntyre, P.J. Zed, Reviewed by: R.S. Green
  • November 2008 10 6
    Daniel Howes, David Easton, Dennis Djogovic, Edward Patterson, Jonathan S. Davidow, Peter G. Brindley, Robert S. Green, Robert Stenstrom, Sara Gray
  • September 2008 10 5
    Daniel Howes, David Easton, Dennis Djogovic, Edward Patterson, Jonathan S. Davidow, Peter G. Brindley, Robert S. Green, Robert Stenstrom, Sara Gray

    Introduction: Optimal management of severe sepsis in the ED has evolved rapidly. The purpose of these guidelines is to review key management principles for Canadian emergency physicians, utilizing an evidence-based grading system.
    Methods: Key areas in the management of septic patents were determined by members of the CAEP Critical Care Interest Group (C4). Members of C4 were assigned a question to be answered after literature review, based on the Oxford grading system. After completion, each section underwent a secondary review by another member of C4. A tertiary review was conducted by additional external experts, and modifications were determined by consensus. Grading was based on peer-reviewed publications only, and where evidence was insufficient to address an important topic, a "practice point" was provided based on group opinion.
    Results: The project was initiated in 2005 and completed in December 2007. Key areas which were reviewed include the definition of sepsis, the use of invasive procedures, fluid resuscitation, vasopressor/inotrope use, the importance of culture acquisitionin the ED, antimicrobial therapy and source control. Other areas reviewed included the use of corticosteroids, activated protein C, transfusions and mechanical ventilation.
    Conclusion: Early sepsis management in the ED is paramount for optimal patient outcomes. The CAEP Critical Care Interest Group Sepsis Position Statement provides a framework to improve the ED care of this patient population.

  • January 2007 9 1
    Andrew Worster, Emanuel P. Rivers, Suneel Upadhye