CJEM Articles: sepsis

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.

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.

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.