Answer: quizzer Vol 1.7

quizzER Winners:

Sam Lee                       Brian Junnila                Daniel Seitz

Shereaf Walid             Bindu Vanapalli            Richard Gordon

Katie Ohlendorf          Marjan Siadat               Brian Kern

Kyle Perry                    Claire Jensen                 Maria Pak

Bao Dang                     Devon Moore                 Rob Klever

Last Week’s Question

Answer

The answer is c

The treatment for sepsis has evolved considerably over the past 10 years. Early recognition and early aggressive therapy for patients with sepsis have a significant impact on mortality. Dr Emanuel Rivers et al, brought this issue to the forefront with their landmark article in the New England Journal of Medicine in 2001, where they instituted a treatment protocol for patients with septic shock, termed Early-Goal-Directed Therapy (EGDT). EGDT emphasizes early recognition of patients with potential sepsis in the ED, early broad-spectrum antibiotics, and a rapid crystalloid fluid bolus, followed by goal-directed therapy for those patients who remain hypotensive or severely ill after this initial therapy. Those patients who did not respond to an initial fluid bolus and antibiotics received a central venous catheter in the internal jugular or subclavian vein to measure central venous pressure (CVP) and an arterial catheter to directly measure arterial blood pressure.

EGDT is basically a three-step process, aimed at optimizing tissue perfusion:

  • The first step involves titrating crystalloid fluid administration to CVP, or administering 500 mL boluses of fluid until the CVP measures between 8 and 12 mm Hg. CVP is a surrogate for intravascular volume, as excess circulating blood volume is contained within the venous system.
  • The second step, if the patient has not improved with fluid alone, is to administer vasopressors to attain a mean arterial pressure (MAP) greater than 65 mm Hg.
  • The third step is to evaluate the central venous oxygen saturation (SvO2). This is obtained from the central venous line, which, in turn, is a surrogate for peripheral tissue oxygenation and cardiac output. A central venous saturation of less than 70% is considered abnormal and indicative of suboptimal therapy. In this case, the hematocrit is checked and blood is transfused until a hematocrit greater than 30% is attained. Once this is attained and the central venous saturation is still low, dobutamine is initiated to increase cardiac output.

Systemic Inflammatory Response Syndrome (SIRS)

Sepsis

Severe Sepsis

Septic Shock

Two or more of the following criteria:

  • HR > 90
  • Temperature > 100.4ºF or < 96.8ºF
  • RR > 20, or PaCO2 < 32
  • WBC > 12,000 cells/mm3, or < 4,000 cells/mm3, or > 10% band forms

SIRS

+

Suspected or proven infections

Sepsis

+

Acute organ dysfunction

Sepsis

+

Refractory hypotension

(a) Vasopressor therapy should not be started until the patient receives at least normal saline fluid boluses to achieve a CVP between 8-12 mm Hg or to maintain a mean arterial pressure of at least 65 mm Hg. (b) Packed red blood cells can be transfused if the central venous oxygen saturation (ScvO2) is less than 70 percent, and the hematocrit is less than 30%. However, this occurs after fluid administration. (d) A CVP of 8-12 mm Hg is the goal. Fluid should be administered when the CVP is less than 8 mm Hg. (e) The femoral vein is not a suitable location to place a central line in early goal directed therapy because it does not accurately measure the central venous pressure.

Thank you for everyone who submitted an answer.  Please stay tuned for next week’s quizzER.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

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