Field Interventions

RAPID FIELD INTERVENTION

            Field units responding to possible septic emergencies must be aware of qSOFA and utilize it when they find out the patient is suspected of having any type of infection.

           

o   “Old-School” medics and Emergency Medical Personnel have some false misconceptions concerning sepsis that need to debunked:

o   “My patient doesn’t have a fever” – Depending on where the patient is in the range of sepsis the fever could possibly be high or your patient could be cold.    Any body temperature under 97.9 could indicate a much worse level of sepsis than a higher temperature.

o   “My patient doesn’t have diabetes so I will not check sugar levels” – Septic patients may very well develop hyperglycemia due to factors such as, “insulin clearance is increased leading to a reduction in insulin-mediated glucose uptake” (Mathonnet & Cariou, 2007, p. 16). 

            Levels above 140 should be taken very serious, especially if the patient does not have a diabetic history.  

CONSIDER TREATMENTS

                

          Depending on your level of certification, field personnel should consider the following where local protocols allow:

Lactated Ringers over Normal Saline:

Normal Saline is basically NACL in water (although for purposes of serum sodium, it neither adds nor subtracts sodium, however Lactated Ringers is different:

Lactated Ringers normally is made up of the following:

130 meq of sodium ion = 130 mmol/l

109 meq of chloride ion = 109 mmol/l

28 meq of lactate = 28 mmol/l

4 meq of potassium ion = 4 mmol/l

3 meq of calcium ion = 1.5 mmol/l

            The important thing about Lactated Ringers is that its lactate ions are involved with acid/base metabolism. Lactate being metabolized in the (normal) will buffer acidosis.   There are different types of crystalloid fluids. Crystalloids such as lactated ringers (LR) or PlasmaLyte are considered "balanced fluids," while chloride-rich fluids such as normal saline (NS) are not.

           

            Dr. Evan Schwarz, MD conducted research on the use of LR vs NS and discovered the following:          

            A recent review cited several studies associating NS infusions with the development of a hyperchloremic metabolic acidosis, in addition to other findings of questionable clinical importance. Recently, other studies demonstrated that NS leads to more adverse events and worse patient outcomes compared with resuscitation with a balanced fluid. A large retrospective cohort study compared patients undergoing either elective or emergent open general surgical operations that received either NS or a balanced fluid the day of the procedure. Unadjusted in-hospital mortality (5.6% CI 5.3-5.8 versus 2.9% CI 2.0-4.2; P<0.001) and the number of patients developing major complications (33.7 versus 23%) were significantly greater in the group that received NS compared with the group that received balanced crystalloids.

           

            After using propensity scoring to correct for multiple variables, the difference in mortality was no longer significantly different; however, patients that received NS were 4.8 times more likely to require dialysis (P<0.001). In addition, an analysis of patients requiring emergent general surgery showed an adjusted odds of death nearly 50% less in the cohort that received a balanced resuscitation compared with NS (OR 0.51 CI 0.28-0.95).(Schwarz, 2015)

           

            While some articles and studies have suggested that the use of LR makes no difference, with just one article that indicates it does make a difference (even though there are tons that indicates LR is best) why not err on the side of caution and use LR for the aggressive treatment of Sepsis?

           

            Rapid restoration of deficient fluid levels not only will modulate inflammation if it exists but will in fact, reduce the need for drug therapy (Levinson, Casserly, & Levy, 2011).

           

             In one study performed on 263 patients there was a 16% mortality reduction in patients that received rapid fluid resuscitation compared to those that did not. 

Early-Goal-Directed Therapy

           

            While this article is meant to focus on field interventions of sepsis it should be mentioned about the importance of ‘Early Goal-Directed Therapy.’  EGDT includes the study mentioned previously where the patients received rapid fluid resuscitation along with the monitoring of central venous pressure (CVP) and central venous oxygen saturation (Scvo2).  Of the 263 patients in the group, those that received EGDT had an overall 46.5% mortality reduction.  Despite clear and documented evidence of the effectiveness of EGDT it is still underutilized and controversial (Levinson et al., 2011).

Vasopressin

           

            In some states, the use of Vasopressin is approved for the use by Advanced EMTs, whereas other frontline medications for sepsis are not, such as dopamine.  Vasopressin is a drug then when used correctly increases MAP (Mean Arterial Pressure) while at the same time decrease catecholamine requirements.

            The goal of using vasopressin is to improve tissue perfusion and also to improve cellular derangements caused by any form of sepsis and septic shock.  While several studies may lead to a possible belief that vasopressin, when used alone, has a little effect on mortality rates, there are no studies that indicate it has a negative effect when used.  A logical theory would be to use vasopressin in extreme cases due to the fact it is a treatment, howbeit small, it is a treatment that could reduce mortality. 

            The use of vasopressin in combination with corticosteroids showed a 44.7% less mortality rate than by not using vasopressin.  The use of just norepinephrine and corticosteroids showed only a 35.9% lower mortality rate. (Gordon, 2014, p. 8)

Dopamine

           

            The goal of any vasopressor therapy is to improve the perfusion of tissue and cellular derangements that is normally caused by septic shock (Levinson, Casserly, & Levy, 2011, p. 5).

Norepinephrine as a first line vasopressor has been a long time recommendation, but also dopamine has been recommended as well as a first line vasopressor.  Whereas dopamine was used as the first line medication, a slight increase in cardiac arrhythmias was reported (Levinson et al., 2011, p. 5).  On most ambulances, dopamine is carried routinely while other drugs used in the treatment for septic shock are not, so dopamine may be the drug to utilize to extreme sepsis patients. 

High Flow Oxygen

           

            While considerations must be given to patients with severe respiratory compromise, the use of high flow oxygen must be used when treating patients with suspected sepsis.  A target of SpO2 of 95% must be utilized at all times.  The EMS worker must also understand that SpO2 devices are not always presenting a true reading and what may appear normal, may indeed be false.  High Flow O2 with a minimum of 10LPM must be maintained in the patient that meets positive qSOFA criteria.  

References

Angus, D. C., & Singer, M. (2016, February 23). The Third International Consensus Definitions for Sepsis and Septic Shock(Sepsis-3). JAMA, 315(8), 801-810. Retrieved from http///jama.jamanetwork.com

Deutschman, C., & Tracey, K. (2014, April 17). Sepsis: current dogma and new perspectives. immunity 40, 463-475.

Gordon, E. (2014, September 12). The Combination of vasopressin and corticosteroids in septic shock. , (), . http://dx.doi.org/Retrieved from

Hunter, C. (2014, March 3 ). Use end-tidal carbon dioxide to diagnose sepsis. Journal of Emergency Medical Services, 1-5.

Levinson, A., Casserly, B., & Levy, M. (2011). Reducing mortality in severe sepsis and septic shock. Semin Respir Crit Care Med, 1-14.

Mathonnet, A., & Cariou, A. (2007). Glycemic Control in Sepsis. Advances in Sepsis, 6(1), 16-18.

Schwarz, E. (2015). In sepsis, fluid choice matters. Retrieved from http://www.medpagetoday.com/Blogs/EPMonthly/51742

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