Objectives:
1. Quantify the prevalence and magnitude of sepsis mortality as it relates to Emergency Medicine.
2. Understand the pathogenesis of early sepsis which provides the therapeutic rationale for early
goal-directed therapy.
3. Understand the components of a sepsis quality initiative and its salutary impact on patient
outcomes and health care resource consumption.
INTRODUCTION
A Change in the Paradigm of Treating
Severe Sepsis and Septic Shock
Improvement in mortality for acute
trauma2
myocardial
infarction1,
3
and stroke have been realized by a
coordinated team approach, beginning
in the emergency department (ED), to
provide early identification of high risk
patients and time sensitive evidencebased therapies. Over 500,000 patients
present each year to the ED with severe
sepsis and septic shock, having a
resulting mortality ranging from 20%The same approach provided
60%.4
for acute myocardial infarction (AMI),
trauma and stroke has been lacking for
early sepsis management until recently.
Early goal-directed therapy (EGDT)
was developed as a quality initiative
which includes 1) assessment of the
hospital sepsis prevalence and mortality,
2) early identification of high-risk
patients, 3) mobilization of resources
for intervention, 4) reversal of early
hemodynamic perturbations, 5) assessing
compliance, 6) dedicated education of
health providers, 7) quantifying health
care resource consumption and 8)
assessing outcomes (Figure 1).
www.emcreg.org
Over 500,000
patients present
each year to the ED
with severe sepsis
and septic shock,
having a resulting
mortality ranging
from 20%-60%.
37
38
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The use of
lactate 4 mmol/L
as a marker for
severe tissue
hypoperfusion and as
Figure 2. The study design of early goal-directed therapy (EGDT)
a predictor of
mortality is supported
by a number of studies.
___________
Lactate levels can
be performed by
venipuncture.
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39
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1. Mortality by 16-20%
2. Components of the inflammatory response
3. Morbidity of organ dysfunction
4. Need for vasopressor therapy
5. Need for mechanical ventilation
6. Sudden cardiopulmonary complications in
the first 24 hours
7. Length of hospital stay
8. Health care resource consumption
41
summary
EGDT results in significant reductions in morbidity,
mortality, vasopressor use, and health care resource
consumption. EGDT modulates some components of
inflammation, which is reflected by improved organ
function. The end-points used in the EGDT protocol,
outcome results and cost effectiveness have subsequently
been externally validated, revealing similar or even better
findings than the original trial. Adherence to the principles
of early recognition, early mobilization of resources,
and multidisciplinary collaboration is imperative if
improvements in the morbidity and mortality associated
with sepsis are to parallel those seen with other severe
disease states such as AMI, trauma and stroke.
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