Updates and Controversies in the Early Management of Sepsis and Septic Shock (Pharmacology CME) -

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Faheem Guirgis, MD, FACEP

Associate Professor of Emergency Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, FL

 

Lauren Page Black, MD, MPH

Research Fellow, Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, FL

 

Elizabeth L. DeVos, MD, MPH, FACEP

Associate Professor, Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, FL

 

Peer Reviewers

 

Michael Allison, MD

Assistant Director, Adult Intensive Care Unit, Saint Agnes Hospital Center, Baltimore, MD

 

Jeremy Rose, MD, MPH

Assistant Medical Director, Emergency Medicine, Mount Sinai Beth Israel Hospital; Assistant Professor, Icahn School of Medicine at Mount Sinai, New York, NY

 

Eric M. Steinberg, DO, FACEP

Assistant Program Director, Emergency Medicine Residency, Mount Sinai Beth Israel; Assistant Professor of Emergency

 

Abstract

 

Sepsis is a common and life-threatening condition that requires early recognition and swift initial management. Diagnosis and treatment of sepsis and septic shock are fundamental for emergency clinicians, and include knowledge of clinical and laboratory indicators of subtle and overt organ dysfunction, infection source control, and protocols for prompt identification of the early signs of septic shock. This issue is a structured review of the literature on the management of sepsis, focusing on the current evidence, guidelines, and protocols.

 

Excerpt From This Issue

A 65-year-old man with COPD and diabetes presents from home with a productive cough (green sputum) for 1 week, dyspnea on exertion, and fever. Albuterol at home provided no relief. His vital signs are: heart rate, 102 beats/min; respiratory rate, 22 breaths/min; blood pressure, 130/89 mm Hg, and SpO₂, 94% on room air. He is speaking in full sentences and does not appear to be in respiratory distress. He has rales at the right lung base, mild wheezes, and tachycardia. Chest radiograph confirms right lower lobe pneumonia. The patient has no recent hospitalizations. You believe that he looks clinically well and may be able to be discharged home with antibiotics, but you are also concerned for sepsis and wonder if this would be a wise decision...

A 45-year-old man with hypertension and prostate cancer in remission presents complaining of 3 days of burning with urination, fevers, and chills. His vital signs are: heart rate, 110 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/90 mm Hg; SpO₂, 98% on room air; and temperature, 38.4°C (101.2°F). He is alert and fully oriented. His physical exam reveals mild suprapubic tenderness without rebound or guarding and bilateral costovertebral angle tenderness. Lab findings include a WBC count of 18,000 with 5% bands, a creatinine of 1.5 mg/dL, a platelet count of 130 x 10³/mm³, 80 WBCs on urinalysis with positive nitrite and leukocyte esterase, and a serum lactate of 1.2 mmol/L. After receiving ibuprofen and a fluid bolus, the patient feels better and states, “I need to go get my dog!” The nurse asks you if she can remove the IV for the patient to be discharged, which sounds reasonable, but something worries you...