Chapters Transcript Video B.L.A.S.T. Sepsis RYAN MCCORKLE: I'm Ryan McCorkle. I'm just an ER doc up at Round Rock, and I'm excited to come and talk to you about things we've been doing there to take care of our septic patients in the emergency room and then throughout the hospital. This is something that I've been passionate about for a long time. I've been doing it for about eight years between Florida and here. And the reason that it excites me is I'm not trying to sell you a new drug, sell you a new device. This is just practicing medicine the way we learned to practice it, doing it in the right time and in the right order in order to save patients' lives. And I think that's why we all went into medicine, so that's why I feel like this is something we can really get excited about-- if we do things in the right order. And that's where this mnemonic BLAST sepsis comes into play. This is a mnemonic I've been using for eight years, and I feel like it works well, both for physicians and for our nursing colleagues, to remember what you need to do when you see a septic patient. That's Blood cultures; Lactic acid; Antibiotics, in less than three hours; saline, minimum of 30 ccs per kilo; and Take repeat vital signs to see how your interventions are doing. BLAST sepsis. We've been doing that at Round Rock for about a year and a half, and we've had really good success moving our mortality numbers. We've been excited about that. And we've been moving it out across the system and seeing the same kind of thing when we implement this. So I know a lot of you have read recent literature that's come out, especially New England Journal of Medicine-- April 2, actually, just a couple of weeks ago, and again about six months ago-- about early goal-directed therapy for sepsis and how outcomes were not necessarily better when they implemented the entire early goal-directed therapy bundle in the emergency department. It was done in England and another one in Australia. I don't want that to impact the momentum that we've got in caring for our septic patients, because if you look at those papers, what it was was early goal-directed therapy, the complete bundle, including arterial lines, blood transfusions, all those things done int he emergency department, versus what they call protocolized therapy. And that's what BLAST sepsis is-- it's protocolized therapy. So when you read those papers, you see, as opposed to the entire art-line, ScvO2 monitoring, blood transfusion, just the protocolized therapy with blood cultures, lactic acid, antibiotics, and saline-- those patients did equivalently well in survival. So that's why we continue to do this-- because it works. And those papers bear that out. So just as a review, because this is the reason we miss septic patients, is going over what the SIRS criteria are, how that continuum moves into sepsis, and then to severe sepsis, and finally to septic shock. Why is this important? I think, across the hospital, we know what to do when STEMI comes in, when stroke comes in. Those things have become rote. If you look at the incidence and the mortality, though, sepsis has twice the incidence of STEMI, three times the mortality. Stroke, it's about half the incidence, because when you factor in TIAs, small strokes versus large strokes, there's more of that. But the mortality is still greater in sepsis. So this is the thing that kills our patients the most. And that's why we have to get excited about it-- because this is where we can save lives. So the SIRS criteria. Even medical-- the medical students that I've had come through from Texas A&M have really gotten on top of this in the last year or so. Before that it's really hard to remember, and I think for even myself, those of us who graduated a little while ago, it's not something that we necessarily remember, because it's not intuitive, especially in the emergency department. The temperature being less than 96.8 or greater than 100.4. Temp of 100.4 doesn't get any of us excited, anywhere in the hospital, but it's a SIRS criteria, and it's gotta to start to raise your level of awareness. This is the big one, I think. Heart rate greater than 90. For those of us that work in the ER, heart rate of greater than 90 is not tachycardic. That does not move the needle at all for us. But you have to remember, when that little old lady comes in from the nursing home with altered mental status and a heart rate of 92 and a white count of 15, she's got two SIRS criteria. And that's what we miss. Respiratory rate greater than 20. PaCO2 we don't measure as much in the ER, but that respiratory rate greater than 20 is also a difficult one to remember. White count less than 4, greater than 12. Less than 4 might get our attention, but a white count of 12 or 13, again, doesn't move the needle very much. That's why you've gotta see the global picture of the patient. If they have two of these and a source of infection, you've got a septic patient on your hands, and you need to pay attention a little more closely than you would otherwise. The other thing that I like to point out is this is where our-- the art of clinical medicine comes into play. If you have a patient with strep throat, they come in, they've got 102 fever and a heart rate of 105-- are they septic? Yes, there are. They have two SIRS criteria and a source of infection. Did that patient get admitted to the hospital? Absolutely not. We treat those patients and send them home all the time. So that's where the art of medicine comes into play, about yes, it's a septic patient. Is this a septic patient who's at risk to move to severe sepsis, septic shock? Because those are the patients that we miss that end up on the floor that end up crashing. Highly suspected infection. So, here, across our partnership at St. David's, 60% of our septic patients have pneumonia. So that's where the interventions can be the most helpful. We have to realize that our patients don't just have pneumonia. They have pneumonia and sepsis. Because those are our patients that go upstairs and crash. We admit a lot of pneumonia. We admit a lot of elderly pneumonia. And those are the people that tend to circle the drain if we're not paying attention to when they develop those two SIRS criteria. Obviously, urinary tract infection. I think the other one we sometimes miss, especially us as emergency physicians, is the abdominal source. A patient with appendicitis and cholecystitis who's tachycardic, febrile, has a high white count, is a septic patient, and our job is not done just with a call to the surgeon. We've got to get the blood cultures, the lactic acid, those antibiotics in, and adequate fluid resuscitation. Obviously, CMS. Meningitis. Skin and soft tissue is one we miss a lot. This is one I talk to the ER doctors about extensively. If you have a patient that you think the cellulitis is bad enough that they need to be admitted to the hospital for IV antibiotics, in the back of your mind you're saying to yourself and to the admitting physician, this patient has potential to do poorly. This patient could become septic. Therefore there's no reason, if you're going to admit for IV antibiotics, not to go ahead and do blood cultures, lactic acid, and at least adequate fluid resuscitation. And that goes for all of these, but I think cellulitis is one where we just go, it looks bad. I'm going to go ahead and give some IV antibiotics and admit. Let's not be done there. Let's cover those patients that are going to go on to do poorly by doing the right things in the right order at the right time. Septic joints, wound infections. Anybody who's had an implantable device. Endocarditis, obviously. Anybody who's got PICC lines, ports, those are often our sources. And even people who have two [INAUDIBLE] abscess. Again, just like we were talking about with cholecystitis and appendicitis, your job's not done just with a call to the OB/GYN. You've gotta do those BLAST interventions. Severe sepsis. I think this is the one we kind of miss out on a little bit. We can recognize those two SIRS criteria, source of infection. Say we have a septic patient. And all of us know septic shock when it comes in the door. They're hypotensive, they're tachycardic, they look terrible. Severe sepsis are patients with two SIRS criteria, source of infection, and evidence of end organ damage. These are the patients that are going to go on to do poorly quickly, but that don't look as severe in the emergency department. Again, it's important to distinguish acute and chronic. If you have a dialysis patient that comes in, their elevated creatinine is not evidence of end organ damage unless it's up from their baseline. And then we can talk about all the-- the different things that are indicative of end organ damage. Something new in the last one to two days. Obviously, if they have respiratory failure from their pneumonia, you need to cover them for sepsis, not just for the pneumonia. You intubate them. They need blood cultures, they need lactic acid, they need their antibiotics in less than 60 minutes for patients in septic shock, less than three hours for severe sepsis. Cardiovascular, obviously, if you're patient's hypotensive. When we talk about the definition, septic shock is hypertension despite adequate fluid resuscitation. You give that patient 30 ccs per kilo, they're still hypotensive-- that's septic shock. But an initial low blood pressure that responds to fluids is still severe sepsis. I think neurologic is the one we see most often, and that's our nonverbal patient from the nursing home who's just not quite as with it as they are normally. That's the bane of our existence in the emergency departments. Really frustrating for us. And we see it over and over and over again. But a lot of times that's telling us this patients is septic. Their mental status has been compromised by an infection going on somewhere, and those are the ones that crash. We talked about renal, bumping your creatinine. Bumping your liver enzymes. And obviously the lactic acid, the reason why we do it is it's a measure of tissue ischemia, right? And that's what all this is. This all means you're not adequately perfusing your end organs, and those are giving you evidence of their end organ damage. The lactic acid is a measure of all that globally. And that's why it's important we have it. Finally, if you've compromised your ability to clot, your platelets are down, your INR is up, that's again indicative of severe sepsis. And again, like we just mentioned, 30 ccs per kilo, you're still hypotensive, you're in septic shock. This is the one where we should get excited. This is our STEMI, this is our stroke. When this patient comes in-- febrile, tachycardic, hypotensive-- everybody should be on board, everybody should be in the room, just like they are for a stroke or a STEMI. These are the patients that need their antibiotics in less than 30 minutes. They need huge fluid boluses. Don't be shy with three, four, five liters. Sometimes they need 18 liters in the first 24 hours. So your two or three are fine. And this is what I preach, preach, preach to our ER doctors-- there's no CHF, there's no renal failure that you can't give 30 ccs per kilo to, because lasix and dialysis can get out any fluids you give, but if you don't give it, your patient's going to do very Poorly. So don't be shy with the fluids. The other thing I talk about with our ER doctors is, if you're giving a pressor, put it in a central line. If they have adequate peripheral access, 18, 20 gauges, you have two of them, three of them, your patient's not hypotensive, doesn't require fluids, that's an intellectual discussion you can have. If you've gotta start a pressor, you need a central line. It's sloppy and it's poor medicine to start giving Levophed through a peripheral line. It's easy to do, and when I used to give this talk five years ago, we would have to talk about using an ultrasound for internal jugular central line, which is my preference, because I have good visualization, it's easy to do. But there's a lot of people that I worked with that weren't comfortable with that, that's not what they were trained in. But we would say, oh, femoral lines are dirty, they have greater rates of infection. That's been disproven now in study after study in the last three years. Femeral line is fine. So I enjoy giving this talk now and being able to tell my colleagues, if you have to put in a femoral, that's OK. We prefer to do the high lines, but don't be shy about a femoral because the literature has borne out. There's no difference in the rate of infection. Base oppressors, this is another question that I get very often. Levophed is your first line pressor. Why? The New England Journal of Medicine, May, 2013, Levophed versus dopamine. Equivalent survival at 30 days. Dopamine, statistically significant more adverse cardiac events. V-fib, V-tach. That's why we use Levophed. They don't survive any better than dopamine, but they have less arrhythmias. So that's why we go with our first-- first line is Levophed. And again, this is where the literature shifts. When I was a resident, they called Levophed leave-em-dead, and it was the last pressor we went to, everybody avoided it like the plague. It's now your first line pressor and your patients survive better with less cardiac events. ICU bed. The other thing is these patients that are a medical emergency, it is our responsibility in the ER to be on top of those patients, get the fluids, get the antibiotics, get the central line, get the pressor started. But they need to move through quickly to the ICU where they have a better ratio, they're taken care of better in a two-to-one environment, rather than a four-to-one environment. And that's the carrot rather than the stick that we use with the ER people of, yes, this is a lot of work, yes, it's gotta be done quickly, yes, you have to be on top of it. But then that patient moves through to where they need to be so they can get their definitive care. This is another thing we've really, really been blessed with in Round Rock-- and I think you all are across the system-- that our intensivists have been extremely involved, very helpful, and very encouraging. When we get on these patients, we do those interventions, they're great about-- even coming into the ER to see them. We're very receptive about taking that patient and arranging to get them a bed in the ICU quickly. We don't need to wait for their hepatic function panel to come back in a septic shock patient, right? I don't have to wait for all the labs to be back. They're hypotensive, they're tachycardic, they're febrile, we've got the source of infection, we've given the broad spectrum antibiotics. I don't need every lab result. This patient needs to be where they can be taken care of in the best way, and our intensivists have been incredibly helpful in that way. And they've been very appreciative of when we have been getting this treatment bundled on and putting in those lines. So the bundle element. This is where the BLAST come in. You're gonna hear me hammer that all talk long. Hopefully you'll remember it by the time we're done. Blood cultures, Lactic acid, Antibiotics, fluid bolas. And when we say fluid bolas, that's 30 ccs per kilo, at least a liter. So there's different reasons how people will come to doing this. It's already CMS requirements for giving an aspirin for STEMI, things we do for stroke. This is going to be a CMS requirement. It will be the next one. If you get good at it now, it will make your life easier in the long run. You're gonna have to do these things. So if you learn to do them now, it becomes your routine, your life will be easier when you have to do it and somebody has given consequences if we don't do it. I hope this is the least motivating for people, but also, when you do these things, even for patients with sepsis, just two search criteria and source of infection, they need to be admitted to the hospital, you are providing critical care. You document your critical care time, you document your interventions, you document how your patient responded to those interventions, and you've given critical care. This is a disease process with 30% to 40% percent mortality. The definition of critical care is a life or limb-threatening intervention. You are doing that. Therefore you are entitled to the critical care and the reimbursement that comes with that. This is one opportunity where doing good can help you do well. I hope that's not your motivation, but you gotta hit everybody where they live. So that is another reason why we need to do this. So blood cultures. Blood cultures are important because, as physicians, we want to be good stewards of our antibiotics. We know that that is the coming plague of the next century, is resisting antibiotics. If we overuse our broad spectrum antibiotics, we're going to lose them. So blood cultures are important so that we can pare down the broad spectrum we start in the ER when the cultures come back. 30% to 50% have positive blood cultures, but then we changed antibiotic medicine, antibiotic treatment, about 10% to 20% of the time. So while it's important, nobody's life was ever saved with a blood culture. Therefore, in the ER, you document you attempted to get them, but you don't hold the antibiotics until you get blood cultures. Antibiotics will help your patient live. Waiting around to get blood cultures before you give them will kill your patient. So you document you attempted it, you couldn't get them, you moved on. They're important, but it's not the lifesaving measure. If you have a patient with a PICC line or a port, always remember to draw one of the cultures off that. Lactic acid. The point of this graph here is to show you kind of where it shifts. It really shifts big time over four. Between two and four it should get your attention. What this is is you may have a patient who hasn't yet become hypotensive, just has their two SIRS criteria, doesn't look that bad. That lactic acid comes back at three and a half or four, all your spider sense should go off that if this patient is gonna do poorly, they're gonna do poorly quickly. That patient has evidence that they're ischemic to their end organs, and they're the one that's going to crash while they're up on the floor. So a normal lactate, you can still be septic, you can still develop septic shock. A high lactate means your patient's about to go down the tubes, you need to be paying attention and paying attention quickly. I encourage our nurses at Round Rock to go ahead and draw lactic acids. I think it's one of the barriers we have to getting the bundle done, because it's a gray top on ice. And a gray top on ice is not in the standard nurse's rainbow. So it has-- it requires communication that not only do we have to draw the regular rainbow, we have to draw that gray top on ice. I think something that's helping that is we're going to the i-STAT lactic acids. It'll be a little bit easier to do those. But you have to remember not to do them with a tourniquet. This is a little bit for our nursing colleagues that were kind enough to show up today. If you do it with a tourniquet on, you've created localized tissue ischemia. You're gonna falsely elevate your lactate. You've gotta take the tourniquet off and draw a new sample to do the i-STAT. But, if we forgot to do the gray top on ice instead of delaying that, you can get one in two or three minutes right there in the emergency room. Antibiotics. So this is what saves our patient's lives. I spent a lot of time doing a masters in public health, but still, statistics make my eyes glaze over and give me [INAUDIBLE]. The only thing that I think is important is the number I put here in red. 5.77. If you get your antibiotics in less than three hours in the emergency room for sepsis or less than an hour for septic shock-- if you do that for six patients, you're gonna a patient who lived who otherwise would have died. And that's why we practice medicine. Nothing should get us more engaged and more excited about taking care of septic patients than that. If you do this, your patient will live. Six times, one will live who would have died. Again, that's also an important number. For every hour that you delay giving their antibiotics, you've increased their mortality 7.6%. I rounded it to 10%. Just say every hour you wait, you've increased that patient's chance of dying 10%. That's why we say try to get blood cultures, don't delay antibiotics to wait for blood cultures. That's why. Here's a second intervention that saves lives. Again, not too much stats, but there's the number. If you give adequate fluid resuscitation to your patients-- at least at 30 ccs per kilo-- do that to seven patients, you'll have a patient who lives who would have died. So we've hammered this over and over and over. It's become part of our culture at Round Rock, and I think that's why our mortality-- I know that's why our mortality has improved significantly. This is everywhere in the ER, it's above every workstation for the nurses and for the doctors. Everybody knows BLAST. It's on the tip of everyone's tongue. The Blood cultures, the Lactic acid, either POC or the gray top on ice. Getting those Antibiotics in. At least a liter of Saline, and not saying, oh, this patient has some CHF, oh, this patient has some renal failure, maybe we should just do a 250cc bolas. No. That is arcane, archaic medicine. We have to give adequate fluid resuscitation to septic patients. Worst case scenario, you have to intubate your patient. If you read Manny Rivers' study, early intubation is a good intervention for a patient in septic shock. There's no downside to giving the fluid. Just do it. And then Take repeat blood pressures. We have to know if that patient drops their pressure, if they progress to septic shock from severe sepsis. So that's where the T comes in. And again, that's for our nursing colleagues. What have we done there? I need to do this again, but it's been about a year ago we met with all the nursing staff. I gave this talk, kind of went over those things. I need to go back and do that again for reinforcement. We also got badge cards made. Our poor nurses' badges hang down to their feet now because they have so many badge cards. But it has the BLAST and it has the surge criteria on it for quick reference. So they have two SIRS, they can't remember what they are-- there they are. What do we need to do? Flipside, there's the BLAST if I can't remember. This is an example of the first ones that had the SIRS on them, the definitions of sepsis, severe sepsis, and septic shock. And then update this to have the BLAST on it. The other thing is we have our monthly emergency department meetings and our interventions have been going back and talking to the physicians, not only about our opportunities for improvement when we had a case that we missed-- because those real cases really are what brings it home to people. This was a patient, this was a person we had in the ER, this was a person who was septic, we didn't do the proper interventions, they did poorly, or they could have done better. That really brings it home for people. On the flipside, I try to always bring a case where we had a patient who was extremely sick, you did the right things, look how well they did. They survived, they went home to their families. That encouragement, that reinforcement really helps on a monthly basis. We also look at our mortality rates. The individual cases, I think, really bring it home. But it's also important to show them, on a global level, here's how well you've done providing that care. Here's how your mortality has come down because you're doing those things. Again, I think a huge element of this has been involving our-- being involved with our critical care specialists. How great they've been, how encouraging they've been, and how involved they are with our septic patients and their care. And because we've talked about how it brings it home, I want to end with a couple of case studies. These are actual patients we had in the Round Rock emergency department that we talked about at our monthly meetings. So you have a 68-year-old male who presents in the ED with right upper quadrant pain after eating for the last two days. No fever, no vomiting, no diarrhea. I think most of us have already got a pretty honed differential in our head already. No real huge past medical history, but he is hypertensive, he is diabetic. Those are his past surgical. He has no allergies, no social history. Now vital signs-- temperature 98, pulse 102, respiration's 18, blood pressure 142 over 89, setting 98% on room air. How many SIRS criteria do we see? One. Right? So maybe you have a suspected source of infection. You've got one SIRS criteria. This is not moving the needle for anybody yet. Physical exam. Pretty unremarkable, other than he's a little bit tachycardic at 102, and he's tender in his right upper quadrant. Here's his labs. How many SIRS criteria does he have? Two. He's got a heart rate of 102, he's got a white count of 14.3. He's got two SIRS criteria, and a potential source of infection in his abdomen. This is a septic patient. Now your needle should move just a little bit, just a little bit. Chest x-ray is clean. Again, I think we all had this in our differential right off the bat. He's got acute cholecystitis. Now he's got a confirmed source of infection and two SIRS criteria. What do we do? He's in pain, we gave him pain medication. Excellent. He was nauseous, we gave him some nausea medication. He improved, he felt better. We called the surgeon, said yeah, thanks for the call, got it taken care of. Acute cholecystitis. Let's put him on the med/surg floor. We'll do his gallbladder in the morning. 3:00 AM, rapid response team called to the floor. Temp's 101, heart rate's 130, blood pressure's 89 over 43. Patient's in septic shock. We took care of their pain, we took care of their nausea. We didn't take care of what threatened their life, and that was the sepsis. We didn't give him the fluids, we didn't give him the antibiotics. Patient went to the ICU, they got their central line placed emergently at 3:00 in the morning. They had to get seven liters of fluid resuscitation. They were on vasopressors for 24 hours. This was a good case to discuss, because the outcome isn't as bad as other ones that we could have done. But we don't want to bring the room down too badly. So he stayed four days in the ICU. Then he got his cholecystectomy. He had to be discharged to a rehab facility. Had a total of 10 days of inpatient stay. As long as we're being honest about how it can be a motivating factor for us that, if we provide good care, you get your reimbursement, this is, of course, a system-wide motivator. If we do these things for the patient, their length of stay is decreased, their ICU length of stay is decreased. And that's where-- on a system level that's where their motivation is. Second case. 45-year-old female presents with fever, cough, rhinorrhea and flu for three days. How many of these patients will we be seeing over the flu season? 10,000? More than that? Does any of this move the needle for anybody? This is a lean-track patient, right? Cough and flu-like symptoms. Hundreds a day. Went to the lean-track for immediate bedding and triage. Feeling a little bit of hypertension. She's had a couple of c-sections. Allergic to sulfa. Not a smoker. Now, after direct bedding, they get their triage in the lean-track. How many SIRS criteria do they have? AUDIENCE: Three. RYAN MCCORKLE: Do they have any evidence of end organ damage? Respiratory? They're hypoxic. Three SIRS criteria. A source. Cough, rhinorrhea, flu. Evidence of end organ damage. What is this? Sepsis. Not just sepsis. Severe sepsis, right? We've got evidence of end organ damage. Our blood pressure's OK right now. It's borderline, but we're not septic shock right off the bat. Here's your physical exam. Obviously the rhonchi that you can hear when you listen to the lungs. And she's tachycardic. Otherwise, not remarkable. Now how many SIRS criteria does she have? She got all four of them. She took them all off. Chest x-ray was unremarkable, though. Didn't have infiltrates at this point. That's why pneumonia is a clinical diagnosis and not a radiological. 15 minutes after the initial triage, lean-track approaches the charge nurse and the physician, says patient looks really bad in the lean-track. We need to move them into the regular part of the ER, the regular bed. Vitals re-checked. Now what does she have? She's in septic shock within 15 minutes of coming through the door. I don't know how these patients do this for three days at home with no problem and then crash within 10 minutes of arriving to the ER, but they do it consistently. So this is where code sepsis comes into play. This is four nurses in the room. You have a young, pretty healthy patient. The docs in the room. Immediately, these are the patients we have to converge on and do our intervention. The doc was in the room. There were three nurses in the room. She gets intubated, she gets her central line, she gets four liters of fluid in the first hour through her central line. Vanco and Zosyn came from the [INAUDIBLE]. She got broad spectrum antibiotics immediately. They were hung in 10 minutes. And they gave rectal Tylenol for her fever. From door to ICU, 70 minutes. Her next set of labs come back in six hours. Her white count's gone to 22. She's got more evidence of end organ damage with her creatinine, her liver enzymes. Lactic acid is 4.7. 4 is where the mortality shifts. We talked about 2 to 4 gets your attention, this patient is going to do poorly soon. Greater than 4, your patient has a hugely increased mortality. Now she's got diffuse bilateral infiltrates on her chest x-ray after her fluid resuscitation. [INAUDIBLE] your pneumonia. But she was influenza A positive. You withhold those antibiotics because she had a viral syndrome. Not in the ER-- again, that's why we do cultures, that's why we do this, so that we can tailor it down. But this is a patient in septic shock. They still needed those broad spectrum antibiotics to be given. She was on the oscillating vent for 24 hours. She got 14 liters in her first 24 hours of stay. Briefly on basic pressors, for a few hours. Weaned from the bed on day three. Moved out of the ICU. Discharged home in seven days. Back to her husband, her two kids. No sequelae of her disease. Why is that? Because the nurses-- especially the nurse, in this case, right off the bat-- and the physicians were on top of it. They did those BLAST interventions. And this is a patient who lived who otherwise would have died. And again, that's why we all practice medicine. And I think that's why we can get excited about treating our septic patients. Appreciate your time. Anybody have any questions? Created by
