Septic shock in the ER: diagnostic and management challenges

Sepsis and Total Joint Arthroplasty

The number of annual total joint arthroplasties (TJA) is increasing. Periprosthetic joint infections (PJI) occur when there is infection involving the prosthesis and surrounding tissue, which has the potential to develop into sepsis if left untreated. Sepsis in patients who have undergone TJA is life threatening and requires urgent treatment. If sepsis is due to PJI, the focus should be on early intravenous antibiotics with aspiration as soon as possible to diagnose the infection. Patients who develop sepsis after surgery for PJI are particularly at high risk for mortality and need to be treated in the intensive care unit.

Normal Saline Solution or Lactated Ringer's Solution to Enhance Lactate Clearance in Septic Patients After Initial Resuscitation in the ED: A Retrospective Cohort Trial

Objective

To compare the effect of isotonic crystalloid solutions between lactated Ringer’s solution (LRS) and normal saline solution (NSS) on lactate clearance in septic patients at the emergency department (ED).

Materials and Methods

This study is a single-center retrospective chart review. The study enrolled patients older than 18 years with sepsis and initial serum lactate level >2 mg/dL in the ED. The primary outcome was to determine which isotonic solution was better for serum lactate clearance in septic patients. The secondary outcomes were serum creatinine change within 24 h and the 48-h survival rate after admission.

Results

A total of 120 patients were enrolled with a median crystalloid volume administered in the ED of 1000 mL. Within 2 h of resuscitation, there was no difference in lactate clearance between the LRS and NSS groups with median values of 29.2% and 25%, respectively (P=0.839). The 48-h survival rate after admission did not differ between the LRS and NSS groups with median values of 90% and 86%, respectively. Both isotonic solutions increased serum creatinine levels within 24 h of treatment with median values of 0.3 for each group (P=0.647).

Conclusion

Among septic patients in the ED treated with NSS or LRS, there was no difference in lactate clearance, serum creatinine change within 24 h, or 48-h survival. However, several factors were associated with increased lactate levels, such as older age and use of vasopressors and immunosuppressive agents.

Beyond the bundle: Clinical controversies in the management of sepsis in emergency medicine patients

Sepsis is a condition characterized by life-threatening organ dysfunction caused by a dysregulated host response to infection. The emergency department (ED) serves as a crucial entry point for patients presenting with sepsis. Given the heterogeneous presentation and high mortality rate associated with sepsis and septic shock, several clinical controversies have emerged in the management of sepsis. These include the use of novel therapeutic agents like angiotensin II, hydrocortisone, ascorbic acid, thiamine ("HAT") therapy, and levosimendan, Additionally, controversies with current treatments in vasopressor dosing, and the use of and balanced or unbalanced crystalloid are crucial to consider. The purpose of this review is to discuss clinical controversies in the management of septic patients, including the use of novel medications and dosing strategies, to assist providers in appropriately determining what treatment strategy is best suited for patients.

Intensive care nurses' awareness of identification of early sepsis findings

AIM

To determine intensive care nurses' awareness of identification of early sepsis findings.

BACKGROUND

The incidence of sepsis is increasing in intensive care units, and if not identified early, it increases morbidity, mortality and cost of care. Intervention within one hour after the diagnosis of sepsis increases survival. Nurses' ability to identify early findings of sepsis affects the time of diagnosis of sepsis.

DESIGN

The study used a cross-sectional design.

METHODS

The sample of the study consisted of 544 nurses working in adult intensive care units of hospitals in Turkey. The study data were collected online between 11 January-8 April 2021 using the snowball method. Data were statically analysed. All procedures of the study adhered to the STROBE guidelines.

RESULTS

The nurses who had been working for 11 years or more, had worked with a patient diagnosed with sepsis in the last month and used a measurement tool in the diagnosis thought that it was significantly easier to determine the early warning findings of sepsis. In the study, the majority of nurses correctly identified the early findings of sepsis, but the rates of the correct responses to the variables of lactate >2 mM, leucopenia and hypothermia were low. Female gender, having a graduate degree, unit type, total work experience, having received training on sepsis and working with a patient diagnosed with sepsis in the last month made a significant difference in determining the early warning findings of sepsis accurately.

CONCLUSIONS

Nurses had a good rate of identifying early sepsis findings. Yet, they could not distinguish between early sepsis and late sepsis findings.

RELEVANCE TO CLINICAL PRACTICE

The results of the study can support nursing practices in the diagnostic process by considering the factors affecting nurses' ability to distinguish early sepsis findings from late sepsis findings and to identify them correctly.