Online CME Questionnaire
The CME test and evaluation form based on this article are located online at www.ACEP.org/focuson.
The participant should, in order, review the learning objectives, read the article, and complete the CME post-test/evaluation form to receive credit. It should take approximately 1 hour to complete. You will be able to print your CME certificate immediately. The credit for this CME activity is available through April 30, 2015.
The management of sepsis requires a life-saving set of skills that emergency physicians are increasingly relied upon to possess at expert-level competency. While many iterations of sepsis management have emerged in the literature, this article will focus on noninvasive management of sepsis by reviewing the epidemiology and evolution of sepsis and sepsis care, as well as highlighting the indications, contraindications, and benefits of noninvasive management of sepsis.
Sepsis is the most expensive disease in the United States, costing the health care system approximately $50 billion annually.1 Sepsis is the number 10 cause of mortality.2 A large epidemiological study in 2001 placed the annual incidence at approximately 750,000 cases per year, with a mortality of 20%-30%.3 Sepsis disproportionately affects the elderly, with a 13-fold increase in relative risk for those older than 65. This same age group represents approximately 65% of total cases of sepsis.2 With our aging population and increasing life expectancy, the emergency physician has the potential to have considerable impact on the care of this disease process.
Table 1. SIRS Criteria
- Temperature >38°C or <36°C
- Heart rate >90 beats/min
- Tachypnea (respiratory rate >20 breaths/min) or PaCO2 <32 mm Hg
- WBC >12,000 cells/microL or <4,000 cells/microL
Sepsis was originally described as the presence of an infectious source plus at least two systemic inflammatory response syndrome (SIRS) criteria (Table 1). Severe sepsis was defined as sepsis with evidence of organ dysfunction. Septic shock is sepsis with hypotension.4 An updated definition of sepsis identifies this disease process as an infection plus some of a larger set of criteria that includes traditional SIRS criteria, as well as other markers of hemodynamic instability, inflammation, and organ dysfunction4 (Table 2).
Evolution of Bundled Therapy
Combining multiple evidence-based treatments in a standardized, bundled approach to sepsis has been discussed since 1976. A study of sepsis in a dog model identified a synergistic effect of fluid resuscitation plus antibiotics.5 In 2001, Dr. Rivers demonstrated that an early, algorithmic application of antibiotics, source control, volume resuscitation, vasopressors for those still in shock, and transfusion in the anemic significantly lowered both mortality and resource utilization.6
Table 2. International Sepsis Definition: Infection + Some of These Variables
General and Hemodynamic Variables
- Fever (38.5°C)
- Hypothermia (36°C)
- Altered mental status
- Arterial BP <90 mm Hg
- MAP <70 mm Hg
- SBP decrease >40 mm Hg
- Band forms >10%
- SvO2 <70%
- CRP >2 SD above reference value
Organ Dysfunction Variables
- Acute oliguria (<0.5 mL/kg per hour)
- Creatinine increase (>0.5 mg/dL)
- Coagulation abnormalities (INR >1.5 or a
- PTT >60 seconds
- Thrombocytopenia <100,000/microL
- Hyperbilirubinemia (>4 mg/dL)
Tissue Perfusion Variables
- Decreased capillary refill >2 seconds
- Hyperlactatemia >1 mmol/L
The real mortality benefit of bundled therapy lies in a consistent and systematic treatment protocol applied to every septic patient. Results of the Surviving Sepsis Campaign showed that bundled therapy for management of sepsis decreased mortality from 37% to 30.8%.7 Mortality decreased the longer an institution used standardized bundle therapy.8 Further, bundle therapy saves hospital and health care resources.5 Studies continue to show that bundled therapy is underutilized in septic patients. Frequently cited barriers include unavailability or expense of central venous monitoring devices, lack of nursing staff able to operate central venous pressure monitoring, and challenges in identifying septic patients.9 Noninvasive sepsis management can help with all of these cited barriers.
The growing literature describes sepsis management that provides an alternative to the invasive central venous pressure (CVP) and mixed-venous oxygen saturation monitoring central to
early goal-directed therapy (EGDT). Noninvasive therapy focuses on using dynamic ultrasound assessment of inferior vena cava (IVC) collapsibility to estimate intravascular volume status as an alternative to invasive CVP monitoring. Also, this model follows lactate to measure response to therapy versus mixed-venous oxygen levels. While the noninvasive management of sepsis is not supported by a body of evidence as robust as that for invasive monitoring, the existing literature is compelling.
Indications for noninvasive sepsis management include:
- Lactate over 4 or MAP less than 65 mm Hg after 2 L 0.9 NS bolus.
- Multiple large-bore (up to 3 × 18 g) IV access that can run fluids and multiple antibiotics simultaneously.
- Goal of treatment is curative.
- Patient habitus allows visualization of the IVC.10 Contraindications for noninvasive sepsis management include:
- Poor peripheral access.
- Poor ultrasound visualization of IVC.
- Vasopressor requirement.
- Severe septic shock.
- Pulse oximetry less than 90% on supplemental oxygen.
- Respiratory distress.
Table 3. Ultrasound Assessment of IVC Collapsibility
- Obtain a long axis view of the IVC by placing a curvilinear abdominal probe parallel with the spine below the subxyphoid, with the probe indicator toward the patient’s head.
- Slide 1-2 cm to the right to bring the IVC into view.
- Aim slightly toward the heart to bring the RA into view. Image should have the RA clearly leading into the IVC with the liver in view.
- Measure (either visually or in M-mode) 1 cm below the hepatic vein or 2-3 cm from the RA. A patient who is fluid responsive will have significant respiratory variation with each breath and will have roughly 50%-100% collapse of the IVC as negative intrathoracic pressure is generated with each breath.
- Resuscitate to the point where you visualize only 30% collapse of IVC.
If habitus limits view of the IVC, use the liver as an acoustic window, aiming from the RUQ toward the head. The solid nature of the liver will conduct sound waves more readily. If bowel gas obscures view, put pressure on the ultrasound probe and shake with low-amplitude, high-frequency oscillations to encourage peristalsis.
Ultrasound of the IVC
Ultrasound is a key component of a noninvasive approach to sepsis. The clinical ability to estimate volume status is limited at best. Dialysis literature has shown that measuring IVC collapse by ultrasound is a reliable method for estimating volume status. Ultrasound also reveals discordances between patients’ stated “dry weight,” vital signs, physical exam, and the patient’s true volume status. IVC ultrasound has been used successfully at many dialysis centers to guide therapy in volume loading or reducing patients.10
Studies have correlated increased IVC collapse with low CVP in septic patients.9 A correlation between low right atrial pressures and increased IVC collapse has also been described.6 Also, IVC collapsibility decreases in response to fluid therapy.11 Patients who were predicted to be volume responders (measured IVC collapse over 50%) showed statistically significant improvements in catheter-measured cardiac index, cardiac output, and mean arterial pressure after fluid resuscitation.12 A decrease in IVC collapsibility was found using visual qualitative and quantitative measures following multiple fluid boluses (20 mL/kg). This study also found a high degree of correlation between visual qualitative and M-mode quantitative measurements. This finding suggests that visual impression is as meaningful as objective measurement.13 These studies support the notion that IVC ultrasound can be used to track volume status in real time, giving emergency physicians data to support the aggressive volume resuscitation required in the early hours after sepsis has been identified.
Learning to estimate CVP is easy for the novice with limited or no ultrasound experience. Trained internal medicine residents with no formal ultrasound training were able to accurately estimate CVP, which was subsequently confirmed by atrial pressure via right heart catheterization.17 The easiest method is a visual, qualitative measurement. The diameter of the IVC is noted; any variation of this diameter with the cardiac cycle or obvious collapse suggests potential for volume responsiveness.18 The formal measurement of IVC collapse occurs as the patient “sniffs.” Qualitative visual IVC collapse of 50%-100% with this negative inspiratory pressure maneuver is highly suggestive of intravascular depletion that is volume responsive. Quantitative measurement involves placing the M-mode indicator 2-3 cm below the RA/IVC junction and measuring the diameter over time. As the M-mode traces the IVC diameter across the screen, ask the patient to “sniff.” If the comparison of caliper measurements of the IVC diameter before and after this maneuver shows collapse ranging from 50% to 100%, the patient is likely to be volume responsive.19
Following serum lactate is the other key component of the noninvasive approach to sepsis management. Lactate is an important marker used as a predictor for mortality in sepsis and shock.20 Lactate is easily obtained from any peripheral source; there is a high correlation between levels from arterial and venous sources.21 Further, lactate is a very reliable point-of-care test.22 A recent multicenter, randomized, controlled trial used lactate-guided therapy in septic patients, which led to patients receiving vasopressors and fluids earlier in therapy. It was also noted that a decreasein lactate levels within the first 8 hours of sepsis correlated with a decrease in mortality and morbidity.23 More specifically, a decrease in serum lactate of 10% over 2 hours in response to therapy corresponds with a significant decrease in mortality.24
Comparing response to therapy with lactate levels versus mixed-venous oxygen levels showed a statistically significant difference in mortality between groups.25 Further, lactate may be a superior marker for physicians to follow versus mixed-venous oxygenation. Response to therapy in patients undergoing EGDT showed that normalized mixed-venous oxygen saturation did not always predict an improvement in lactate or mortality.24 Trending lactate as a peripheral marker of sepsis is a valuable and valid tool in identifying and treating this disease process.
Initiating Noninvasive Management
Multiple protocols have adapted Dr. Rivers’ EGDT protocol to a noninvasive approach. The below protocol is adapted from the STOP Sepsis Collaborative (http://emcrit.org/wp-content/uploads/non-invasive.pdf).
For initial resuscitation, all patients should have reliable 18-g IV access at multiple sites, be placed on supplemental O2, and have blood drawn and sent for basic labs, ABG/VBG, and lactate levels in addition to blood cultures. Draw cultures from all indwelling vascular access devices. This resuscitation should not be performed with a single IV or one that is positional. The following also apply:
- Antibiotics should be given as soon as possible. Giving broad-spectrum antibiotics within the first hour carries a clear mortality benefit.25,26,28
- Source control is paramount.29 Note if the patient has a tense belly, necrotic tissue, decubitus ulcers, signs of CNS infection, indwelling devices, or rales or other pulmonary infectious symptoms.27
- Assess volume status using IVC ultrasound to estimate CVP/RA pressure. If greater than 50% collapse, large-volume resuscitation is needed.
- Administer 20-30 mL/kg crystalloid fluid bolus. Large volumes (over 6 L) of normal saline resuscitation will cause hyperchloremia and a resultant nongap acidosis. Consider lactated ringer’s for subsequent boluses if easily available.
- Be aware of laboratory values for evidence of severe sepsis (Table 2). Consider switching these patients to invasive management if they fail to improve their lactate by 10% in the first 2 hours.24
For management of noninvasive resuscitation, the following apply:
- Perform serial ultrasound assessments of the IVC after each bolus of crystalloid.
- Continue giving 500-mL to 1,000-mL boluses of crystaloid every 20 minutes until the IVC no longer shows significant collapse on ultrasound. There still should be respiratory variation of about 30% collapse (Table 3).
- Recheck MAP: If the patient remains hypotensive (MAP under 65 mm Hg) after adequate fluid loading, switch to invasive strategy in order to begin vasopressor therapy.
- Evaluate response to therapy with lactate levels every 2 hours. Assess mental status and urine output.
- If the lactate has decreased by 10%, continue resuscitation and admit to a non-ICU monitored bed.
- If lactate is rising or has decreased to less than 10% and hemoglobin is less than 7 g/dL, transfuse 1 U of PRBC.
- Transfusion may be considered in patients with hemoglobin of 7-10 g/dL. Also, continue additional 1,000-mL crystalloid volume resuscitation or start peripheral dobutamine to improve cardiac output.
- If the above therapies fail to reduce lactate by the second lactate level measured 4 hours into resuscitation, switch to invasive sepsis management.
Nonresponse to Management
For patients refractory to noninvasive sepsis therapy, place a central line and admit to the ICU.
Noninvasive management of sepsis is a compelling therapy from a number of perspectives: 1) prevention of central line placement, 2) broad applicability to centers with limited resource to follow central venous monitoring, 3) quicker and individualized approach to resuscitation. Time and well-conducted prospective trials will tell the difference between the invasive and noninvasive approaches. Currently, the data suggest that noninvasive sepsis management is safe and effective in appropriate patient populations.
Dr. Pendley is a third-year resident at the University of Chicago’s Emergency Medicine Residency Program. Dr. Ahn is a Medical Education Fellow and Clinical Instructor in the Section of Emergency Medicine at the University of Chicago Medical Center. Dr. Robert Solomon is Medical Editor of ACEP News and editor of the Focus On series, core faculty in the emergency medicine residency at Allegheny General Hospital, Pittsburgh, and Assistant Professor in the Department of Emergency Medicine at Temple University School of Medicine, Philadelphia.
Dr. Pendley, Dr. Ahn, and Dr. Solomon have disclosed that they have no significant relationships with or financial interests in any commercial companies that pertain to this article.
ACEP makes every effort to ensure that contributors to College-sponsored programs are knowledgeable authorities in their fields. Participants are nevertheless advised that the statements and opinions expressed in this article are provided as guidelines and should not be construed as College policy. The material contained herein is not intended to establish policy, procedure, or a standard of care. The views expressed in this article are those of the contributors and not necessarily the opinion or recommendation of ACEP. The College disclaims any liability or responsibility for the consequences of any actions taken in reliance on those statements or opinions.
- Shorr A. Economic implications of an evidence-based sepsis protocol: Can we improve outcomes and lower costs? Crit. Care Med. 2007;35:1257-62.
- Hotchkiss RS, et al. Apoptotic cell death in patients with sepsis, shock, and multiple organ dysfunction. Crit. Care Med 1999;27:1230-51.
- Angus DC, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit. Care Med 2001; 29:1303-1310.
- Angus DC, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29:1303-1310.
- American College of Chest Physicians/Society of Critical Care Medicine. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit. Care Med 1992;20:864-74.
- Rivers EP. Point: adherence to early goal-directed therapy: does it really matter? Yes. After a decade, the scientific proof speaks for itself. Chest 2010;138:476-80, 484-5.
- Rivers E. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N. Engl. J. Med. 2001;345:1368-77.
- Levy MM, et al.; Surviving Sepsis Campaign. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit. Care Med. 2010 Feb;38(2):367?74.
- Dellinger RP, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit. Care Med. 2008;36:296-327. Erratum in: Crit. Care Med. 2008;36:1394-6.
- Carlbom DJ, Rubenfeld GD. Barriers to implementing protocol-based sepsis resuscitation in the emergency department. Crit. Care Med. 2007;35:2525-32.
- Brennan JM, et al. Handcarried ultrasound measurement of the inferior vena cava for assessment of intravascular volume status in the outpatient hemodialysis clinic. Clin. J. Am. Soc. Nephrol. 2006;1:749-53.
- Carr BG, et al. Intensivist bedside ultrasound (INBU) for volume assessment in the intensive care unit. J. Trauma 2007:63:495-502.
- Kircher BJ, Himelman RB, Schiller NB. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am. J. Cardiol. 1990;66:493-6.
- Weekes A, et al. The sonodynamic study: Comparison of qualitative versus quantitative assessment and inter-rater reliability in serial ultrasonography evaluations of inferior vena cava dynamics and left ventricular systolic function in fluid resuscitation of emergency department patients with symptomatic hypotension. Ann. Emerg. Med. 2010;56(suppl):S77.
- Murphy C. The importance of fluid management in acute lung injury secondary to septic shock. Chest 2009;136:102-9.
- Dorrestrijn M. Iso-osmolar prehydration shifts the cytokine response towards a more anti-inflammatory balance in human endotoxemia. J. Endotox. Res. 2007;11:287.
- Ospina-Tascon G. Effects of fluids on microvascular perfusion in patients with severe sepsis. Intensive Care Med. 2010;36:949-55.
- Brennan JM, et al. A comparison by medicine residents of physical examination versus hand-carried ultrasound for estimation of right atrial pressure. Am. J. Cardiol. 2007;99:1614-6.
- Nagdev AD, et al. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. Ann. Emerg. Med. 2010;55:290-5.
- Yanagawa Y, Sakamoto T, Okada Y. Hypovolemic shock evaluated by sonographic measurement of the inferior vena cava during resuscitation in trauma patients. J. Trauma 2007;63:1245-8.
- Nguyen HB, et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit. Care Med. 2004;32:1637-42.
- Gallagher EJ, Rodriguez K, Touger M. Agreement between peripheral venous and arterial lactate levels. Ann. Emerg. Med. 1997;29:479-83.
- Shapiro NI, et al. The feasibility and accuracy of point-of-care lactate measurement in emergency department patients with suspected infection. J. Emerg. Med. 2009 (doi:10.1016/j.jemermed.2009.07.021).
- Jansen TC, et al., for the LACTATE Study Group. Early lactate-guided therapy in intensive care unit patients. Am. J. Respir. Crit. Care Med. 2010;182:752-61.
- Arnold RC, et al. Multicenter study of early lactate clearance as a determinant of survival in patients with presumed sepsis. Shock 2009;32:35-9.
- Jones AE, et al., and Emergency Medicine Shock Research Network Investigators. Lactate clearance vs. central venous oxygen saturation as goals of early sepsis therapy. JAMA 2010;303:739-46.
- Rivers EP, Coba V, Whitmill M. Early goal directed therapy in severe sepsis and septic shock. Curr. Opin. Anaesthesiol. 2008;21:128-40.
- Gaieski DF, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit. Care Med. 2010;38:1045-53.
- Marshall J, et al. Source control in the management of severe sepsis and septic shock. Crit. Care Med. 2004;32(11 suppl):S513-26.