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The Resus Room

Podcasts from the website TheResusRoom.co.uk Promoting excellent care in and around the resus room, concentrating on critical appraisal, evidenced based medicine and international guidelines.
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Now displaying: February, 2018
Feb 22, 2018

So the three of us are back together and going to take on Sepsis!

It's vital to have a sound understanding of sepsis. It has a huge morbidity and mortality but importantly there is so much that we can do both prehospital and in hospital to improve patient outcomes.

In the podcast we cover the following;

  • Definitions
  • Scale of problem
  • Different bodies; NICE/Sepsis Trust/3rd international consensus definition including qSOFA
  • Handover and pre alerts
  • Treatment; Sepsis 6
  • The evidence base behind treatment
  • Contentious areas
    •  Prehospital abx
    • Fever control
    • Steroids
    • ETCO2

We hope the podcast helps refresh your knowledge on the topic and brings about some clarity on some contentious points. As always don't just take our word for it, go and have a look at the primary literature referenced below.

Enjoy!

SimonRob & James

References & Further Reading

Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Kumar. Critical Care Medicine. 2006

Prognostic value of timing of antibiotic administration in patientswith septic shock treated with early quantitative resuscitation. Ryoo SM. Am J Med Sci. 2015 

The association between time to antibiotics and relevant clinicaloutcomes in emergency department patients with various stages of sepsis: a prospective multi-center study. de Groot B. Crit Care. 2015

Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Puskarich MA. Crit Care Med. 2011

Early goal-directed therapy in the treatment of severe sepsis and septic shock. Rivers E. N Engl J Med. 2001

Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Nguyen HB. Crit Care Med. 2004 

The prognostic value of blood lactate levels relative to that of vitalsigns in the pre-hospital setting: a pilot study. Jansen TC Crit Care. 2008

Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. Jones AE. JAMA. 2010

Lower versus higher hemoglobin threshold for transfusion in septic shock. Holst LB. N Engl J Med. 2014

A randomized trial of protocol-based care for early septic shock. ProCESS Investigators. N Engl J Med. 2014

Trial of early, goal-directed resuscitation for septic shock. Mouncey PR. N Engl J Med. 2015

Goal-directed resuscitation for patients with early septic shock. ARISE Investigators. N Engl J Med. 2014

Acetaminophen for Fever in Critically Ill Patients with SuspectedInfection. Young P. N Engl J Med. 2015

NICE; Sepsis: recognition, diagnosis and early management

The Sepsis Trust

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Singer M. JAMA. 2016

NHS E; Improving outcomes for patients with sepsis. A cross-system action plan

Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. Alam N. Lancet Respir Med. 2018

Adjunctive Glucocorticoid Therapy in Patients with Septic ShockVenkatesh B. N Engl J Med. 2018

PHEMCAST; End Tidal Carbon Dioxide

Current clinical controversies in the management of sepsis. Cohen J. J R Coll Physicians Edinb. 2016

St Emlyns; qSOFA 

RCEM; Severe Sepsis and Septic Shock Clinical Audit 2016/2017 National report

RCEM & UK Sepsis Trust; Toolkit: Emergency Department management of Sepsis in adults and young people over 12 years- 2016

Feb 12, 2018

On a not infrequent basis we will come across patients in hospital who have a CT head scan that appears to show an unsurvivable event. Having sourced opinion from our neurosurgical and neurology colleagues we may well be given the advice to withdraw care for the patient.

It has become increasingly recognised that prognosticating in such patients at an early stage is extremely difficult with numerous cases surviving what was initially thought to be an unsurvivable event, with a good neurological outcome.

This joint document from the Intensive Care Society, Royal College of Emergency Medicine, Neuro Anaesthesia and Critical Care Society of Great Britain & Ireland and the Welsh Intensive Care Society gives new guidance for such perceived devastating brain injuries and will challenge many peoples thinking on the topic with additional questions being asked on resource utilisation.

In this podcast Caroline Leech, EM and PHEM Consultant in Coventry, discusses the guidelines and the implications they hold for our practice.

As always make sure you read the document yourself, we would love to hear your thoughts.

Enjoy!

Simon & Caroline

References

Management of Perceived Devastating Brain Injury After Hospital Admission; A consensus statement 

A case for stopping the early withdrawal of life sustainingtherapies in patients with devastating brain injuriesManara AR. J Intensive Care Soc. 2016

Feb 1, 2018

Welcome back, we've got 3 absolute beauties of papers for you this month!

You'll have struggled not to have heard about the ADRENAL trial, a trial of iv steroids in the sickest of patients with septic shock. We also have a look at a trial that many have been quoting as sound evidence for the utility of pH during the prognostication of patients in cardiac arrest. Finally we have a look at a paper that may shed some concern on the use of Double Sequential Defibrillation that we covered recently on the podcast...

We'd love to hear from you with any thoughts or feedback you have on the podcast. And we've now launched of Critical Appraisal Lowdown course, so if you want to gain some more skills in critical appraisal make sure you go and check out our online course here.

Enjoy!

Simon & Rob

References & Further Reading

TheBottomLine; ADRENAL

St Emlyns; ADRENAL

Adjunctive Glucocorticoid Therapy in Patients with Septic ShockVenkatesh B. N Engl J Med. 2018

External Defibrillator Damage Associated With Attempted Synchronized Dual-Dose CardioversionGerstein NS. Ann Emerg Med. 2018

Initial blood pH during cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients: a multicenter observational registry-based study. Shin J. Crit Care. 2017

 

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