Sepsis in der Notfallmedizin

[Lactate in emergency medicine]

The basis of all metabolic processes in the human body is the production and metabolism of carriers of energy. Lactate is the end-product of anaerobic glycolysis. Lactate can serve as a substrate for gluconeogenesis and as an oxidation substrate. Hyperlactatemia can be detected as the result of a multitude of acute events (e.g. shock, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine deficiency, liver failure and intoxication). Hyperlactatemia can be associated with increased mortality, therefore in emergency medicine the search for the cause of hyperlactatemia is just as important as an effective causal treatment. Repetitive measurements of lactate are components of several treatment algorithms as observation of the dynamic development of blood lactate concentrations can help to make a better assessment of the acute medical condition of the patient and to evaluate the effectiveness of the measures undertaken.

Validity of the Manchester Triage System in patients with sepsis presenting at the ED: a first assessment

BACKGROUND

The Manchester Triage System (MTS) does not have a specific presentational flow chart for sepsis. The goal of this investigation was to determine adequacy of acuity assignment for patients with sepsis presenting at the ED and triaged using the MTS.

MATERIALS AND METHODS

This retrospective analysis included patients >16 presenting to an ED in Bonn, Germany, on the first 12 days of each month between June 2012 and March 2014. Patients were classified into one of three septic groups, or no sepsis. For those with sepsis, adequacy of acuity assignment was based on the criteria of the first consensus conference of the American College of Chest Physicians and Society of Critical Care Medicine, first published in 1992. Adequacy of prioritisation is expressed as sensitivity and likelihood ratio (LR-).

RESULTS

Among 20 836 patients evaluated, 801 (3.8%) were septic; of these, 581 (72.5%) had sepsis, 194 (24.2%) had severe sepsis and 26 (3.2%) had severe sepsis with circulation dysfunction. Patients who met the criteria for sepsis were correctly prioritised with a sensitivity of 70.4% (95% CI 66.5 to 74.0). The LR- was 0.628 (95% CI 0.564 to 0.698). Patients with severe sepsis were appropriately prioritised with a sensitivity of 84.5% (95% CI 78.1 to 89.4), and LR- was 0.330 (95% CI 0.243 to 0.450). In the group with severe sepsis and circulation dysfunction, sensitivity of MTS was 61.5% (95% CI 39.3 to 79.8), and LR- was 0.466 (95% CI 0.286 to 0.757).

CONCLUSIONS

The MTS has some weaknesses regarding priority levels in emergency patients with septic illness. Overall, target key symptoms (discriminators) which aim at identifying systemic infection and ascertaining vital parameters are insufficiently considered.

Severe sepsis and septic shock in pre-hospital emergency medicine: survey results of medical directors of emergency medical services concerning antibiotics, blood cultures and algorithms

Delayed antibiotic treatment for patients in severe sepsis and septic shock decreases the probability of survival. In this survey, medical directors of different emergency medical services (EMS) in Germany were asked if they are prepared for pre-hospital sepsis therapy with antibiotics or special algorithms to evaluate the individual preparations of the different rescue areas for the treatment of patients with this infectious disease. The objective of the survey was to obtain a general picture of the current status of the EMS with respect to rapid antibiotic treatment for sepsis. A total of 166 medical directors were invited to complete a short survey on behalf of the different rescue service districts in Germany via an electronic cover letter. Of the rescue districts, 25.6 % (n = 20) stated that they keep antibiotics on EMS vehicles. In addition, 2.6 % carry blood cultures on the vehicles. The most common antibiotic is ceftriaxone (third generation cephalosporin). In total, 8 (10.3 %) rescue districts use an algorithm for patients with sepsis, severe sepsis or septic shock. Although the German EMS is an emergency physician-based rescue system, special opportunities in the form of antibiotics on emergency physician vehicles are missing. Simultaneously, only 10.3 % of the rescue districts use a special algorithm for sepsis therapy. Sepsis, severe sepsis and septic shock do not appear to be prioritized as highly as these deadly diseases should be in the pre-hospital setting.