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Using Emergency Departments to Stop the Deadly Spread of Sepsis

Monday, August 07, 2006

Stopping the deadly spread of sepsis when an infected person arrives at its emergency department is the aim of a new program being introduced at the University of Rochester Medical Center – the first of its kind in Rochester. An inflammatory infection that affects the entire body, sepsis is legendary for how quickly it can spread, becoming a fatal disease in a matter of hours.

“Time is of essence for a patient with sepsis,” said Christine Miyake, M.D., a third-year resident in Strong Memorial Hospital’s Emergency Department who is leading the collaborative effort with the hospital’s critical care physicians. “We have a very short window of opportunity to stop the spread of sepsis, or at least, greatly diminish its destructive – and often fatal – attack on the body.”

The new procedure, called “Early Directed Goal Therapy,” is based on a program created and tested by an emergency room physician in Michigan, who showed that aggressive treatment while a patient is still in the emergency department, and not yet admitted to an intensive care unit (ICU), led to a 16 percent reduction in overall mortality rates. This landmark study, first published by Emanuel Rivers, M.D. in 2001 in the New England Journal of Medicine, is now becoming the standard of care at large academic medical centers nationwide.

“Up until this study was published, we really had no effective intervention for sepsis,” Miyake said. “Now, just like we fast-track very specific treatments for heart attack and stroke patients, we can begin aggressively treating septic patients.’

Researchers estimate that 750,000 cases of severe sepsis occur each year, more than congestive heart failure, or breast cancer, colon cancer and AIDS combined. It begins with an infection that triggers an inflammation response throughout a person’s entire body. This whole-body response to infection – termed sepsis – produces changes in temperature, blood pressure, heart rate, white blood cell count, and lung function. Half of all people diagnosed with sepsis will die. Strong estimates that it treats about 150 sepsis patients each year in its intensive care units.

Early Directed Goal Therapy aggressively aims to treat patients during what is known as the “golden hours.”  During these “golden hours,” which tend to occur while a patient is being evaluated in an emergency department, dramatic changes are occurring at the cellular level, but a patient is not yet showing classic symptoms of acute onset of sepsis.  As the massive infection spreads throughout the body, it interferes with the body’s ability to maintain adequate oxygen at the cellular level. Once these oxygen levels start to skew, the body quickly begins to experience a domino-like series of events including high fever, respiratory distress, low blood pressure and eventually, multiple organ failure.

The new protocol aims to maintain a steady balance of oxygen at the cellular level, by placing a sophisticated catheter near the heart to measure central venous oxygen levels. Using continuous readings from the catheter as a guide, physicians then use a variety of therapies, including drugs, assisted ventilation and even blood transfusions, to help reach very specific “goals” in patients’ oxygen levels and other vital signs.

Emergency medicine physicians at Strong will seek to diagnose septic patients and start the aggressive therapy within one hour of being seen. The entire cycle of Early Directed Goal Therapy takes about six hours to complete. Both emergency department and ICU physicians are trained in the protocols so that treatment can be continued seamlessly, regardless of the patient’s location.

Barry Evans, R.N., a critical care nurse who is collaborating with Miyake to implement the therapy at Strong Memorial, is hopeful it will improve the prognosis of admitted sepsis patients.

“Often, by the time septic patients come to our unit, their body is spiraling into organ failure, making it a very difficult recovery process, if they survive at all,” Evans said.  “It’s gratifying to know that we now have a very specific protocol that we know is proven to improve both mortality and morbidity outcomes which can be administered the moment the patient enters the hospital.”

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