Early Detection and Treatment of Patients with Severe Sepsis by Prehospital Personnel

Guerra, Wayne; Mayfield, Thomas R.; Meyers, Mary S.; Clouatre, Anne E.; Riccio, John

doi:10.1016/j.jemermed.2012.11.003

Cited by 87 publications

(69 citation statements)

References 32 publications

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“…A compelling case has been made for increasing EMS involvement in the recognition and care of patients with severe sepsis and septic shock, but we have identified only one report that has detailed the implementation of and preliminary experience with a specific sepsis-targeted EMS educational curriculum and treatment protocol 10–15,25. The practical execution of EMS sepsis programs, particularly those that incorporate diagnostic tools not traditionally available in the prehospital setting, should be an area of focus for contemporary EMS research agendas.…”

Section: Discussionmentioning

confidence: 99%

Prehospital Lactate Measurement by Emergency Medical Services in Patients Meeting Sepsis Criteria

Boland

Hokanson

Fernstrom

et al. 2016

WestJEM

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IntroductionWe aimed to pilot test the delivery of sepsis education to emergency medical services (EMS) providers and the feasibility of equipping them with temporal artery thermometers (TATs) and handheld lactate meters to aid in the prehospital recognition of sepsis.MethodsThis study used a convenience sample of prehospital patients meeting established criteria for sepsis. Paramedics received education on systemic inflammatory response syndrome (SIRS) criteria, were trained in the use of TATs and hand-held lactate meters, and enrolled patients who had a recent history of infection, met ≥ 2 SIRS criteria, and were being transported to a participating hospital. Blood lactate was measured by paramedics in the prehospital setting and again in the emergency department (ED) via usual care. Paramedics entered data using an online database accessible at the point of care.ResultsPrehospital lactate values obtained by paramedics ranged from 0.8 to 9.8 mmol/L, and an elevated lactate (i.e. ≥ 4.0) was documented in 13 of 112 enrolled patients (12%). The unadjusted correlation of prehospital and ED lactate values was 0.57 (p< 0.001). The median interval between paramedic assessment of blood lactate and the electronic posting of the ED-measured lactate value in the hospital record was 111 minutes. Overall, 91 patients (81%) were hospitalized after ED evaluation, 27 (24%) were ultimately diagnosed with sepsis, and 3 (3%) died during hospitalization. Subjects with elevated prehospital lactate were somewhat more likely to have been admitted to the intensive care unit (23% vs 15%) and to have been diagnosed with sepsis (38% vs 22%) than those with normal lactate levels, but these differences were not statistically significant.ConclusionIn this pilot, EMS use of a combination of objective SIRS criteria, subjective assessment of infection, and blood lactate measurements did not achieve a level of diagnostic accuracy for sepsis that would warrant hospital prenotification and committed resources at a receiving hospital based on EMS assessment alone. Nevertheless, this work provides an early model for increasing EMS awareness and the implementation of novel devices that may enhance the prehospital assessment for sepsis. Additional translational research studies with larger numbers of patients and more robust methods are needed.

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Section: Discussionmentioning

confidence: 99%

Prehospital Lactate Measurement by Emergency Medical Services in Patients Meeting Sepsis Criteria

Boland

Hokanson

Fernstrom

et al. 2016

WestJEM

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“…Septic shock and multiple organ dysfunction syndrome (MODS) often occur in patients with sepsis (1,2). Despite decades of research, the mortality rates of patients with sepsis remain high and sepsis is one of the major reasons for deaths of patients in ICU (3).…”

Section: Introductionmentioning

confidence: 99%

IGF-1 may predict the severity and outcome of patients with sepsis and be associated with microRNA-1 level changes

Zhang

Liu

et al. 2017

Experimental and Therapeutic Medicine

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Abstract. IGF-1 functions as an anti-oxidative stress molecule and some critical patients with sepsis have a lower level of serum IGF-1. However, the association between IGF-1 and the severity or prognosis of sepsis remains unclear. This study aimed to elucidate the relationship between serum IGF-1 levels and the severity and prognosis of sepsis, and the possible mechanism was analyzed. Clinical characteristics of patients with sepsis were recorded and analyzed. Serum IGF-1 levels and micro (mi)RNA-1 levels were tested using radioimmunoassay and reverse transcription-quantitative polymerase chain reaction (RT-qPCR) analysis, respectively. The A549 cell line and HKC cell line were cultured in vitro and exposed to H 2 O 2 with or without IGF-1 treatment. Cell death was detected by analyzing cell death markers via ELISA kits, and miRNA-1 levels were detected after H 2 O 2 exposure using RT-qPCR analysis. miRNA-1 in cells was upregulated by transfection and IGF-1 mRNA was detected to determine its relationship with miRNA-1. Once again, cell ELISA kits were used to analyze cell death markers after transfection. Serum IGF-1 levels were reduced in patients with sepsis, whereas miRNA-1 levels were higher (P<0.05 vs. healthy control). Patients in the septic shock subgroup or dead patients had the lowest IGF-1 levels and the highest miRNA-1 levels (P<0.05 vs. sepsis and severe sepsis). IGF-1 levels were inversely proportional to the miRNA-1 level. In vitro, IGF-1 reduced the cell death caused by H 2 O 2 . miRNA-1 transfection effectively increased the sensitivity of cells to H 2 O 2 damage by reducing the expression of IGF-1, which was able to prevent cells from injury caused by H 2 O 2 . The transfection of negative control miRNA did not influence the level of IGF-1 miRNA and the sensitivity to H 2 O 2 damage. In conclusion, low IGF-1 levels in patients with sepsis may predict increased severity of the condition and poor prognosis. The possible mechanism is that the excessive miRNA-1 levels reduce IGF-1 levels, resulting in insufficient anti-oxidative action by IGF-1 which increases the injury caused by oxidative stress in patients with sepsis.

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“…Small studies suggest that EMS recognition of severe sepsis may be beneficial in reducing time to initiation of antibiotic and intravenous fluid administration [9, 10]. However, these reports have utilized screening tools that demonstrate low sensitivity to rule out sepsis, have not been formally validated, or require point-of-care diagnostic testing such as point-of-care venous lactate that is not readily available to most EMS providers [10–12].…”

Section: Introductionmentioning

confidence: 99%

Prehospital recognition of severe sepsis: development and validation of a novel EMS screening tool

Polito

Isakov

Yancey

et al. 2015

The American Journal of Emergency Medicine

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Objective-To derive and validate a predictive model and novel Emergency Medical Services (EMS) screening tool for severe sepsis (SS). Design-Retrospective cohort study.Setting-A single EMS system and an urban, public hospital.Patients-Sequential adult, non-trauma, non-arrest, at-risk, EMS-transported patients between January 1, 2011 and December 31, 2012. At-risk patients were defined as having all 3 of the following criteria present in the EMS setting: heart rate >90bpm, 2) respiratory rate >20bpm, and 3) systolic blood pressure <110mmHg. Interventions-None.Measurements and Main Results-Among 66,439 EMS encounters, 555 met criteria for analysis. Fourteen percent (n=75) of patients had SS, of which 19% (n=14) were identified by EMS clinical judgment. In-hospital mortality for patients with SS was 31% (n=23). Six EMS characteristics were found to be predictors of SS: older age, transport from nursing home, Emergency Medical Dispatch (EMD) 9-1-1 chief complaint category of "Sick Person", hot tactile temperature assessment, low systolic blood pressure, and low oxygen saturation. The final predictive model showed good discrimination in derivation and validation subgroups (AUC 0.843 and 0.820, respectively). Sensitivity of the final model was 91% in the derivation group and 78% in the validation group. At a pre-defined threshold of 2 or more points, prehospital severe sepsis (PRESS) score sensitivity was 86%.Corresponding Author: Carmen C Polito, MD, MS, Division of Pulmonary, Allergy, and Critical Care Medicine, Emory University School of Medicine, 615 Michael Street, Suite 205M, Atlanta, GA 30322, Phone: (404) 712-2970, Fax: (404) 712-2974, cpolito@emory.edu. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Conclusions-The PRESS score is a novel EMS screening tool for SS that demonstrates a sensitivity of 86% and specificity of 47%. Additional validation is needed before this tool can be recommended for widespread clinical use. HHS Public Access

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Early Detection and Treatment of Patients with Severe Sepsis by Prehospital Personnel

Cited by 87 publications

References 32 publications

Prehospital Lactate Measurement by Emergency Medical Services in Patients Meeting Sepsis Criteria

Prehospital Lactate Measurement by Emergency Medical Services in Patients Meeting Sepsis Criteria

IGF-1 may predict the severity and outcome of patients with sepsis and be associated with microRNA-1 level changes

Prehospital recognition of severe sepsis: development and validation of a novel EMS screening tool

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