Emergency medicine clinics of North America
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Emerg. Med. Clin. North Am. · Feb 2017
ReviewAntimicrobial Stewardship in the Management of Sepsis.
Sepsis represents a unique clinical dilemma with regard to antimicrobial stewardship. The standard approach to suspected sepsis in the emergency department centers on fluid resuscitation and timely broad-spectrum antimicrobials. The lack of gold standard diagnostics and evolving definitions for sepsis introduce a significant degree of diagnostic uncertainty that may raise the potential for inappropriate antimicrobial prescribing. Intervention bundles that combine traditional quality improvement strategies with emerging electronic health record-based clinical decision support tools and rapid molecular diagnostics represent the most promising approach to enhancing antimicrobial stewardship in the management of suspected sepsis in the emergency department.
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Pediatric sepsis is distinct from adult sepsis in its definitions, clinical presentations, and management. Recognition of pediatric sepsis is complicated by the various pediatric-specific comorbidities that contribute to its mortality and the age- and development-specific vital sign and clinical parameters that obscure its recognition. This article outlines the clinical presentation and management of sepsis in neonates, infants, and children, and highlights some key populations who require specialized care.
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Our evolving understanding of the physiologic processes that lead to sepsis has led to updated consensus guidelines outlining priorities in the recognition and treatment of septic patients. However, an enormous question remains when considering how to best implement these guidelines in settings with limited resources, which include rural US emergency departments and low- and middle-income countries. The core principles of sepsis management should be a priority in community emergency departments. Similarly, cost-effective interventions are key priorities in low- and middle-income countries; however, consideration must be given to the unique challenges associated with such settings.
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Sepsis is a challenging, dynamic, pathophysiology requiring expertise in diagnosis and management. Controversy exists as to the most sensitive early indicators of sepsis and sepsis severity. ⋯ Awareness of these potential knowledge gaps is important for the emergency provider managing the septic patient. Specific areas of management including the initiation and management of mechanical ventilation, the appropriate disposition of the patient, and consideration of transfer to higher levels of care are reviewed.
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Emerg. Med. Clin. North Am. · Feb 2017
ReviewThe Past, Present, and Future of the Centers for Medicare and Medicaid Services Quality Measure SEP-1: The Early Management Bundle for Severe Sepsis/Septic Shock.
SEP-1, the new national quality measure on sepsis, resulted from an undertaking to standardize care for severe sepsis and septic shock regardless of the size of the emergency department where the patient is being treated. SEP-1 does not necessarily follow the best current evidence available. ⋯ SEP-1 is the first national quality measure on early management of sepsis care. This article provides a review of SEP-1 and all its potential implications on sepsis care in the United States.