# Sepsis and exacerbation of copd



## philslat (Nov 7, 2016)

A patient will/could  have sirs markers when having exacerbation of copd.
Are the conditions exclusive and would the treatment of the exacerbation take precedence over the sepsis or should both be treated at the same time.


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## FLdoc2011 (Nov 7, 2016)

Not entirely sure what is being asked as there are 3 different scenarios here:

1: COPD exacerbation 
2: Sepsis
3: COPD exacerbation AND sepsis

You're right though in that technically you meet criteria for SIRS during a COPD exacerbation,  not hard to do.   

The short answer is I would treat whatever I thought was going on.  If I thought there was a source of infection causing sepsis AND he also had a COPD flare then of course I would treat both as best I could.   

If he just has a COPD flare and meets SIRS criteria but I didn't think he had an ongoing infection then I'm just going to treat the COPD.


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## VentMonkey (Nov 7, 2016)

Short answer will mirror what @FLdoc2011 says. Assuming the COPD is exacerbated and more than likely caused the sepsis ( most likely pneumonia--->ARDS), the "ultimate fix/ treatment" is aimed at treating the _underlying cause_, meaning the sepsis.


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## VFlutter (Nov 7, 2016)

Many critically ill patients will meet SIRS criteria by definition but that does not necessarily mean they are truly having an inflammatory response. Take into account their labs, suspicion of infection, etc. Almost every patient in the ICU will meet SIRS criteria, many of whom are not septic/infected.


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## VentMonkey (Nov 7, 2016)

Chase said:


> Almost every patient in the ICU will meet SIRS criteria, many of whom are not septic/infected.


In your experience, how aggressive (or not), is the ICU in treating patients on the cusp, though by definition (repeat lab values, etc.) not septic, prophylactically?


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## philslat (Nov 7, 2016)

Thanks

Had a patient with copd exacerbation that had expected sirs markers ie resp and pulse rate added to an elevated blood glucose not a diabetic. I treated the copd with nebs and hydrocortisone but was wondering on reflection should I have treated her also as as sepsis. pt was Apyrexic.


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## VentMonkey (Nov 7, 2016)

philslat said:


> Thanks
> 
> Had a patient with copd exacerbation that had expected sirs markers ie resp and pulse rate added to an elevated blood glucose not a diabetic. I treated the copd with nebs and hydrocortisone but was wondering on reflection should I have treated her also as as sepsis. pt was Apyrexic.


Question: are we talking prehospital? If so aside from aggressive IVF in the face of severe sepsis and/ or hypotensive, not much more to do...unless you're at one of the few services trialing prehospital ABX.

Also without an iSTAT telling me their lactate was (>) 4, I don't know how much more aggressive I would be here.


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## Summit (Nov 7, 2016)

SIRS criteria are notoriously non-specific.

The intention was so that you do not forget to consider Sepsis in your differential, not to push it at the top.


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## philslat (Nov 8, 2016)

VentMonkey said:


> Question: are we talking prehospital? If so aside from aggressive IVF in the face of severe sepsis and/ or hypotensive, not much more to do...unless you're at one of the few services trialing prehospital ABX.
> 
> Also without an iSTAT telling me their lactate was (>) 4, I don't know how much more aggressive I would be here.



This was pre hospital in a rural setting
I suppose the question is how aggressive in the field should we be with sirs markers in a situation like this
I needed initially to use the copd exacerbation protocol/cpg. My sepsis protocol is paracetamol if temp warrants it. Benzylpenicillin and fluid bolus amount dependent on blood pressure. In this case her bp would have indicated a 250ml bolus of 9% normal saline and our antibiotic dosage pre hospital is 1200 mg


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## VentMonkey (Nov 8, 2016)

philslat said:


> This was pre hospital in a rural setting
> I suppose the question is how aggressive in the field should we be with sirs markers in a situation like this
> I needed initially to use the copd exacerbation protocol/cpg. My sepsis protocol is paracetamol if temp warrants it. Benzylpenicillin and fluid bolus amount dependent on blood pressure. In this case her bp would have indicated a 250ml bolus of 9% normal saline and our antibiotic dosage pre hospital is 1200 mg


Very good, kind sir. Clearly you aren't in "The States". Aggressiveness varies from region to region, country to country I would imagine.

FWIW, I too would like to know how aggressive you should have in regards to the region you practice in.


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## Summit (Nov 8, 2016)

Should you treat aggressively for sepsis?

The question is do you think there is a septic pathology present on top of the COPD exacerbation? Do you think there is a source of infection whether occult or not? That is what makes it sepsis.

And if you do think it is sepsis, 250mL NS is pissing on a forest fire.

Recommend you look at Sepsis-3 and qSOFA as another way to think of it. SBP<100, tachypneic, GCS<15? Two or more of those with suspected infection? That is the quick field alternative assessment to SIRS criteria.


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## VentMonkey (Nov 8, 2016)

Summit said:


> And if you do think it is sepsis, 250mL NS is pissing on a forest fire.


Nice! In all seriousness though, all solid points.


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## MonkeyArrow (Nov 8, 2016)

Summit said:


> Recommend you look at Sepsis-3 and qSOFA as another way to think of it. SBP<100, tachypneic, GCS<15? Two or more of those with suspected infection? That is the quick field alternative assessment to SIRS criteria.


qSOFA hasn't been shown to be a reliable indicator of sepsis. Instead, it has been proven as a prognostication factor for in-hospital morbidity and mortality.


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## Summit (Nov 8, 2016)

MonkeyArrow said:


> qSOFA hasn't been shown to be a reliable indicator of sepsis. Instead, it has been proven as a prognostication factor for in-hospital morbidity and mortality.


I think it is worthy of thought in a pre hospital pt with sirs criteria and confounding non infectious pathology.  I'm not saying to hang your hat on qSOFA alone .


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## VentMonkey (Nov 9, 2016)

I think something else worth mentioning here is that SIRS _criteria _does not equal sepsis. It can certainly _lead_ to sepsis, but to my knowledge there is a cascade of events beginning with SIRS (criteria) being markers, or signs/ symptoms, and perhaps indicative of sepsis. Perhaps @Summit, and/ or @Chase can even enlighten us as to how "sepsis bundles" work in hospital. While again, prehospital providers can initiate part of the 3 hour bundle, I view it like a STEMI or Stroke alert; you better be damn well sure you know what it is you're doing, and who you're treating. Let's not give ABX to every patient with a slight head cold.

Sepsis can quickly develop into severe sepsis--->septic shock--->MODS. The reason I bring this up is merely as a point to be made to all prehospital clinicians. The link in the chain of survival we provide is obviously system, and protocol dependent, but furthermore, understanding what it is we are ultimately trying to prevent, and what all we truly need to consider in order to help the ED point said patient in the right direction treatment-wise is crucial in about 15-20% of all patients encountered in the prehospital setting, this is one of those categories.

Again, I encourage _*all*_ paramedics to develop a better understanding of patient presentations, and clinical differences; I can't, and won't stop stressing it enough. That's the beauty of this forum. It's also another reason as a whole we stand to learn a lot from one another on here if not, when you encounter that EM physician, ICU nurse, or intensivist at a hospital. Learning opportunities come in many forms, do not waste them. There's no such thing as knowing too much, or knowing enough, but there is such a thing as knowing it all and blindly swinging at the wind when dealing with the very sick...don't be that guy, or gal...steps off soapbox.


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## medichopeful (Nov 9, 2016)

For a patient to be considered septic, they must also have a suspected or documented infection, remember.  Meeting SIRS criteria =/= septic in all patients.  Consider a trauma patient, or a case of heat exhaustion or heat stroke.  These patients will technically meet SIRS criteria, but will not (in most cases) be septic.

COPD exacerbations are often caused by an infection, but not always.  It's good that you're keeping sepsis in the back of your mind, because it's missed often and kills an absurdly high number of people in this country.  But not all patients that meet SIRS criteria are septic.

On a separate note, a patient can not meet SIRS criteria and be septic as all hell.  Things to consider.


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## medichopeful (Nov 9, 2016)

VentMonkey said:


> Question: are we talking prehospital? If so aside from aggressive IVF in the face of severe sepsis and/ or hypotensive, not much more to do...unless you're at one of the few services trialing prehospital ABX.
> 
> Also without an iSTAT telling me their lactate was (>) 4, I don't know how much more aggressive I would be here.



This, along with early administration of pressors for hypotension not responsive to fluids.


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## VentMonkey (Nov 9, 2016)

medichopeful said:


> For a patient to be considered septic, they must also have a suspected or documented infection, remember.  Meeting SIRS criteria =/= septic in all patients.  Consider a trauma patient, or a case of heat exhaustion or heat stroke.  These patients will technically meet SIRS criteria, but will not (in most cases) be septic.
> 
> COPD exacerbations are often caused by an infection, but not always.  It's good that you're keeping sepsis in the back of your mind, because it's missed often and kills an absurdly high number of people in this country.  But not all patients that meet SIRS criteria are septic.
> 
> On a separate note, a patient can not meet SIRS criteria and be septic as all hell.  Things to consider.


I think we're of the same thought process.


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## RRTMedic (Nov 13, 2016)

Have we forgotten that history of present illness is still an important diagnostic tool? Verses these "criteria" and protocols.


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## VentMonkey (Nov 13, 2016)

RRTMedic said:


> Have we forgotten that history of present illness is still an important diagnostic tool? Verses these "criteria" and protocols.


This goes without saying, IMO, but good point.


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## RRTMedic (Nov 13, 2016)

VentMonkey said:


> This goes without saying, IMO, but good point.



When we started doing "Sepsis Alerts" in my previous EMS company, it seemed that I could make anyone fit the criteria to call it in, start bilateral IVs, give 500 cc of fluid, and potentially start a pressor if their BP was low. I know it goes without saying, but I'm afraid we all get tied up in protocols at times and forget to look at the big picture and to see what is really going on. I know I catch myself doing that at times


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## VentMonkey (Nov 13, 2016)

RRTMedic said:


> When we started doing "Sepsis Alerts" in my previous EMS company, it seemed that I could make anyone fit the criteria to call it in, start bilateral IVs, give 500 cc of fluid, and potentially start a pressor if their BP was low. I know it goes without saying, but I'm afraid we all get tied up in protocols at times and forget to look at the big picture and to see what is really going on. I know I catch myself doing that at times


Yeah, I don't think you're wrong for pointing it out, @RRTMedic, I just think it's an issue when we as a whole have to constantly point it out to the not-so-critical-thinking inclined providers


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## gotbeerz001 (Nov 13, 2016)

Our criteria is:
1. Known source of infection AND 2 of the following 3 vitals: 
a. Temp over 99.4
b. HR over 90
c. RR over 20

I cannot fit everybody into this nor find starting fluids to be a bad thing in the presence of


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