September 13 is World Sepsis Day and the whole month of September is filled with campaigns designed to help both the public and healthcare facilities recognize sepsis symptoms and seek help faster. I once thought that sepsis was diagnosed by a positive blood culture. Now I know that belief is overly simplistic. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. The body begins to shut down with responses beyond the immune system.
- Sepsis affects 27 to 30 million people each year.
- Sepsis kills 7 to 9 million people annually – one death every 3.5 seconds.
- One-third of survivors have increased risk of death the following year.
- One-sixth of survivors experience cognitive impairment or severe physical disability.
At the American Association of Clinical Chemistry (AACC) annual meeting this past August, there were eight sessions updating laboratorians on usage of lactate and procalcitonin measurements in the first critical hours upon presentation to the emergency room. Some workshops included agreements between the ER and the laboratory to provide rapid turnaround times on both collection and report completion. Within one hour the blood cultures are drawn prior to starting antibiotics. The risk of death from sepsis increases by as much as 8 percent for every hour treatment is delayed. Admission to the ICU will enable monitoring as fluids are pushed and tissue perfusion is watched. As many as 80 percent of sepsis deaths could be prevented with rapid diagnosis and treatment.
Current guidelines involve source control intervention as soon as possible. If shock is refractory to fluids, initiate vasopressor therapy with mean arterial pressure (MAP) target >= 65 mmHG (norepinephrine as first line; vasopressin or epinephrine can be added if necessary).
Some of us recall a fellow informaticist who died of untreated septic shock. Eileen came from Singapore to the January 2012 San Antonio Health Level 7 (HL7) meeting. An expert informaticist in her thirties, recently married and on track to attain leadership status in the Singapore Ministry of Health, she had run a half-marathon two weeks before the meeting. She left Singapore feeling healthy and well, but arrived in San Antonio with low grade fever, nausea and vomiting. On the second day of the meeting, Eileen collapsed in the hallway of the hotel. Unconscious, she was transported to the closest ER, in a 300-bed community hospital.
She was in the ER for five hours. They did lab tests and a complete history and physical exam, but they were thinking of exotic tropical diseases due to her recent travel and home country. Admitted to a regular medical ward, she went into cardiac arrest and was resuscitated. They moved her to the ICU, but Eileen never regained consciousness and developed full body edema and renal failure. Her cause of death was Group A Streptococcus sepsis. Her sepsis went unrecognized even with classic symptoms (fever, nausea, vomiting, hypotension, high lactic acid, abnormal white count).
The clinicians were not bad, they just didn’t apply all the knowledge they held. When trying to make a diagnosis, it is important to focus on the most likely possibilities first. As the saying goes, “when you hear hoof beats, think of horses not zebras.” There are sepsis decision support algorithms and protocols that can be implemented. A recent article in the Journal of the American Medical Association found the 2013 implementation of sepsis regulations in New York State significantly reduced sepsis mortality rates, from 26.3 percent to 22 percent, compared to four states without regulation implementation. Evidence-based medicine would not only mean greater survival with early detection, but also follow up with strategies to watch survivors for cognitive impairment or physical deterioration after discharge. Another article found that sepsis accounts for more 30-day readmissions (and is more costly) than chronic obstructive pulmonary disease (COPD), pneumonia, heart attacks and heart failure, all of which are tracked by Center for Medicare & Medicaid Services.
For the sake of your loved ones, know the physical signs of sepsis and when to seek help. Remember that it’s about “TIME”:
T – Temperature. Higher or lower than normal
I – Infection. May have signs of respiratory or urinary tract infection
M – Mental decline. Are they confused, sleepy, hard to wake up
E – Extremely ill. Severe pain, discomfort, or a feeling of impending doom
Be sure to state at the beginning of a call for help for your loved one that you are concerned about sepsis. Get the clinician and staff to invoke protocols quickly.
We wish you and your families wellness.