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Management of the Sepsis Patient

Steven Q. Simpson, MD, pulmonology/critical care

Sepsis kills more than 500 people in the United States every day. Thanks to continued advancements in identification and early treatment, community physicians and their partners in larger Metropolitan hospitals are making a dent in that number. 

Sepsis is the major cause of morbidity and mortality worldwide. In the U.S., it is the 7th leading cause of death overall and the single most common cause of death among noncoronary ICU patients. Although we are making good progress in identifying and treating the condition, we expect the number of severe cases to increase more rapidly than the population growth, due to the graying of America and the high incidence of sepsis among the elderly.

Sepsis characteristics

Sepsis affects microcirculation and blood flow, resulting in:

  • Decreased RBC deformity
  • Increased capillary permeability
  • Disseminated intravascular coagulation
  • Intravascular pooling
  • Congestion and hemorrhage
  • Altered blood flow and resistance
  • Increased blood viscosity
  • Opening of A-V shunts and redistribution of organ flow

These factors can lead to organ dysfunction, severe hypotension or hypoperfusion, multiple organ dysfunction and death.

Identifying sepsis and severe sepsis 

Identifying sepsis at the bedside is clearly a challenge. Diagnosis often comes late in the progression, when treatment is less effective. Although the ICD-9 codes include clear diagnostic criteria, there is no single diagnostic test, such as troponin in myocardial infarction. Here's what the American College of Chest Physicians and Society of Critical Care Medicine agreed upon in 1992. 

Stages of sepsis

  1. Infection inflammatory response to microorganisms or invasion of normally sterile tissues
  2. SIRS (Systematic Inflammatory response Syndrome) Systemic response to a variety of processes
  3. Sepsis Infection PLUS 2 or more SIRS criteria
  4. Severe sepsis Sepsis PLUS organ dysfunction
  5. Septic shock Sepsis PLUS hypotension despite fluid resuscitation

SIRS criteria

  • Temperature > 38°C or < 36°C
  • HR >90 beats/min.
  • Respirations >20/min.
  • WBC >12,000/μL, <4,000/ μL, or >10% immature neutrophils

The biggest mistakes we make in this area are not recognizing that an infection has become septic and not taking action quickly enough to significantly affect mortality. The minute an infection causes an organ dysfunction, the mortality rate increases from around 5-30 percent or higher.

Often, we see something like pneumonia with fever. And then we detect a high WBC or tachypnea. The treatment team may treat this like a bad pneumonia but not sepsis – a potentially fatal misdiagnosis. At this stage, the patient has infection + SIRS. We need to be treating this as severe sepsis – delivering antibiotics immediately – before it turns into septic shock. We have to get past our fear of overreacting. In fact, the evidence indicates that we err on the side of over treatment. With a rapid response, we can save lives.

Mortality rates

Septic shock: 60-80%
With antibiotics in first hour: 18%

Rapid response is critical

In some cases, we identify the potential for sepsis early and prescribe antibiotics, but we don’t get them into the patient quickly enough. The answer can be as simple as issuing a STAT order or following up with the hospital's inpatient pharmacy and the patient to ensure rapid delivery. When we see a patient with a severe injury – say a bleeding artery – we don't delay. We take immediate action to stop the bleeding.

Similarly, if a patient enters the emergency room with an infection, he is probably sick enough to warrant STAT antibiotics.

  • Every hour we delay treatment, we add 7 percent to the mortality rate.
  • Elevated creatinine levels increase mortality dramatically.
  • Mortality for severe sepsis without rapid response is 30-50 percent.
  • If the patient develops shock, the mortality rate rises to 60-80 percent.
  • This is not just a community hospital problem. Even in major academic medical centers, the mortality rate for sepsis is 50 percent if treatment for septic shock is delayed more than four hours.

Kansas project improves outcomes

The University of Kansas Hospital has made great strides in improving outcomes for sepsis patients through early identification and a well established sepsis management protocol. The real opportunity for improvement lies in identifying and treating sepsis in the office or community hospital before it becomes severe.

The Kansas Sepsis Project is reducing sepsis mortality rates with a program that approaches continuing medical education in a unique way. Rather than taking rural physicians from their practices for a lecture, we are providing education in the field – through webcasts and on-site, small-group meetings. Participating physicians receive credits for using the program's online tools to measure and report sepsis treatment and follow patient outcomes through transfer, if needed. The project also fulfills the practice improvement requirement for family medicine and internal medicine board recertification.

Funding for the project comes from the American College of Chest Physicians, The University of Kansas Hospital, the University of Kansas Medical Center Office of Continuing Medical Education and Area health Education Centers and Pfizer. I am leading it, along with Lucas Pitts, MD, Pulmonary/ Critical Care, and Elizabeth Wenske-Mullinax, PhD.

We've begun the project at critical access hospitals in northwest Kansas. We chose this region not just because of our hospital’s relationship but also because of the state's geographic disparity. Kansas is at around the 10th largest among the 50 states in square miles. But its population is 32nd. More than half the population lives in rural counties with fewer than five people per square mile. 

We conducted focus groups around the state before launching the project. When talking with critical access hospitals, we found that few patients were being diagnosed with severe sepsis. Informally, the data we collected would indicate only about 100 cases of severe sepsis per year in the state. Actual epidemiological data puts the number at 10,000 – 100 times the perceived rate.

The project has been operational for nearly two years, but preliminary results are encouraging. When they begin, participants pull their hospitals’ infection records from the last six months. Of all the infected patients admitted, their analysis showed that nearly half had severe sepsis. However, even among patients who were transferred to larger facilities with a diagnosis such as severe pneumonia or renal failure, none were actually diagnosed with severe sepsis. Since beginning the project, participating critical access hospitals have made substantial improvements in the recognition and early treatment of sepsis, diagnosing nearly every case that presents to their hospitals.

We're expanding the project to reach the rest of the state, and we hope to extend it eventually throughout the country. 

Sepsis is an extremely deadly, yet quite treatable condition. Its identification and treatment protocols are clear. The gaps are in our education and in our practice. We simply aren't following the statistically proven science to identify and treat it as we should. We have a tremendous opportunity to change the sepsis mortality rate – at a time when its incidence is steadily increasing.

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