1. “She wasn’t febrile, so this can’t be sepsis.” Especially in the elderly, but also in patients with immunocompromise and malignancy, the febrile response to infection can be blunted. These patients also have a higher risk of multi-drug resistant pathogens and higher mortality, so they should be carefully handled.
2. “He has a history of congestive heart failure, and he presented short of breath and with peripheral edema; he looked pretty bad, so I put him on BiPAP, and I just gave him a little Lasix™. Lab just called me with a BNP of 550 so this is definitely CHF.” It may be CHF, but not necessarily. The role of BNP in the diagnosis of any disease is contextual, and its elevation in sepsis should make physicians wary of its use to guide decisions. CHF is a common comorbidity of patients with sepsis, and a septic patient with a history of CHF could easily present with shortness of breath, chronic edema, and abnormal lung sounds possibly suggesting volume overload. BNP elevations can occur in sepsis acutely, and it is also possible that the patient chronically has an elevated BNP.
3. “This guy was really sick, so I just threw in the central line quick.” The Institute of Health 100,000 Lives campaign identified a number of interventions that hospitals could institute to decrease mortality. Among the interventions were adopting a hospital-wide policy on central line placement and encouraging full sterile technique with pre-procedure hand washing, full drape, surgical cap, mask, gown, and gloves in addition to good technique, no matter the time constraints. Both via this campaign and in smaller studies, adopting a policy for better technique for central line placement had a noticeable impact on morbidity and mortality and has become the accepted standard of care.92
4. “My nurses just can’t get a central venous pressure, and he had good peripheral access, so I didn’t want to risk a central line. The ICU team can put it in.” Early Goal-Directed Therapy and subsequent studies have demonstrated a survival benefit in patients receiving goal-directed therapy within the first 6 hours. Accurate measurement of CVP and central venous oxygen saturations are critical to demonstrating the success of interventions intended to volume resuscitate and reverse the oxygen delivery derangements seen in sepsis. Put in the line now; do not wait for transfer to the ICU.
5. “He came from home, so I treated the pneumonia as community acquired.” The use of antibiotics with coverage of the eventual isolated organism has been shown to decrease mortality, length of ICU stay, and duration of antibiotics. Patients with health-care associated pneumonia (HCAP) have much the same pattern of atypical and potentially multi-drug resistant organisms as hospitalized patients. HCAP includes anyone hospitalized for 2 or more days within the previous 90 days, anyone residing in or recently discharged from a long term care facility, patients who received intravenous antibiotics, chemotherapy, or complicated wound care within the preceding 30 days, and all hemodialysis patients. Just coming from home does not qualify as “community acquired,” and patients who receive their care from multiple institutions and locations may require careful questioning to determine that they need a different cocktail of empiric antibiotics.
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