Sepsis Diagnosis

Documented Or Suspected Infection And “Some” Of The Following

 

• Hyperthermia (T > 38.3°C [100.94°F])

• Hypothermia (T < 36°C [96.8°F])

• Tachycardia (HR > 90/minute)

• Tachypnea (respiratory rate > 20/minute)

• Acutely altered mental status

• Hyperglycemia (glucose > 120 mg/dL) in the absence of diabetes

• Significant edema (> 20 mL/kg positive fluid balance in 24 hours)

 

Signs Of Inflammation

• Leukocytosis (WBC > 12,000/mm) or > 10% immature forms

• Leukopenia (WBC < 4000/mm)

• C-reactive protein > 2 standard deviations above normal

• Plasma procalcitonin > 2 standard deviations above normal

 

Hemodynamics

• Hypotension (SBP < 90 mmHg, MAP < 70 mmHg)

• SvO  > 70%

• Cardiac index > 3.5 L/min/m

 

Organ Dysfunction

• Arterial hypoxemia (PaO/FIO2 < 300)

• Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hours

• Creatinine increase > 0.5 mg/dL

• Coagulopathy (INR > 1.5 or PTT > 60 seconds)

• Ileus

• Thrombocytopenia (platelet count < 100,000/mm)

• Hyperbilirubinemia (bilirubin > 4 mg/dL)

 

Tissue Perfusion Variables

• Lactate > 2 mmol/L

• Decreased capillary refill or mottling

Sepsis: Risk Management Pitfalls

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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Sepsis: Case Study

Case Study…
As you start your shift, you’re handed the chart of an 82-year-old nursing home patient with urosepsis who is waiting for a bed. Your colleague remarks, “She got some fluids, the antibiotics are in, she looks good, and she’s much more ‘with it’ now. The family says she’s pretty much at baseline mental status now. She’s headed to the floor in a bit.” 

Later in your shift, you see a 43-year-old male with a history of well-controlled diabetes but no other medical history. He presents awake, alert, but ill appearing and short of breath. Over the next few hours he becomes febrile and confused. His respiratory status declines, and he requires intubation. His blood pressure is difficult to support despite aggressive fluid resuscitation and vasopressors. His blood glucose is greater than 600, his blood lactate level was elevated on arrival, and it further increased prior to transfer to the ICU. His creatinine is very elevated and he develops DIC. He requires 1-to-1 nursing with additional help from other staff and a considerable amount of your time, essentially grinding your ED to a halt. Upon moving the patient to the ICU, you report to the admitting intensivist, “This guy is really septic.” In following up on the patient, you discover that he expired after 48 hours in the ICU. 

In reviewing the shift, it occurs to you that the same diagnostic label was applied to a disease process in which an 82-year-old nursing home patient recovered largely in the ED and went to the floor while a reasonably healthy younger person became desperately ill and expired in an ICU. 

Is this really the same disease process? Are there symptoms, signs, or tests that accurately identify patients with infections that are likely to become septic? Are there interventions in the ED that could improve the chance of survival of the young man above?

Conclustion of the above case study…
Returning to our initial cases: The decision to admit a nursing home patient to a medical ward after therapy in the ED was informed by the use of a MEDS score78 and a lactate level64 to determine a low risk of mortality and to identify a patient unlikely to require or benefit from more aggressive interventions and unlikely to need subsequent transfers to the ICU. 

As for the second case, our ability to review pathophysiology and prognostic indicators of poor outcome reveal a patient with increasing rather than improving lactate, altered mental status, DIC, and multi-organ failure. His blood cultures return positive with a Gram-negative organism in less than 24 hours. His chance of survival is very small. The application of a goal-directed therapeutic plan with aggressive volume correction, optimized oxygen delivery, prompt delivery of antibiotics with activity against the responsible organism, support of cardiac output and function, and possibly the addition of specific medications for reversal or moderation of sepsis physiology may result in improvement. This may include a decreasing lactate4 preserved or improving cardiac performance, a normal or near normal glucose, replacement steroids for a dysfunctional adrenal gland, and replacement of depleted blood products, such as oxygen-carrying hemoglobin or even coagulation cascade products like protein C.

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