Down with the Surviving Sepsis Campaign

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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Ian L., Dr -

The utilisation of Healthcare prior to Sepsis diagnosis Hospitalisation by LIu VX et al in Critical Care Medicine 2018 .
They concluded that over 45% of sepsis patients had clinician based encounters in the week prior to hospitalisation.
Therefore it ought be concluded that there is a "PreSepsis Incubation Time " .
LiuVX et al stated in their conclusion that these PreSepsis encounters offered potential opportunities to improve recognition risk stratify and treat prior to hospitalisation that one might conclude could well reduce the incidence of current Sepsis Morbidity and Mortality and deserves
investigation .
Crit Care MED 2018 April ; 46(4) 513-516 Liu VX et al .

Patrick S. -

Surviving Sepsis Campaign is currently recommending hospitals do NOT implement the 1 hour bundle due to vigorous opposition of clinicians:

http://www.survivingsepsis.org/News/Pages/SCCM-and-ACEP-Release-Joint-Statement-About-the-Surviving-Sepsis-Campaign-Hour-1-Bundle.aspx

Hopefully this is the first crack in the dam...

Ian L., Dr -

To diagnose blood stream infection in Adults Low Supine Systolic Blood Pressure less than 100mmhg in the context of an infection or a drop from normal systolic Blood Pressure of 20 mmHg is indicating SBI .
Drop between supine and Standing systolic Blood Pressure don't seem to have time to measure in the chaos of triage .
In Pneumonia Severity Index Scores a Respiratory Rate greater than25- 30 per minute scores danger but in qSOFA it's Respiratory Rate above 22
Primary Care Doctors ought test the vital signs in sicker looking adults or adults at risk by age Comorbidities and Reduced Immune Competence to diagnose blood borne infections before sepsis
In a Study by Yaazoe M et al of Nursing Home patients with pneumonia comparing positive .blood culture patients with negative blood culture patients the Odds Ratio for Systolic blood pressure <= 90mmhg was 6.03 95%CI 1.06- 34.25 .
Respiratory Rates Pulse Rate and Po2 oximetry or Altered Mental Status was not mentioned .
Altered Mental Status could be graded in a discriminatory way : Months of the Year Backwards Serial 7s Does a stone float on water? like Questions.
Reference :Yamazoe M et al Journal of Infection and Chemotherapy Dec 29 2017.
The British Royal College of Physicians developed theNational Early Warning Score (NEWS) based on six physiological parameters for primary care providers prehospital ambulance services and hospitalised patients .
Regular Review of Signs and Symptoms is also important like serial ECGs and Serial Troponins in ACS .
The recommended Physiological Parametres :
Respiratory Rate
Oxygen Saturation
Temperature
Systolic blood Pressure
Pulse Rate
level of consciousness
But Not some Circulatory Parameters Skin Color Skin Turgor Tears Eyes Mucous Membranes Capillary Refill.

Rory S., MD -

Thanks for the comments Ian. While Liu et al present interesting data, I think that is a very dangerous proposal. It only looks at the few patients who end up having sepsis. What about the thousands of patients that present with simple infections that will never go on to develop into sepsis? Imagine how many patients would receive needless antibiotics in the hopes on intervening on the few that actually end up having sepsis. Not only would such a screening screening cause an overwhelming burden on the healthcare system, we have no idea whether this type of early intervention has any effect on the downstream consequences of sepsis.

Ian L., Dr -

Thanks for your careful attention to the dangers of slippimg into knee jerk over treatment .
But I believe it will not be a policy of treating simple infections with antibiotics to prevent sepsis .
There is the concept of the Early Warning System of vital sign abnormalities that portend danger .
In the UK a National Early Warning System Study has developed Red Flag Signs and Symptoms that alert health care .p rofessions to initiate careful review .
In adults in the context of suspected infection feeling "Off" with also hypotension Systolic BP below 100mmHg Tachycardia Pulse rate at rest above 100 Tachypnoe Respiratory Rate above 21 Altered Mental acuity and Pulse oximetry Po2 below 94 alert the physician to the need to regular review of the signs and Symtoms indicating the descent into serious illness that will need escalated attention and intervention .

Rory S., MD -

Thanks for all who have listened and commented. Just a brief correction which was pointed out by one of our listeners (thanks Shannon). In the episode we state that the previous 3 and 6-hour bundles originated from the 2016 surviving sepsis update (Rhodes et al., Intensive Care Med, 2017). This is in fact incorrect. The 3 and 6-hour bundles first appeared in the 2012 guideline update (Dellinger et al., Crit Care Med, 2013), and the 2016 guideline did not publish any revisions to these bundles. The 1-hour bundle discussed in this segment is intended as the revision to the 3 and 6-hour bundles that best reflects the 2016 updates to sepsis care.

Anand S., M.D. -

Via Rory:
Thanks for all who have listened and commented. Just a brief correction which was pointed out by one of our listeners (thanks Shannon). In the episode we state that the previous 3 and 6-hour bundles originated from the 2016 surviving sepsis update (Rhodes et al., Intensive Care Med, 2017). This is in fact incorrect. The 3 and 6-hour bundles first appeared in the 2012 guideline update (Dellinger et al., Crit Care Med, 2013), and the 2016 guideline did not publish any revisions to these bundles. The 1-hour bundle discussed in this segment is intended as the revision to the 3 and 6-hour bundles that best reflects the 2016 updates to sepsis care.

Michael M., MD -

In cases where the lactate has cleared with the initial fluid bolus, I'm struggling with the concept of chasing hypotension with pressors, CVL's, and enormous volumes of fluid beyond the initial 30 cc/kg. If lactate is the final common pathway, and the best measure of end-organ hypoperfusion, and the lactate clears, are pressors still needed anyway? My understanding of this literature (I'm probably grossly oversimplifying here) is that the only consistent predictors of improved survival in sepsis are 1) time to antibiotic administration; and 2) whether the patient had fever in the ED (Cochrane review). A case I saw recently may help clarify my question:
72 yo man (vasculopath with known AAA, and recent outpatient antibiotics for UTI) whose only symptom was a rigor and a feeling of impending doom at home two hours PTA, rectal temp of 102.6 in ED, HR of 100, initial BPS of 90. Ordered 30 cc/ kg bolus, Ceftriaxone for presumed UTI, first lactate was 3.6. After bolus and about one hour later, lactate was down to 2.3 and BP had come up to 100. Awake, alert, and comfortable sitting semi-recumbent throughout (i.e. he looked much better than his numbers did). About that time he went into narrow SVT at about 150s, pressure dropped into 80's, but without very little change in how he felt. I then followed the unstable SVT algorithm and sedated/ tried to cardiovert him at 50j without success. He exclaimed "don't ever do that to me again". Gave adenosine total 18 mg without success, then I cajoled him into another attempt at cardioversion, this time at 150j. He converted to Afib/ RVR in the 140's. Through all this his BP never got above 90, but he didn't look bothered much by it. I didn't give any more fluid at that point--my concern was that he was hypotensive due the SVT, and was hoping if I converted him to SR the BP would come up. But no such luck, he didn't convert to SR, and pressure stayed in the 80's. So I put in a CVL, started pheynylephrine, sent him to ICU, and pressure gradually came up over the next several hours. But was it the phenylephrine, or just "tincture of time"? My gut told me to be permissive about the blood pressure, but the protocol, and the nurses, said otherwise. I've had a fair number of these cases, so any evidence that would shed light on this issue would be appreciated.

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