May 2, 2018

Friends, Concern regarding the Surviving Sepsis Campaign (SSC) guidelines dates back to their inception.  Guideline development was sponsored by Eli Lilly and Edwards Life Sciences as part of a commercial marketing campaign (1).  Throughout its history, the SSC has a track record of conflicts of interest, making strong recommendations based on weak evidence, and being poorly responsive to new evidence (2-6).

April 16, 2018

Background: It is well established that the rapid identification of patients with sepsis is needed in order to initiate timely care to improve morbidity and mortality.  The systemic inflammatory response syndrome (SIRS) criteria have been used for some time for screening, however the sensitivity and specificity of these criteria have been brought to question based on recent evidence [2]. This may have been one of the many reasons why the Sepsis-3 task force recommended the quick sequential (Sepsis-related) organ failure assessment (qSOFA) for prediction of mortality in sepsis. qSOFA consists of low blood pressure (SBP ≤100mmhg), increased respiratory rate (≥22bpm), and altered mental status (GCS ≤14).  2 or more of these criteria indicates  an increased risk of death.  There have been several studies calling into question the sensitivity of this criteria.  In this post, we will review a recent systematic review and meta-analysis assessing the prognostic value of qSOFA vs SIRS in adult patients with suspected infection in the ED, hospital wards, and the ICU.

April 16, 2018

Background: It is well established that the rapid identification of patients with sepsis is needed in order to initiate timely care to improve morbidity and mortality.  The systemic inflammatory response syndrome (SIRS) criteria have been used for some time for screening, however the sensitivity and specificity of these criteria have been brought to question based on recent evidence [2]. This may have been one of the many reasons why the Sepsis-3 task force recommended the quick sequential (Sepsis-related) organ failure assessment (qSOFA) for prediction of mortality in sepsis. qSOFA consists of low blood pressure (SBP ≤100mmhg), increased respiratory rate (≥22bpm), and altered mental status (GCS ≤14).  2 or more of these criteria indicates  an increased risk of death.  There have been several studies calling into question the sensitivity of this criteria.  In this post, we will review a recent systematic review and meta-analysis assessing the prognostic value of qSOFA vs SIRS in adult patients with suspected infection in the ED, hospital wards, and the ICU.

April 2, 2018

Background: Skin and soft tissue abscesses are a common emergency department (ED) presentation. The approach to management has changed little in recent decades: incision and drainage (I+D) and then discharge home with follow up. However, increasing rates of methicillin-resistant staph aureus (MRSA) over the last decade have led to further consideration of adjunct therapy with oral antibiotics to improve cure rates. Two recent studies (Talan 2016, Daum 2017) have shown a modest but consistent benefit to oral antibiotics.

March 29, 2018

Background: There have now been several trials published on the use of steroids in sepsis.  In 2002, we had the Annane Trial, with 299 patients showing mortality and shock reversal benefit in sepsis with hydrocortisone.  Then in 2008 we had the CORTICUS trial, with 499 patients, which found a faster reversal of shock, but no benefit in mortality.  Next the HYPRESS trial published in 2016 with 380 patients, with severe sepsis, not septic shock,  showed no difference in mortality or time to reversal of shock.  And finally the ADRENAL Trial published this year with 3800 patients show no difference in mortality, but a small benefit in reversal of shock.  Due to these mixed results, many physicians have variable practice patterns with the use of steroids in sepsis/septic shock.  Now, we have the APROCCHSS trial looking at hydrocortisone plus fludrocortisone for adults with septic shock (By the way the lead author is the same author that published the 2002 steroids in sepsis trial…Annane).
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