December 10, 2018

Background Information: Sepsis is a complex syndrome frequently encountered in the ED. This infection-triggered, multifaceted disorder of life-threatening organ dysfunction is due to the body’s dysregulated response to pathologic and biochemical abnormalities.2-4 There has been significant debate regarding the use of clinical decision tools such as Systemic Inflammatory Response Syndrome (SIRS) and quick Sepsis-related Organ Failure Assessment (qSOFA) in the early recognition of sepsis.2,5-7­ Multiple studies have shown SIRS to not be specific enough for the early detection of sepsis as many non-infectious processes, including exercise, can often meet many of its criteria.8-10 On the other hand, qSOFA has been criticized as having poor sensitivity and moderate specificity for short-term mortality.11,12 Furthermore, qSOFA  has been described as clinically valuable but an imperfect marker of sepsis as some forms of organ dysfunction, such as hypoxemia and renal failure, are not assessed using qSOFA.5 Another severity score known as the National Early Warning Score (NEWS) focuses on inpatient deterioration in detecting patients with increased risk of early cardiac arrest, unanticipated ICU admission and death.13 One study showed that utilization of NEWS in the emergency department (ED) has been shown to be effective in recognizing patients with sepsis who are at a higher risk of adverse outcomes.14  The authors of this study sought to review the use of NEWS as an early sepsis screening score, a predictor of severe sepsis/septic shock, and compare it to SIRS and qSOFA in an ED triage setting.

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.

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).

May 1, 2017

Background: Just a few months ago the surviving sepsis campaign published their international guidelines for management of sepsis and septic shock [1].  There has been a lot of talk in the FOAM world about sepsis 3.0 and this is the first update since the introduction. This was a 67 page document that made a total of 93 statements on the early management and resuscitation of patients with sepsis or septic shock.  1/3 of the statements were strong recommendations and just over 1/3 were weak recommendations. Instead of going through every component of this document, we thought we would discuss one of the potentially biggest components of sepsis care that  would affect clinical practice for those of us on the front lines. One of the main reasons we have seen a mortality decrease in sepsis overtime is due to the proactive nature health care professionals have taken in sepsis management.  The so called ABC’s of sepsis management: Early identification, Early fluids, and Early antibiotics. One of the biggest components of this is early identification of these patients.