Sepsis: Can we pick who’s sick?
I have been going on about sepsis for a while now around the hallways. So – what is all this talk about? I think we need to have a robust system in place that allows a small hospital to detect early (occult) sepsis, intervene early and manage it in a way that is evidence-based and inline with the ‘best practice’ out there.
If you are like me you find new information hard to process – so I think the best analogous process we have to “map” this onto is the “Chest Pain Pathway“. The principle is the same:
- Acute coronary syndromes and sepsis are both severe life-threatening problems
- They can be subtle / difficult to diagnose, especially in the early stages, or in patients with atypical presentations
- They both benefit greatly from early aggressive intervention (thrombolysis vs.resus & IV ABs)
- We need to cast the net wide to ensure we “catch” all the badness – this means we will find nothing in 99 out of 100 people we screen – but that is OK, if we catch the sick one (eg. we do ECG and troponin on anyone with pain between their head and bum “just in case” – it is a low-cost, low-risk test to do)
- The protocol is “nurse-based” – it kicks off at triage, therefore gets done early and is not dependent on the whim of the doctor or the busy-ness of the department – it just happens.
So how do I think it should work? well, similar to the Chest Pain pathway. Here goes:
IDENTIFY Patients at risk
This is where we cast the net wide. Essentially this is the same as using the current MET criteria or COMPASS tool that has been rolled out in the last year or so.
I have hijacked a simple set of criteria out of the Greater NY Hospital Sepsis Collaborative – with a few modifications which I think are a reasonable screening tool for triage nurses to use in identifying patients who should be in the 100 we look at to find the 1 sick one. Here are my proposed Sepsis Screening criteria –
STEP 1 Does the patient have any 3 of the following?
- Suspected infection
- Temp > 38 deg or under 35.5 deg, or history of rigors
- Heart rate > 90 (or over age adjusted max.)
- RR > 20 (or over age adjusted max.)
- Any altered mental state
- SpO2 < 90
- Systolic BP < 90 mmHg (or under age adjusted minimum)
- Prolonged > 2 sec central capillary refill
- Any child under 3 months of age
- Any indwelling invasive devices (PICC, IDC, Hickman etc)
- Dialysis patient (Haemo or peritoneal)
So if your patient meets these criteria, then you go to step 2 – activate the screening tool:
STEP 2
If 3 criteria met => Activate the Sepsis screening panel
- Notify senior Doctor
- IV access and take blood set:
- FBP, UECr, CRP, VBG / lactate, blood cultures, coags – URGENT to lab / ED gas analyser
- Catch urine culture
3. Commence frequent obs in monitored bay.
So now – if you screen include 100 patients at Step 1, you can hopefully narrow it down to 10 using Step 2. The bloods will either be OK, or not OK. Your best indicator of early sepsis if you had to pick 1 is the lactate. Lactate can be < 2: normal; 2 – 4: grey zone, > 4: bad – needs resus
Lactate is difficult to understand for the uninitiated – so here is a nice summary (Click) (Emcrit)
STEP 3
So now we have narrowed it down to a handful of patients whom might have sepsis from the general ED population. Armed with a bit more info we can now treat them and split them into 2 groups –
- Fluid responders: those who get a bolus of fluids and they get better – BP comes up, pulse down, maybe their lactate clears to normal – you are winning. These patients are good to go to the ward with “normal care”. They need monitoring for subsequent deterioration on the charts but are not looking likely to “go south”.
- Non-responders: these patients still ahve dodgy looking Obs and unwell after a generous fluid resuscitation over 30 – 60 minutes. This is the 1 out of 100 whom is going to need the full treatment – and probably invasive monitoring
SAFETY NET
Of course no system is perfect so there are a few Safety net concepts I would like to introduce. We can also catch patients at the backdoor of the ED. Those who did not get identified at triage, got the usual workup then came to a point where they need admission or further investigation for PUO, or other infection. So I think we should runa VBG (lactate) on any body who meets any of the following:
- Doctor takes blood cultures for any reason – if you do a BC, then do a lactate at the same time.
- Admission diagnosis = pyelonephritis, pneumonia, severe skin infection, PUO, diabetic foot etc… anyone with a possible severe infection that might go systemic
- Any infant (< 6 months) sick enough to need admission for infectious cause
Lactate is not the “golden-bullet” for sepsis, but it is better than nothing, and cheap as chips. The idea is to identify patients who were off to the ward for “usual care” who might benefit rfom a more aggressive strategy and closer monitoring.
Let me know what you think. More sepsis stuff this week
Check out the post on Shock: beyond the BP if you are interested
Casey
Casey, I like it – you are doing a great job of culling the literature and presenting ‘real world’ solutions for hard-pressed rural docs in Australia and wider afield
Agree that need to be more aggressive in looking for sepsis sensu lato
My difficulty (and I suspect shared by many others in the bush) is that have no access to labs. Whilst the Compass criteria and their ilk are useful, how do we sift after that?
All I’ve got is an iStat and an INR machine. Is doing a venous lactate and running through the iStat enough? Or should I be transferring suspected cases early rather than expectant Mx? Turn around for bloods in my locale is at least 12 hours, often 24 hrs (have to fly them to capital city). So we make decisions on the hoof, which is all part of the challenge of rural practice.
It’s easy when patients are crashing ie: more septic than a hospital-volunteers shop sandwich (you’d have to have eaten one to understand this)…not so easy when they are ‘vaguely unwell’…
Anything else we can do to help decision making? I’m a big fan of regular (1-2 hrly) obs when my spidey-sense is tingling and there’s nothing overtly wrong…been caught out once with a ‘simple gastro’ that evolved into fulminant septic peritonitis at 2am – clue was the change in RR the hour before…and serial abdo exam changed at 2am necessitating reus/retrieval/eLap
Tim
I agree it is tough to run with no labs. Been there and actually find them less useful now they are more available in Broome.
The POCT machine we use for gases gives me a lactate , so it takes 2 minutes to get a number. I can also use it to do a SVCO2. So with a lactate, svco2, art line and IVC analysis I have a lot of data. Enough to run the basic EGDT protocols in a commonsense manner. All this without getting the nice lab scientists out of bed!
Hi guys
Very timely discussion! I am in remote Cape York at the moment and only evacuated a patient last night with presumed early sepsis! He had a conscious collapse on the street and came in with a fever and hypoglycamia (BSL 1.8) for no obvious cause. Significant history of myeloma and on oral cyclophosphamide, so alarm bells ringing already!. The surprising thing on ISTAT that made me decide to evacuate him was his K of 2.7!
So absolutely POCT can make a big difference to your decision making.
Couple of comments : remember lactate maybe normal in a small percentage of those with sepsis..the trend of lactate may help more here so serial measures analgous to troponins/CK is probably more useful in that group.
the assertion that chest pain pathway and serial troponins is low cost , easy to do strategy, is in my view open to debate. The cost of observing a patient in a monitored bed for 8 hrs or so is not insignificant. To try to do this for everyone in a small remote clinic or hospital with only one rostered nurse on overnight, is majorly significant in terms of fatigue and staff burnout. So for example you might have your ISTAT troponin kit in a remote clinic, but trying to do the chest pain pathway with it and limited staffing is not always practical nor low cost, if your staff get fried and leave.