The Suspicion of Sepsis

Sepsis has become the number one cause of hospital deaths in USA with 258,000 fatalities annually at a cost of over US$ 20 billion annually. ¹

In the USA the most prevalent cause of medical error is an “error in diagnosis” at about 6 times the rate of “medication errors”. Of these diagnostic errors, about 10% are correct diagnoses, 20% delayed diagnoses and 55% missed diagnosis. ⁶

sepsis in its early stages often displays the symptoms of the flu

Sepsis so often falls into the category of incorrect, late and delayed diagnosis. Like so many infections, sepsis in its early stages often displays the symptoms of the flu. The diagnosis becomes anchored to flu until sepsis displays its pathognomonic symptoms of disseminated intravascular coagulation (DIC) by which time it is almost certainly fatal despite the very best resuscitative attempts.

The key to the successful treatment is to have an early suspicion of sepsis and the early initiation of iv antibiotics and intensive care measures. However, the push towards antibiotic stewardship has had the unintentional effect of raising the bar for suspicion of sepsis.

The key to early suspicion of possible sepsis is SIRS (systemic inflammatory response syndrome) which is based on the scoring of pyrexia, tachycardia, tachypoenia and hypotension with the absence of cough and coryzeal symptoms. ⁵

Of these symptoms the one most often overlooked is respiratory rate.

One study reported as few as 30% of hospitalised patients had their respiratory rate measured, despite it often being a strong and specific predictor of intensive care admission. ² Pulse oximetry is not a substitute or surrogate for respiratory rate, which requires nothing more technologically advanced than a watch to measure. ²

A second study found the hospital admission notes recorded vitals signs inconsistently with 49.4% recording heart rate, 46.1% noted blood pressure, 38.9% recorded patient temperature, and 19.5% respiratory rate. ³

The key to an early suspicion of sepsis lies not in expensive technology but good old fashioned vital signs at general practice level. They are called “vital signs” for a very sound reason.

The other basic lesson we can learn about the early suspicion of sepsis comes from referral patterns. In many instances the general practitioner refers the patient directly to a consultant or ward, bypassing the emergency department (ED). Always refer through ED first!

One study found that patients with an eventual diagnosis of sepsis or septic shock who were referred to a general ward versus ED had significantly fewer patients given iv antibiotics within 2 hours (81% vs 41%, p<0.001), longer hospital stay (13.9 vs 9.3 days, p<0.001) and higher mortality (24.8% vs 17.3%, p=0.03). ⁴

Our son Zachary was a 22 year old 4^th year student doctor who awoke one morning feeling very unwell. He went to his general practitioner (GP) who omitted to measure pulse and blood pressure. However, the GP did decide to admit Zachary by ambulance directly to general medicine at the local tertiary hospital. The ambulance measured Zachary’s temperature as 39.5^oC without clothes, heart rate of 140 bpm, low blood pressure and a respiratory rate of over 30 per minute. The preliminary diagnosis by the GP was flu. It took nearly 5 hours before Zachary was seen by an intensivist when he was immediately admitted the Critical Care. We saw Zachary in general medicine at 5:30pm and he was dead at 7:15pm from septic shock. We never got to say goodbye. The DCC nurse told us to run if we wanted to see Zachary alive, and we ran, but it was too late.

How simply and inexpensively this could have been avoided.

References:

1. Shan K M. Sepsis No. 1 reason of hospital deaths in US. Poughkeepsie Journal. 2015: 18^th
2. Cretikos M A et al., Respiratory rate: the neglected vital sign. MJA. 2008: 188; 657-659.
3. Daly C et al., Safety comes first: are doctors attentive enough to their initial clinical assessment notes? Ir Med J. 2013: 106 (10); 316-8.
4. Garcia-Diaz J et al., Severe Sepsis And Septic Shock: Worse Outcomes Seen In Patients Transferred To ICU From Wards Compared To Emergency Department. Am J Respir Crit Care Med. 2013: 187; A1563
5. Davies M G and Hagen P O. Systemic inflammatory response syndrome. BJS. 1997: 84(7); 920-935.
6. Graber M L. The incidence of diagnostic error in medicine. BMJ Qual Saf. 2013: 22; 21-27.