The Changing Face of Sepsis

Abstract:

There are few infections that can result in death or lifelong impairment in mere hours. Sepsis is caused by an inflammatory response by the body to combat infections in the blood.  This inflammatory response can worsen, eventually resulting in organ failure, and hypoperfusion (shock). At the recent Knowlex Infection Prevention and Control Conference, held in London on February 23, 2016, Dr. Ron Daniels (CEO, UK Sepsis Trust and Global Sepsis Alliance) discussed the danger of sepsis, and the need to coordinate efforts between both healthcare workers and the public to combat this deadly complication.

Main Article:

Introduction

Sepsis is the inflammatory response that can be associated with the presence of pathogens (infection) of the blood. In recent years, sepsis has taken more lives than bowel, prostate and breast cancers combined. This is in part because sepsis can sometimes arise from treatment from these and many other illnesses. From 2013 to 2014, 123,000 sepsis cases occurred, and that number has been steadily increasing since the National Health Service (England) began extensive monitoring of sepsis¹. Mortality resulting from sepsis typically ranges from 20% to 30%. This represents approximately 44,000 deaths per year, of which 1200 to 1500 are pediatric patients¹.

Mortality resulting from sepsis typically ranges from 20% to 30%

Survivors of sepsis are especially prone to cognitive impairment following treatment. In a recent study by Iwashyna et al (2010), patients who survived severe sepsis showed increased prevalence of moderate to severe cognitive impairment compared to patients who did not have sepsis². Although this cohort study was performed in an older adult population, the cognitive and functional impairment was found to be significant, and may be applicable to younger patients as well.

Diagnosis and Treatment

There are a number of symptoms that may indicate sepsis. Working with numerous research groups, the UK Sepsis Trust has defined a number of bedside criteria to facilitate fast, accurate diagnosis of sepsis, allowing physicians to react quickly and appropriately.  Healthcare workers should be looking for changes in symptoms, such as:

• Systolic Blood Pressure <90 mmHg/ >40mmHg below
• Lactate >2 mmol/l
• Heart rate >130 per minute
• Respiratory rate >25 per minute
• Needs oxygen to keep SpO2 >92%
• Responds only to voice or pain/unresponsive
• Purpuric rash

Patients with any two of these symptoms, and in some cases even one, should be under consideration for sepsis.  In response, the UK Sepsis Trust has published the “Sepsis Six,” a series of treatment guideline for patients with suspected sepsis:

1. Give oxygen as needed to target SpO2 > 94%
2. Take blood cultures (consider source control)
3. Give IV antibiotics (according to local protocol)
4. Start IV fluid resuscitation (Hartmann’s or equivalent)
5. Check lactate (repeat within 2h to monitor changes)
6. Monitor urine output (consider catheterisation)

A Public Matter

In an independent report on sepsis in the United Kingdom revealed that, although sepsis diagnosis is almost exclusive to hospitals, almost 53% of patients enter the hospital with pre-existing sepsis. These patients were typically admitted through the emergency department³. This suggests that sepsis is not so much a hospital acquired infection, as it is a community acquired infection. As the public is generally less aware of sepsis, this usually means delayed diagnosis, and thus delayed treatment, resulting in poorer patient outcomes. Even for patients with septic shock, it can take healthcare professionals up to 4 hours to deliver a sepsis diagnosis³.

Septic shock is the most severe form of sepsis, with a mortality rate of 50%

Septic shock is the most severe form of sepsis, with a mortality rate of 50%. Prior to septic shock, patients usually start with an infection, which has a low mortality rate (< 1%).  Left untreated, this can progress through a systemic inflammatory response into sepsis (mortality rate of 10%), worsening into organ dysfunction into severe sepsis (mortality rate of 30%) and ultimately hypoperfusion, resulting in septic shock. It has been reported that every one hour delay in a sepsis diagnosis results in an increase in the mortality rate of 7.6%³.

As this is a community issue, the public is encouraged to become Sepsis-aware. The above information provides specific symptoms for clinicians to accurately diagnose the condition, but patients who suspect sepsis should look out for six symptoms that can present at home or in the workplace:⁴.

S          Slurred speech

E          Extreme shivering or muscle pain

P          Passing no urine (in a day)

S          Severe breathlessness

I           “I feel like I might die”

S          Skin mottled or discoloured

Sepsis acts quickly, and can be lethal in a large portion of the population. Awareness, quick diagnosis and immediate action by both patients and physicians is required to curb the progression of this infection.

About Knowlex:

Knowlex, shorthand for ‘Knowledge Exchange’, is a new organisation that has been set up with the ambition of disseminating information on research and innovative practice to help healthcare professionals in their working lives.

http://www.knowlex.co.uk/

Upcoming Conference:

Tuesday 6th September 2016 RNCM Manchester, UK
European City of Science 2016

In light of estimates that the total cost of AMR to healthcare systems within OECD countries will reach £1.9 trillion by 2050, on 8th September 2016, Knowlex will welcome more than 350 healthcare professionals to Manchester, European City of Science, for Infection Prevention & control 2016.

Conference Website: http://www.infectioncontrolmanchester2016.co.uk/

References:

1. Hospital Episode Statistics H. Sepsis:Written question – 10526. Parliament.UK. 2015 [cited 2016 Apr 20]. Available from: http://www.parliament.uk/business/publications/written-questions-answers-statements/written-question/Commons/2015-09-16/10526/
2. Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term Cognitive Impairment and Functional Disability Among Survivors of Severe Sepsis. J Am Med Assoc. American Medical Association; 2010 Oct 27 [cited 2016 Apr 20];304(16):1787.
3. National Confidential Enquiry into Patient Outcome and Death. Just Say Sepsis! National Confidential Enquiry into Patient Outcome and Death. 2015. p. 1–130. Available from: http://www.ncepod.org.uk/2015report2/downloads/JustSaySepsis_FullReport.pdf
4. The UK Sepsis Trust. 2016 [cited 2016 Apr 20]. Available from: http://sepsistrust.org/