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Sepsis: The Most Under-Recognized Killer in the U.S.

Celebrity deaths demonstrate that providers need to sharpen their recognition of sepsis onset

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It wasn't a punch that fatally KO'd heavyweight champion Mohammed Ali. It was an opponent tougher than anyone he'd faced in the ring: sepsis. Earlier this year, Academy Award-winning actress Patty Duke, then 69, also died after developing sepsis secondary to a ruptured intestine. As such public incidents illuminated this "medical cause célèbre," Google reported that searches for "sepsis" increased 800%.

But it is not only the general public that is in need of heightened sepsis awareness. Clinicians --- primarily those outside of the ICU, where sepsis is already well-known --- must sharpen their recognition of sepsis onset. Primary care providers also must become more diligent in considering sepsis as a possible cause of aches and pains in outpatient populations.

Deadly and Costly
According to the CDC, sepsis affects more than 800,000 Americans annually, claiming more than 258,000 lives per year. In cases of severe sepsis, 40% to 50% of patients do not survive. The Agency for Healthcare Research and Quality lists sepsis as the most expensive condition treated in U.S. hospitals, costing more than $24 billion annually.

Part of these unacceptable figures fall on the shoulders of healthcare providers who are ill-equipped to recognize sepsis at its earliest stages, said Steven Q. Simpson, MD, professor of medicine and acting director of the division of pulmonary and critical care medicine at the University of Kansas. He is also chair of interdisciplinary critical care at the University of Kansas Hospital and medical director of three intensive care units.

intubated patientGenerally defined as "a life-threatening organ dysfunction due to a dysregulated response to infection," sepsis still confounds some medical professionals. "Even today, there are clinicians who are learning, for the first time, what it is," said Simpson. "I was presenting at a conference about three years ago. When I finished, a doctor --- visibly angry --- stood up and spit out, 'You are completely redefining sepsis.' I said, 'I didn't make this up; I am not redefining anything. This is the only definition there has ever been.' The problem is that some people think sepsis is hypotension (low blood pressure), or that a patient has to be in shock to have sepsis. Not true."

SEE ALSO: Responding to Sepsis

Yet Simpson doesn't really cast blame on the clinicians. "The actual diagnostic criteria for recognizing severe sepsis were first published in 1992. Clinicians in the prime of their careers, or moving toward retirement, were already finished their training when those criteria were crafted," explained Simpson. "For a long time after the criteria were established, the only place you could read about them was in critical-care literature. That isn't what your average doctor or nurse would be reading. Add to that the estimate that it takes about 18 years for important innovations in medicine to make it into mainstream medicine, and you've got a frightening situation in the face of such a deadly illness."

Clinical Criteria
The diagnostic guidelines for recognition of systemic inflammatory response syndrome (SIRS) indicative of sepsis are as follows:

• rapid heart rate (more than 90 beats per minute)

• rapid respiratory rate (more than 20 breaths per minute or arterial carbon dioxide tension [PaCO2] of less than 32 mm Hg)

• fever (more than 38°C [100.4°F] or less than 36°C [96.8°F])

• high white blood cell count (>12,000/µL or < 4,000/µL or >10% immature [band] forms).

These criteria comprise one of the building blocks of a sepsis familiarization program Simpson takes around to hospitals in Kansas. A board member of the Sepsis Alliance, Simpson initiated in 2007 the Kansas Sepsis Project, a statewide program to improve severe sepsis care and outcomes throughout the state via continuing education, both in sepsis and in quality-improvement principles, and via inter-professional collaboration.

"The training points I hit are these: every single time you see a patient with an infection or suspected infection, ask yourself: Do they have SIRS? Do they have organ dysfunction? If they do, act rapidly; jump on it with antibiotics as fast as you can. Administer IV fluids very quickly to resuscitate underperfused organs," advised Simpson. "And then do one more key thing: track yourself. Keep track every time you see one of these patients and ask: did we get antibiotics in on time? Did we get fluids in on time? Did we do all of the appropriate measures?"

The Need for Speed
Recognizing sepsis early in its course is absolutely critical to patient outcome. "Any time you suspect infection, suspect severe sepsis," said Simpson. "They go hand-in-hand. Severe sepsis is the most deadly consequence of any infection, so we always need to be looking for it proactively. Look for a fever, rapid heart rate and severe pain. Ask yourself if this new pain is different from what brought the patient to the hospital originally. Pay careful attention to that. If there is a drop in blood pressure, look for signs and symptoms referable to an infection, and tie them to SIRS symptoms."

Next, a clinician must look for evidence that one of the organs is malfunctioning in one way or another, Simpson said. "Sometimes patients become obtunded -- poorly arousable, not well-oriented in their surroundings. This is particularly common in elderly people developing severe sepsis," Simpson said.

Laboratory tests are critical to diagnosis as providers must also consider the cardiovascular system to see if there is a degree of low blood pressure, the respiratory system to see if the patient has developed low blood oxygen, the kidneys to see if certain creatinine has picked up or urine output has dropped off, and the liver to determine if enzymes are up. Microbiology and POCT applications can identify pathogens and bacteria responsible for sepsis (e.g., enterobacter, Escherichia coli, staphylococcus, streptococcus, MRSA).

"Look, too, for disseminated intravascular coagulation to determine if blood-clotting mechanisms are off. And last, but by no means least, look for lactic acidosis," ­cautioned Simpson. "We know historically that with severe sepsis, every organ that dysfunctions results in about a 15% to 20% increase in the risk of death."

Calling sepsis "the most under-recognized medical killer in the United States," Simpson added, "If you are fortunate to catch it early, many times the dose of broad spectrum antibiotics and fluids will turn a patient around in just hours. But if you allow severe sepsis to develop by not recognizing it in the early stages, it can result in a prolonged ICU stay for the patient, and a life-or-death circumstance. And even if the patient doesn't die in the hospital, the risk of dying from many other causes is increased for at least two years after an episode of severe sepsis. Post-sepsis syndrome is a debilitating illness which is characterized by weakness, difficulty in ­performing ­activities of daily life, even difficulty in thinking clearly. It can be absolutely terrible."

Simpson also stated that once clinicians become fully apprised of the danger associated with sepsis, it is incumbent on them to spread the word to patients and the public at large. He noted that the Sepsis Alliance stands ready with a wealth of information for both patients and clinicians to help raise sepsis awareness. Public awareness is crucial because sepsis is not considered a hospital-acquired infection. It is far more common in the outpatient world; about 60% of sepsis cases occur outside of the hospital.

"We want every American to understand that sepsis is an urgent medical emergency. When people have chest pains, they know to call 911. We want people to know that if they have symptoms of sepsis, they should be calling 911 too," said Simpson, adding, "Infection is mankind's oldest enemy. It's been here since the day we first walked the planet."

Valerie Newitt is on staff at ADVANCE. Contact: vnewitt@advance web.com

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