Walking through the hospital, we used to hear “code blue” for cardiopulmonary arrest, “Acute MI” alert for acute heart attack. But now there is a new word that we need to get familiar with called “Sepsis Alert”. When Sepsis Alert is called, Physicians, nurses, pharmacists, phlebotomists, and respiratory therapists will converge on the area announced in order to assist and expedite the process.
Sepsis is becoming very common throughout the hospitals due to increased incidence and high mortality rate. In fact, severe sepsis accounts for 29% of death (or 215,000 cases) while acute MI accounts for 25% (or 225,000 cases). Sepsis is a major cause of morbidity and mortality worldwide. It is the leading cause of death in hospitals and 10th leading cause of death overall. There are more than 750,000 cases due to severe sepsis in the US annually and more than 500 people die per day.
Sepsis is a medical emergency, just like heart attack or stroke. In these events there is an interruption of oxygen and nutrients to the tissues including the vital organs such as the brain, heart, lung, liver, and kidneys, mainly due to drop in blood pressure. Patients develop confusion, fever, tachycardia, tachypnea, and hypotension.
Sepsis alert, will fire if a patient has sign and symptoms of infection and 2 or more of systemic inflammatory response syndrome (SIRS) criteria, including temperature more than 101 F, tachycardia (heart rate more than 90), tachypnea (respiratory rate more than 20), blood sugar more than 140 mg/dL, and either white blood cell count more than 12,000 or less than 4000 or band more than 10%. Other criteria are also available to assess organ failure. High Serum lactate level correlates with higher mortality regardless of the presence of shock or other organ dysfunction.
Severe sepsis is defined as sepsis plus sepsis induced organ dysfunction or tissue hypo perfusion. Septic shock consists of the most severe cases where sepsis-induced hypotension persisting despite adequate fluid resuscitation.
Treatment consists of early recognition of the problem. Appropriate blood tests including blood cultures, Chest x-ray, urinalysis and serum lactate level are drawn immediately on arrival of the patient. Early goal directed therapy started with prompt aggressive fluid resuscitation. One litre of normal saline is given within 30 minutes. According to an NEJM 2001 article, the 28-day mortality rate was significantly decreased with this approach. An antibiotic is administered as early as possible and always promptly within one hour of recognising the severe sepsis. The site of infection should be established as rapidly as possible and within the first six hours of presentation in order for the antibiotic to be as specific as possible. In case of hypotension, vasopressors are started in order to perfuse the vital organs.
Low dose intravenous corticosteroids should only be given to adult septic shock patient after it has been confirmed that blood pressure is poorly responsive to fluid resuscitation and vasodepressor therapy. Hydrocortisone is the preferred choice. Duration of shock was reduced by administration of this medication, but the incidence of super infection, including new episode of septic shock was also reported. Recombinant human activated protein C administration is recommended for patients at high risk of death or sepsis-induced multiple organ failure. It is also significantly decreases the 28-day mortality rate in these patients with main concern of bleeding. Blood sugar control including use of IV insulin with a blood sugar less than 150 has significantly lowered the number of deaths.
According to the critical care medicine article 2010 (38), surviving sepsis campaign 252 hospitals in 18 countries and involving 15,022 patients showed that use of bundle (a set of preselected steps) has improved the hospital mortality rate from 37 to 30%.
Sepsis, being one of the most important causes of death during hospitalisation requires prompt recognition and treatment. In the Trinity health system, there is major collaborative effort to develop sepsis alert system protocol with goal of reduction in overall mortality rate by 40% by next year.
[ANIS ANSARI, MD, is Chairman, Department of Medicine, Mercy Medical Centre Clinton, Iowa, U.S.A.]