REMSTARBC.ca Rural Emergency Medicine Simulation Training and Resource - British Columbia
This page is less a definitive discussion of Sepsis than a personal opinion
on the state of diagnosis and treatment of sepsis from the rural perspective.
Although it is well recognized that sepsis has a high mortality
and that there is an ever increasing body of literature on the means of
diagnosing this condition early and its subsequent impact on outcomes,
there still seems to be a lack of a coherent, simple and
readily applicable means of early detection better than
the 'instinct' of the clinician.
Hopefully the attached Power Point will make some sense of this argument.
Since initially putting up this page in 2016, there seems to be an ever increasing voice looking at the Sepsis Guidelines
and either completely revamping them or scrapping them altogether.
Below is a link to an editorial of Dr. Josh Farkus of Pulmcrit.org
who advocates "retiring the existing sepsis guidelines"
The qSOFA Debate Continues
A meta-analysis showed low sensitivity and good specificity when the quick Sequential Organ Failure Assessment is used as a screening tool for sepsis.
In 2016, a new definition of sepsis (Sepsis-3) was proposed, which abandoned use of the systemic inflammatory response syndrome (SIRS) criteria (NEJM JW Gen Med Mar 15 2016 and JAMA 2016; 315:775) and introduced a new prognostication tool, the quick Sequential Organ Failure Assessment (qSOFA). During the past 2 years, investigators have made numerous attempts to assess qSOFA.
In a meta-analysis of 38 studies, investigators examined the effect of qSOFA screening on emergency department (ED) patients, inpatients, and intensive care unit (ICU) patients with suspected infection. Most studies (63%) were retrospective analyses, and most reported ED use of qSOFA. No randomized controlled trials of qSOFA have been published.
qSOFA's pooled sensitivity was 61%, and specificity was 72%. In contrast, SIRS criteria resulted in a pooled sensitivity of 88%, but with only 26% specificity. A similar pattern was seen for separate analyses of ED and inpatient populations. Both SIRS and qSOFA demonstrated very low specificity in ICU populations.
Comment by NEJM reviewer
This meta-analysis affirms that qSOFA has poor sensitivity (with reasonable specificity) outside of the ICU. SIRS criteria's low specificity, with higher sensitivity, in all populations results in fewer missed patients but many more false positives. Neither qSOFA nor SIRS is an ideal screening tool, but for programs already using SIRS, abandoning that practice for qSOFA would not make sense. Ideally, we will find a way to use these tools together and prospectively study their use in identifying at-risk patients and those with high likelihood for deterioration.
A Future Step for Sepsis Treatment?
Although initial skepticism might be high, it may be worth taking a look at some rather fascinating research originally published in Chest, 2016, by Dr. Paul Marik regarding the treatment cocktail for sepsis including Hydrocortisone, Thiamine and Vitamin C! Yes really!?
Chest. 2017 Jun;151(6):1229-1238. doi: 10.1016/j.chest.2016.11.036. Epub 2016 Dec 6.
Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study.
The global burden of sepsis is estimated as 15 to 19 million cases annually, with a mortality rate approaching 60% in low-income countries.
In this retrospective before-after clinical study, we compared the outcome and clinical course of consecutive septic patients treated with intravenous vitamin C, hydrocortisone, and thiamine during a 7-month period (treatment group) with a control group treated in our ICU during the preceding 7 months. The primary outcome was hospital survival. A propensity score was generated to adjust the primary outcome.
There were 47 patients in both treatment and control groups, with no significant differences in baseline characteristics between the two groups. The hospital mortality was 8.5% (4 of 47) in the treatment group compared with 40.4% (19 of 47) in the control group (P < .001). The propensity adjusted odds of mortality in the patients treated with the vitamin C protocol was 0.13 (95% CI, 0.04-0.48; P = .002). The Sepsis-Related Organ Failure Assessment score decreased in all patients in the treatment group, with none developing progressive organ failure. All patients in the treatment group were weaned off vasopressors, a mean of 18.3 ± 9.8 h after starting treatment with the vitamin C protocol. The mean duration of vasopressor use was 54.9 ± 28.4 h in the control group (P < .001).
Our results suggest that the early use of intravenous vitamin C, together with corticosteroids and thiamine, are effective in preventing progressive organ dysfunction, including acute kidney injury, and in reducing the mortality of patients with severe sepsis and septic shock. Additional studies are required to confirm these preliminary findings.
If you want to explore further the physiology behind the Vit. C and Thiamine sepsis concept,
below is a link to a discussion by Dr. Josh Farkus on March, 2017 on his 'Pulmcrit' site.