Sepsis in the ED

Improving Outcomes in Sepsis Patients in the Emergency Department Sepsis is a left threatening illness that affects millions of people each year. The Center of Disease Control reports sepsis as the 10th leading cause of death in the United States (V). For adults age 65 and over hospital admission because of sepsis have increased 48%. The body’s immune system switches into “high gear” which overwhelms the body’s normal blood flow and oxygenation of tissues throughout the body. This process, if not treated in time, can quickly lead to organ failure and death. Approximately one third of people diagnosed with sepsis die from it. The role of emergency departments throughout the country has become vitally important to the early detection and treatment of sepsis. With the implementation of sepsis protocols in the emergency department the mortality of patients with sepsis admitted through the ED is significantly lower. The word sepsis is commonly used to diagnose patients, but the debate continues as to the true definition. The word sepsis comes from the Greek meaning decay or to putrefy.” (A). Sepsis is a general term that is applied to patients that develop clinical signs of infection. Unlike other diseases sepsis is not diagnosed by the location or type of microbe involved in the infection. Some of the criteria used to diagnose sepsis are abnormalities of body temperature, pulse, respirations, and white blood cell counts. Some symptoms that are common in septic patients are fever, hypothermia, heart rate greater than 90 beats per minute, altered mental status, swelling of the extremities, and high blood glucose in diabetic patients. Sepsis is considered severe when there is organ dysfunction involved. Some examples of this kind of dysfunction are low oxygen level, low urine output; high levels of creatnine in the blood, absent bowel sounds, and low platelet count in the blood. The scary fact about sepsis is that it can occur in incidents as minor as a scrape from a minor fall. American hospitals spend approximately twenty billion dollars a year fighting sepsis. Sepsis must be considered a medical emergency. “A 2006 study showed that the risk of death from sepsis increase by 7.6% with every hour that passes before treatment begins.” (A). Sepsis begins with the entry of an organism into the bloodstream through the skin, respiratory, genitourinary, or gastrointestinal tract. The organism can be bacteria, yeast, virus, or parasites. Sepsis is a complex syndrome characterized by the body’s activation of inflammation and coagulation in response to the introduction of the foreign organism into the bloodstream. The body also releases cytokines, which play an important role in the inflammatory and immune response. As the foreign organism circulates throughout the bloodstream, more phagocytes, leukocytes, and cytokines are activated. The cytokines and white blood cells increase capillary permeability, neutrophil activation, and adhesion of platelets to the endothelium (V). Due to this platelet aggregation and vasodilation the patient’s blood pressure begins to fall. As a result of this drop in blood pressure baroreceptors in the carotid arteries and aorta activate the body’s sympathetic nervous system. The sympathetic nervous system responds by releasing vasoconstrictors to maintain blood flow to vital organs. At the same time blood is redirected away from non-vital organs such as lungs, kidneys, gastrointestinal tract, and skin. These changes eventually lead to decreased cardiac output, volume of circulating blood, and blood pressure. This can lead to organ dysfunction and eventually death. Septic shock occurs when there is acute circulatory failure related to the infection. Hypotension, systolic blood pressure lower than 90mm Hg or a reduction of more than 40mm Hg from baseline, despite fluid resuscitation and no other explanation for the decrease in blood pressure. At this point in the disease cycle the patient is dependent on vasopressors to maintain their blood pressure. The transition from sepsis to septic shock occurs most often in the first 24 hours of treatment. Septic shock comes with a significant increase in the mortality rate.
The patient’s history is essential in determining the likely source of the septic process (C). Once the clinician is able to determine what is causing the septic process to occur, the proper antibiotics can be administered. In some cases the early symptoms may be difficult to detect. The populations that are at most risk of sepsis are people under the age of one and older than sixty five, people with chronic illnesses, immunosuppressed patients, patients who are taking a broad spectrum antibiotic regularly, and patients who have undergone a surgical or other invasive procedure. There are also other physical deficits in the elderly population that can be a higher risk for sepsis. These deficits are dementia, decreased gag and cough reflex, immobility, skin breakdown, poor urinary bladder emptying, and other obstruction leading to infection. The most common infection that leads to sepsis is pneumonia. Patients in hospitals are also at risk for acquiring infections that can lead to sepsis due to the use of indwelling catheters, invasive catheters, ventilators, and intravascular access. The most common causative agent found in hospitals is Staphylococcus aureaus (V).
Because sepsis can be masked by symptoms of the patients underlying illness, organ dysfunction may be the first sign of sepsis. One of the tests clinicians rely on to diagnose sepsis is serum lactate level. Lactate is generated by anaerobic cellular metabolism and can give an indication of the severity of the sepsis. Lactate levels can also give an indication of the effect of the resuscitation efforts.
Patients that present to the emergency department with severe sepsis require a “constellation” of evidence-based interventions (K). Emergency departments use a group of treatments known as a bundle. A bundle is a group of evidence-based interventions that, when executed together, result in better outcomes than interventions implemented individually (K). These bundles give a standardized treatment plan for patients who present to the ED in a septic state. In a landmark study, this algorithm for the first six hours of sepsis management reduced in-hospital mortality by 34.4%, reduced hospital stay by 3.8 days for survivors, and was associated with a 50% decrease in the rates of sudden cardiopulmonary demise (K).