Critical Care, Improving Outcomes

Sepsis – Setting the Course

Sepsis and real estate have more in common than you think.  The three big things I can think of that affect outcomes are location, location, and location.

     A retrospective study looked at almost 8000 septic shock patients across 29 facilities – a mix of academic & community settings, and across the US, Canada, and Saudi Arabia from 1989-2008.  Quite an undertaking.  Their results are interesting, and should encourage all EM providers to think just a bit more when they have a lactate of 6 come across their screen.

     Variables that did not change mortality within a given source of sepsis:  Year.  Geographic location.  Age.  Sex.  Comorbidities.  Community vs healthcare acquired process.  Organism involved.

     That is, dead bowel causing septic shock caused mortality 75% of the time, regardless of the above variables.  70 years old without comorbidities in 2007 vs 95 years young with the works in 1990- similar mortality rate.  I’m a bit surprised.  Variation in mortality by source was also unexplained by APACHE II score, number of organ failures on day one of hospitalization, presence of bacteremia, or appropriateness of antibiotic treatment.  Now I’m really surprised.

     Despite appropriate antibiotics, source of sepsis was the most reliable predictor of mortality after adjusting for predisposing and downstream factors.  The ED is the gatekeeper, and often sets the wheels in motion for course of hospitalization.  What takes us from good to great is finding the infected stones, the dead bowel, the emphysematous cholecystitis and emphysematous pyelonephritis.  As evidenced by this paper,  your early fluid resuscitation and VancoPime does not mean much if the patient really needed the IR suite or the OR.

Sepsis.  Find a source, set the course.

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PMID:  24635548

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