According to Annals of Emergency Medicine, sepsis is a significant driver of hospital deaths, with more than 850,000 patients with sepsis presenting to the emergency department (ED) each year. To improve patient outcomes and, in some cases, save patient lives, it’s crucial for ED physicians to identify and begin effective sepsis treatment as soon as possible.
Understanding Sepsis
Sepsis occurs when an infection triggers a systemic inflammatory response. This can lead to tissue damage, organ failure, and even death if not managed effectively. While any type of infection can potentially lead to sepsis, the Centers for Disease Control and Prevention highlights the most common culprits include infections originating in the lung, urinary tract, abdomen and skin.
Signs and Symptoms
The World Health Organization cites the following common signs and symptoms of sepsis:
- Fever or low temperature
- Difficulty breathing
- Clammy skin
- Significant body pain
- High heart rate, low blood pressure/weak pulse
- Confusion
- Low urine output
It’s important to remember that not all patients will exhibit the full spectrum of symptoms. The National Institute for Health and Care Excellence (NICE) recommends a high index of suspicion for patients with the following characteristics:
- Elderly
- Immunocompromised
- Recent surgeries
- Pregnant, postpartum, or terminated/miscarried a pregnancy in the previous 6 weeks
- Chronic medical conditions
Children are among the most at risk groups for sepsis, especially babies less than one year old. Read more information about pediatric sepsis diagnosis and treatment here.
Rapid Identification
The publication Diagnostic Errors in the Emergency Department: A Systematic Review highlights sepsis as the sixth most misdiagnosed condition in EDs, with high rates of both under-diagnosis and overdiagnosis. Quickly identifying patients with sepsis has been a challenge in emergency departments due in part to a lack of rapid tests. Approved in November 2021, Seypticite Rapid delivers results in 1 hour. In early 2023, the FDA approved Intellisep (Cytovale), a truly rapid sepsis test that delivers results in less than 10 minutes. This test can serve as a tool for both diagnostic aid and risk assessment by emergency department physicians.
Initial Management
Upon identification of sepsis or septic shock, immediate actions should be taken to stabilize the patient and initiate appropriate treatment. The 2021 update of Critical Care Medicine Surviving Sepsis Campaign guidelines offers the following recommendations:
- Patients with possible sepsis without shock: Quickly assess likelihood of infection versus non-infectious illness. If there is continued concern of infection after fast investigation, administer antimicrobials within 3 hours from when sepsis is suspected. NOTE: Given Intellisep was not approved at the time of the Surviving Sepsis Update, it was not recommended as a diagnostic tool. If available, a rapid test like Intellisyp should be administered.
- Patients with minimal likelihood of infection and no shock: Closely monitor patient,delaying antimicrobials until necessary.
- Patients with probable sepsis or with probable or possible sepsis with shock: Begin administration of antimicrobials within 1 hour and at least 30 mL/kg of intravenous balanced crystalloid fluids within the first 3 hours. If there is a clinical reason to provide less than the maximum fluid resuscitation that reason should be documented in the medical record.
- Patients with septic shock: Begin vasopressors peripherally (with norepinephrine as first-line option), along with antimicrobial and fluids as recommended in number 3 above.
Finally, the Surviving Sepsis Campaign recommends that patients with sepsis be admitted to the hospital within 6 hours.
Recap
As emergency medicine clinicians, your role in recognizing and initiating treatment for sepsis is paramount. Stay updated on the latest research and guidelines, and continue to refine your clinical acumen for detecting this life-threatening condition. By doing so, you can significantly impact patient survival rates and contribute to better outcomes in the fight against sepsis.
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