September is Sepsis Awareness Month. It’s got us thinking about how far we have come in combating this deadly illness. But, we still have a ways go, especially in the prehospital environment.
Unfortunately, one of the leading causes of mortality in U.S. hospitals is sepsis. Most of these deaths, however, are avoidable through better adherence to evidence-based recommendations and practices.
In 2012, the Society of Critical Care Medicine’s Surviving Sepsis Campaign issued updated guidelines for the treatment of sepsis that remain largely accepted in the medical community. The problem remains that sepsis often goes undetected initially, which delays recommended treatments.
Identifying sepsis
Tara Vlaun, NRP, CCP-C, EMS-I
One question that continues to plague healthcare providers at all levels is where does recognition truly begin?
Should we begin treatment in the prehospital setting beyond managing fluid resuscitation and ongoing hypotension with vasopressors? Clinicians and educators alike, from ground operations to flight programs, share this mindset.
Shane Farmer, FPC, works as the clinical director for Air Methods, a Colorado-based air medical transport company. Farmer says providing such treatment could greatly reduce morbidity and mortality in septic patients.
“There is a great deal of evidence to support administration of broad-spectrum antibiotics in the prehospital environment,” he said. “Much like the hospital, we often administer antibiotics immediately following culture draws, later verifying that the antibiotics administered are appropriate for whatever was detected in the cultures. I do not see why prehospital would be any different, and it could have a very positive impact on patients.”
More aggressive prehospital sepsis treatment
Some ground organizations already have begun to provide more aggressive prehospital treatment, and the response has been quite positive.
EMS professionals in Greenville County, SC, added antibiotic therapy treatment to their protocol in 2015. This came after additional training on proper techniques to draw blood cultures and manage patients with antibiotics.
In accordance to a retrospective study of a six-month trial period, contamination incidents were very low. “A total of 946 blood cultures were collected in the prehospital setting, with a 95.04% no-contamination rate, according to a 2016 article in Medical Training magazine.
This still means that 4.96% of prehospital settings suffered from contamination. Contamination, a concern that resulted in initial push back for prehospital blood culture draws, was proven to be a non-issue with the proper training Greenville County EMS received.
Sepsis guideline adjustments
The management of sepsis using antimicrobial therapy in the field is yielding positive results. But, there have been some changes to the 2016 guidelines put in place by the Surviving Sepsis Campaign.
The criteria for sepsis have historically been based on the SIRS criteria. This is a great starting point for sepsis identification, however, it is not fail safe.
A 2015 study published in the American Journal of Respiratory and Critical Care Medicine revealed that nearly half of the adult patients admitted to hospital wards fulfilled two or more SIRS criteria at least once during their ward stay.
Research published in a 2015 New England Journal of Medicine article showed that about 12% of the adult ICU patients with some infection and at least one organ dysfunction were negative for the SIRS criteria, but their mortality rate was still substantial.
These findings questioned the efficacy of using the SIRS criteria alone as the screening tool for sepsis, urging for advocacy of new criteria in 2017.
“The Sepsis-3 redefined the disease as an infection complicated by one or more organ dysfunctions,” according to the Journal of Intensive Care. The SOFA (Seqential Organ Failure Assessment) scoring system uses points with an increase in two or more points. This kinds of an increase indicates the presence of sepsis in the patient.
What does it mean?
These changes are mostly applicable in the adult population as of now.
Sepsis identification in the pediatric population using the SIRS criteria carries its own challenges. For example, vital signs considered normal tend to overlap depending on the age of the pediatric patient.
It is currently being advocated that organ dysfunction be the stronger identifier of sepsis in pediatrics as well, noted the Journal of Intensive Care article.
Pediatrics tend have a higher incidence of mortality in younger ages. On the other hand, adults have a higher incidence in older age groups. The common denominator is the presence of comorbidities.
Data on pediatric sepsis, however, remains limited and tends to be contradictory from one study to another.
The Surviving Sepsis Campaign still recommends the “sepsis bundle” laid out in the PALS algorithm. However, adherence is challenging in some emergency departments.
The five goals defined by PALS include:
- Early recognition
- Vascular access
- IV fluids up to 60ml/kg
- Vasopressors for fluid-refractory shock
- Antibiotic administration
Studies have shown some EDs struggle with adhering to the fluid resuscitation guidelines, as well as timely vasopressor support.
Teams often overcome this through further education and initiatives to improve adherence. For the prehospital environment though, SIRS is still a strong indicator of sepsis.
For those organizations using point-of-care testing, Lactate levels can be helpful in confirming sepsis suspicion. But, this should not be used as a sole indicator.
Sepsis is serious business
We should take sepsis as seriously as we do an ST-elevated MI or a life-threatening trauma.
Per the Surviving Sepsis Campaign, “Sepsis and septic shock are medical emergencies, and we recommend that treatment and resuscitation begin immediately.”
Furthermore, the campaign recommends beginning antimicrobial therapy within 1 hour of identification and treating sepsis-induced hypoperfusion with at least 30ml/kg of IV crystalloids.
To put that in perspective, a 70kg patient would need to receive 2.1 liters of fluid over the first 3-hour period, provided they are not showing signs of fluid overload. Frequent reassessment is urged by qualified medical personnel to gauge the efficacy of the treatment.
Experts recommend Norepinephrine as the first-line vasopressor. They also recommend Vasopressin or Epinephrine as second-line vasopressors.
Corticosteroid use remains a weak recommendation. Additionally, this would only be in the event that hemodynamic instability ensues despite previously mentioned therapies.
EMS role in sepsis care
It remains a strong argument that if sepsis can be identified in the field by EMS, treatment with antibiotics would help reduce mortality rates.
The campaign guidelines urge early recognition and treatment, but the question remains how to identify.
SIRS is still a strong indicator, especially with the presence of a suspected infection. Increased lactate levels on top of the SIRS indicator adds more validity to the sepsis suspicion.
Data shows that qualified and well-trained paramedics can effectively draw cultures and blood for lactates in the field. Therefore, should we all be moving toward these protocol changes?
We have made huge leaps and bounds with STEMI alerts and timely treatments for MIs, but it took changes and training for prehospital providers.
With sepsis being a culprit of high mortality rates, perhaps we should be as aggressive in treating it in the field as well.