Hello, welcome to the first clinical podcast and blog from FOAMdation. The following podcast was recorded 13/1/17 with Dr Santokh Singh, Consultant Anaesthetist and Intensivist at the Countess of Chester Hospital, England. Dr Singh is also the sepsis lead for the hospital and is currently working to update the hospital sepsis policies in line with the most recent published evidence and guidelines.
What we present is a basic understanding of the more recent evidence and guidelines and our attempt to provide a practical application of this for Foundation Doctors in the UK. Our discussion centres upon the most recent guidelines from NICE for Sepsis (1). The concept of “Red Flag Sepsis” is recommended in the NICE guidelines as a method of recognising those patients with sepsis who are at the highest risk of severe illness or death.
We do accept there are a multitude of different methods for assessing the unwell patient and for assessing for the possibility of sepsis (2). qSOFA (2) is but one of them and it is worth investigating the emerging prospective evidence for yourselves. The best advice will always be to follow what your hospital itself uses for policy and procedure. If you feel that what has been discussed can influence your practice or hospital practises then seek out those responsible for the sepsis policy and discuss with them.
Lactate is an important biomarker when it comes to sepsis with regard to mortality and prognosis (3, 4). The article mentioned by Suetrong and Walley, Chest 2016 is worth reading in order to understand the mechanisms of its production (5). The evidence supporting the use of lactate as a biomarker in sepsis is useful to understand the implications for your patients and just how sick they are. Indeed, Mikkelsen et al found that a raised lactate without haemodynamic compromise independently predicted a higher mortality in sepsis (4). The haemodynamically stable patient may not be the patient that we would traditionally be measuring a lactate in and is worth thnking on.
There are no official guidelines regarding the clearance we should be aiming for in septic patients, however some research has provided clues (6, 7, 8). Nguyen et al (7) found that a clearance of >10% confirred a decrease likelihood of mortality of 11%, and whilst it may be helpful to bear this in mind, there is no official level we should be aiming for. Instead, we should be using serial lactates to assess how well the patient responds to resuscitation alongside other clinical parameters and not waiting for a post-take review or ward round to be ordering these repeats.
Fluids will for a long time be a contentious issue in sepsis and illness and we do not seek to join the discussion around the purpose of fluids in sepsis. The three trials of PROMISE (9), PROCESS (10) and ARISE (11) certainly show that we can step away from Early Goal Directed Therapy () as a driving principle of management. However, these were looking into expert care and would not necessarily be applicable to a Foundation Doctor initially seeing patients on the ward with a suspected infection.
What a Foundation Doctor can do is be active and involved in the care of these patients, simply increasing an eight hourly bag of fluid to four hourly is not the same as providing fluid resuscitation. As described by Dr Singh, a mainstay of fluid therapy is ensuring it has had the response you were looking for. That response may be haemodynamic stability, lactate clearance or urine production to name but three possibilities. We aimed to provide a practical view of fluids in sepsis, however plenty of resources are available to review the utility of fluids but our aim was not a perilous dive into this. Whatever your end points may be, it comes down to the individual to ensure staff looking after the patient know what you are aiming for with your efforts.
The bottom line for me as a junior doctor is that sepsis is life threatening. It kills people even when treated properly but we have an opportunity to treat patients effectively and in a timely fashion we can make a difference to their outcomes. However, sepsis is also a conditions where escalation of care is also essential and we should not be trying to just do our best alone and without senior support. Those people who are identified as being severely unwell or have the potential to be should be escalated when they are identified. Antibiotics and fluids are not the sole answer everytime.
If you want to delve deeper into other discussion regarding sepsis and it’s definitions, lactate and the latest surviving sepsis guidelines then seek out other FOAM resources such as Pulmcrit, FOAMcast, St Emlyns.
Find the full podcast below. Please get in touch if there are any other aspects of sepsis you would like covered.
- Sepsis: recognition, diagnosis and early management, NICE guideline [NG51] Published date: July 2016 Last updated: July 2016
- Seymour CW et al, Assessment of Clinical Criteria for Sepsis For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774.
- Thomas-Rueddel, Daniel O. et al, Hyperlactatemia is an independent predictor of mortality and denotes distinct subtypes of severe sepsis and septic shock. Journal of Critical Care. 2015;30(2): 439.e1 – 439.e6
- Mikkelsen et al, Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Critical Care Medicine. 2009;37(5):1670-1677
- Suetrong B et al, Lactic Acidosis in Sepsis: It’s Not All Anaerobic: Implications for Diagnosis and Management, Chest, 149(1), 252-261
- Arnold R et al, Multicenter Study of Early Lactate Clearance As A Determinant Of Survivial In Patients With Presumed Sepsis.Shock. 32(1):35-39
- Nguyen H et al, Early lactate clearance is associated with improved outcome in severe sepsis and septic shock, Crit Care Med 2004;32(8):1637-1642
- Chertoff et al. Prognostic utility of plasma lactate measured between 24 and 48 h after initiation of early goal-directed therapy in the management of sepsis, severe sepsis, and septic shock. Journal of Intensive Care 2016;4:13
- Mouncey P, Trial of Early, Goal-Directed Resuscitation for Septic Shock. N Engl J Med. 2015;372(14): 1301-1311
- Lilly CM. The ProCESS trial—a new era of sepsis management. N Engl J Med. 2014;370(18):1750–1.
- Arise Investigators, ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496–506.
- Rivers E, Early goal–directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-77.