Sepsis is a silent killer. It attacks indiscriminately and systemically. With surgical precision the attack is both methodical and aggressive. Like an apex predator in the wild sepsis hunts the weak and the frail. As such, the immunocompromised are especially susceptible to the merciless onslaught. Sepsis begins with a mere infection that progresses to hemodynamic instability, organ failure, and subsequently death. Sepsis’ furtiveness amplifies it’s efficacy as the infection is allowed to fester undetected and undeterred. Often times before this powerful and destructive disease process is even discovered it is too late. Also, although silent to the outside world the body is well aware of the killer within. Part of the consequential aspect of Sepsis is the fact that not only does the parasitic bacteria and or virus infect the body with toxins there is also a hyperresponsive immunological reaction that is counterintuitive and problematic. The results are quantifiably daunting and qualitatively disheartening.
Every year, severe sepsis strikes more than a million Americans. It’s been estimated that between 28 and 50 percent of these people die—far more than the number of U.S. deaths from prostate cancer, breast cancer and AIDS combined.
Often misunderstood as “blood poisoning”, sepsis today is one of the leading causes of death around the world.
Sepsis arises when the body’s response to an infection damages its own tissues and organs. It can lead to shock especially if it is not recognized early and treated promptly. Between one-third and one- half of all sepsis patients die. In developing countries, sepsis ac- counts for 60-80% of all deaths. It kills more than 6 million infants and young children, and 100,000 new mothers every year. Every few seconds, someone in the world dies of sepsis. (4)
Once such case made international headlines and has been the dri- ving force behind change being enacted in the New York state and city hospital systems.
When Rory Staunton scraped his arm diving for a basketball, no- body thought much about it. But two days later, the 12-year-old was fighting for his life in a New York City hospital as bacteria from the injury raced through his bloodstream. He died in the intensive care unit. The bacteria and his body’s reaction to it — a condition known as septic shock — killed him, doctors determined.
The night after Rory scraped himself he started to experience odd symptoms. “A little after midnight I heard him in the bathroom throwing up,” his mom, Orlaith Staunton, told TODAY.
“So I went in. He was screaming with a pain in his leg. He said ‘it’s my leg, mom. It’s my leg.’” Rory’s parents took him to their pedia- trician the next morning. “She said, ‘this is a stomach virus,” Orlaith said. “’It’s making its way around New York. I’ve seen it before. Be- cause he hasn’t eaten he needs to be rehydrated. You need to go to the ER and have him rehydrated.’”
Rory was given fluids at NYU Langone Medical Center and sent home, his parents said. The problem was, symptoms such as Rory’s could be caused by a variety of illnesses. But lab results that arrived hours after Rory left for home held one important clue, The New York Times reported— his white blood cell count was disturbingly high, indicating a significant infection. But his parents say nobody ever told them about that. By the following night, Rory was so sick that he requested a wheelchair in the ER. This time doctors knew something was very wrong. “They were all around him,” Orlaith said. “I was trying to listen to conversations and finally got this doctor to talk to me. He said, ‘Your son is very ill. He is seriously ill”. They diagnosed sepsis, and explained the potentially deadly condition characterized by an infection and a body-wide state of inflammation. They treated for sepsis with a two-pronged approach: antibiotics coupled with therapies to combat inflammation and its fallout. None of the therapies given to Rory would save his life, however. On April 1, he died in the intensive care unit of the hospital. Three days after sustain- ing a mere abrasion to his arm the 12 year old boy was needlessly gone.
Fortunately there are many campaigns that exist internationally that are spreading the word on the health implications of sepsis. One such campaign puts it very simply by offering a basic truth: Sepsis Kills. The campaign comes from the CEC, Clinical Excellence Commission. An Australian health organization. The campaign focuses on recognizing Sepsis involves a three prong approach:
Recognition
Resuscitation
Referring (for further specialized care)
Symptoms of Sepsis
Shivering, fever or very cold
Extreme pain or general discomfort
Pale or discolored skin
Sleepy, difficult to rouse, confused
I “I feel like I might die”
Short of breath
Please maintain an especially high index of suspicion with the presence of a multitude of comorbidities and even the slightest inkling of an infection.
While the first step may be the recognition and acceptance that a problem is present the next logical step is how to treat the condition. The solution to the pollution is dilution. OK, it’s not the solution, but it’s the beginning of our treatment. As the cytokine (proteins important in cell signaling) levels increase, the immune response causes massive vasodilation as well as a decreased systemic vascular resistance, resulting in hypotension. The goal of the fluid resuscitation is to get enough fluid in the vasculature to increase the blood pressure enough to perfuse the vital organs. It’s important to remember that unlike hypovolemic shock, septic shock doesn’t need more oxygen- carrying fluid. Isotonic fluids are adequate, especially in the initial phases of treatment, for increasing the blood pressure.
Of course our treatment modalities in EMS are limited fluid boluses we can administer en route to the closest ER. However, if one would talk to an intensivist about treating sepsis you’re likely to hear an old adage with a new twist: Time is tissue. In taking a page from their colleagues in cardiology, the critical care community is trying to impart the same sense of urgency that’s used in treating myocardial infarction to sepsis. Mounting evidence shows that when it comes to treating sepsis, what physicians do—or don’t do—in the early hours after diagnosis can have long-lasting effects in terms of organ function. Dr. Derek C. Angus of the University of Pittsburgh School of Medicine also offered the following, “If you don’t give enough fluids, and organ dysfunction results, you may well be giving patients a death sentence.”
During a recent lecture on sepsis, a case review was done involving a 27 year old female, who was dealing with debilitating concerns related to Sepsis. It was said that over the course of her treatment the patient received a total of 72 L of crystalloids from SIRS to Septic Shock to full recovery. It was even specifically stated in the presence of congestive heart failure and fluid on the lungs in conjunction with Sepsis related symptoms you would still give fluid because without the Sepsis may end the patient’s life before CHF exacerbation does.
In the end, increasing awareness on sepsis will be what matters most.
