Pitfalls in the Treatment of Sepsis

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Key points

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    There have been recent changes in the diagnostic criteria for sepsis due to criticism of prior definitions.

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    The diagnosis of sepsis is challenging in special patient populations (eg, the elderly, children, patients taking medications that alter typical physiologic responses).

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    There is significant controversy in “bundled” care for septic patients because it is unclear which aspects are most helpful and which aspects may pose the potential for harm.

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    The disposition of a septic patient out of the

Systemic Inflammatory Response Syndrome

The original definition of sepsis relied on the presence of 2 or more criteria outlined in the systemic inflammatory response syndrome (SIRS). In fact, the SIRS criteria acted as the building blocks for identifying and diagnosing sepsis, severe sepsis, and septic shock. SIRS incorporated changes in heart rate, body temperature, respiratory rate, and white blood cell count. If there was a known or suspected infection in a patient with 2 or more SIRS criteria, the patient was diagnosed with

Failure to Communicate to the Treatment Team

The management of sepsis is a team sport. The clinician may order fluids, antibiotics, and diagnostic studies, but unless the whole treatment team is aware of the concerns about the patient and their risk for decline, other patients or tasks may take priority. ED crowding, a proxy measure for how busy the clinical environment is, has been implicated as a factor causing delays to antibiotic treatment.25 Similarly, ED crowding has been associated with decreased sepsis resuscitation protocol

Failure to Ensure Follow-up, Failure to Admit to the Correct Level of Care

“Disposition is destiny” is a maxim in emergency medicine revealing the importance of determining where the patient is to go at the end of their ED encounter. Answering the question, “can this patient be safely discharged?” is sometimes vexing. In addition, if the patient is admitted, what level of care should the patient be assigned?

There is a small subset of patients who are at high risk for severe infection, but after their ED assessment may not clearly require admission. Patients with

Summary

Sepsis is the most challenging disease process faced in the ED environment for myriad reasons. This article has outlined some of the key pitfalls EPs may encounter when caring for patients with suspected sepsis in the ED. Pitfalls begin with the failure to consider sepsis and the numerous ways it can present and carry on through the consideration of various underlying causes, the complex and intensive management, and finally, the consideration of disposition whether that ends up being the

Acknowledgments

Dr. Peterson would like to thank the Division of Pulmonary and Critical Care Medicine and the Department of Emergency Medicine of the University of Rochester Medical School of Medicine & Dentistry for supporting his authorship of this article.

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