SEPSIS

Course overview

Sepsis is a high-risk diagnosis for all physicians, particularly those providing acute or episodic care. Sepsis presents a unique problem. The practitioner usually has one opportunity to make the diagnosis of “early sepsis” and begin empiric antibiotic therapy. If that opportunity is missed, the patient often returns severely immune compromised and with problems too advanced to treat. Review of malpractice cases involving sepsis reveals that risk often results from a failure to recognize the subtle vital sign abnormalities of early sepsis. In addition, three sources of sepsis (meningococcal meningitis, intrabdominal processes, and necrotizing fasciitis) are commonly seen in malpractice cases, especially when delays in definitive diagnosis and treatment lead to adverse outcomes. The key to making an early diagnosis of sepsis and avoiding medical errors is knowing how the syndrome begins. Textbook chapters on sepsis describe the causative agents and the clinical response, physiologic changes, and management. However, what the textbooks do not describe are the subtleties and nuances of early sepsis. How do patients with symptoms of early sepsis present? Why is it missed or overlooked? Why do physicians make the incorrect diagnosis? In this activity, we answer these questions and present a number of cases of the failure to diagnose sepsis. We point out common themes in these cases to assist practitioners in identifying early sepsis, distinguishing specific causes of sepsis that need urgent consultation or specific management for source control, and effectively managing high-risk situations that can otherwise lead to delays in appropriate, early goal-directed therapy (EGDT). We also discuss changes in the management of severe sepsis and septic shock, as recent research focused on early aggressive management of severe sepsis has demonstrated that certain treatment modalities significantly alter morbidity and mortality. After completing this activity, practitioners should be able to: recognize the presence of pulse-temperature disparity in febrile patients with tachycardia in order to improve timely diagnosis of sepsis; apply current recommendations regarding early antibiotic administration in suspected septic patients in order to reduce the incidence of morbidity and mortality; and implement all appropriate aspects of EGDT in patients with sepsis and septic shock in order to reduce the incidence of morbidity and mortality.