COMMENTARY

Detecting Sepsis on the Wards

Aaron B. Holley, MD

Disclosures

August 30, 2016

Defining Sepsis

In the wake of the recent revisions to the definitions for sepsis[1] and septic shock[2] comes a review published online by the journal CHEST.[3] The article summarizes the literature on the identification of sepsis in patients receiving care on hospital wards. In so doing it indirectly addresses a major concern expressed over the new Sepsis-3 definitions: Will abandoning the systemic inflammatory response syndrome (SIRS) criteria delay the identification of sepsis?[4,5] I share this concern, and I have criticized Sepsis-3, mainly because early identification is so critical to outcomes.

That said, I was operating under the assumption that the SIRS criteria actually help us improve outcomes; in other words, they allow identification of sepsis before it becomes severe sepsis or septic shock (to use pre Sepsis-3 nomenclature). My evidence for this is anecdotal and probably biased. Intensivists get used to dealing with sepsis late in its course when outcomes are poor.[6] Despite knowing that the SIRS criteria have poor specificity,[7] I have been willing to accept this to maximize sensitivity for early detection.

Much Yet to Learn About Sepsis

According to the CHEST review,[1] we have much to learn about sepsis identification and treatment on the hospital wards.[3] Apparently none of the randomized controlled trials cited by the Surviving Sepsis Campaign (SSC) guidelines enrolled ward patients. The trials were focused on the emergency room or intensive care unit. The SSC used a limited number of prospective studies and observational data to argue that their recommendations apply to ward patients.[8]

The CHEST review summarizes existing data on screening patients for SIRS (or SIRS with slight modifications) with manual or automated reminders. The data largely come from before-after studies and are subject to the bias inherent to this design. SIRS reminders increase implementation of SSC-recommended therapies but don't alter intensive care unit transfers or mortality rates.[3]

In summary, I came away less confident that we know the optimal strategy for identifying and treating sepsis on the wards. Although some argue that ward patients might respond differently to common sepsis treatments, like fluids,[8] it's still probably reasonable to apply the SSC guidelines. Still, we have a lot of work to do before we will know the best method for screening to allow early, important interventions. The pivot away from SIRS by Sepsis-3 may not have a major effect on ward patients.

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