The management of sepsis requires a life-saving set of skills that emergency physicians are increasingly relied upon to possess at expert-level competency. While many iterations of sepsis management have emerged in the literature, this article will focus on noninvasive management of sepsis by reviewing the epidemiology and evolution of sepsis and sepsis care, as well as highlighting the indications, contraindications, and benefits of noninvasive management of sepsis.
Sepsis is the most expensive disease in the United States, costing the health care system approximately $50 billion annually.1 Sepsis is the number 10 cause of mortality.2 A large epidemiological study in 2001 placed the annual incidence at approximately 750,000 cases per year, with a mortality of 20%-30%.3 Sepsis disproportionately affects the elderly, with a 13-fold increase in relative risk for those older than 65. This same age group represents approximately 65% of total cases of sepsis.2 With our aging population and increasing life expectancy, the emergency physician has the potential to have considerable impact on the care of this disease process.
Sepsis was originally described as the presence of an infectious source plus at least two systemic inflammatory response syndrome (SIRS) criteria (Table 1). Severe sepsis was defined as sepsis with evidence of organ dysfunction. Septic shock is sepsis with hypotension.4 An updated definition of sepsis identifies this disease process as an infection plus some of a larger set of criteria that includes traditional SIRS criteria, as well as other markers of hemodynamic instability, inflammation, and organ dysfunction4 (Table 2).
Evolution of Bundled Therapy
Combining multiple evidence-based treatments in a standardized, bundled approach to sepsis has been discussed since 1976. A study of sepsis in a dog model identified a synergistic effect of fluid resuscitation plus antibiotics.5 In 2001, Dr. Rivers demonstrated that an early, algorithmic application of antibiotics, source control, volume resuscitation, vasopressors for those still in shock, and transfusion in the anemic significantly lowered both mortality and resource utilization.6