Just as we should not get too far out in front with recommendations based on exciting but insufficient evidence, we should also be cautious about overstating cause and effect from temporal associations. In other words, just because it rained the night before and you woke up with frogs on your lawn, doesn’t mean it rained frogs.
Explore This IssueACEP Now: Vol 37 – No 03 – March 2018
To wit, Lindenauer et al demonstrated that coincident with the SSC, more patients, including low-risk ones, were being given a sepsis diagnostic code.6 For example, patients with pneumonia who were at an intermediate risk of death had been shifted from the “pneumonia bucket” to the “sepsis bucket,” lowering the mortality rates of both. In reality, though, sepsis survival rates had not changed.
Sepsis and severe sepsis diagnosis–related group codes are also associated with significantly higher payment than pneumonia codes alone. In addition, it’s up to the physician’s judgment whether the patient has sepsis or just systemic inflammatory response syndrome (SIRS), and all that’s required is documenting “sepsis” in the notes. Severe sepsis requires organ dysfunction, including an elevated lactate alone. The attention brought to sepsis by the SSC likely promoted earlier recognition, although we do not know the extent to which SIRS and then lactate screening led to unnecessary care and costs. And Centers for Medicare and Medicaid Services, thank you for the new sepsis core measure requirements in time for this year’s flu season, especially the lower lactate threshold of 2 mmol/L. This new directive illustrates the trade-off of enhanced screening to catch a few cases of bacterial sepsis earlier and the unintended consequence of excessive care for many stable but dehydrated patients with a benign viral illness.
What remains of SSC recommendations? Primarily fluid resuscitation, now at 30 cc/kg initially and then additional fluid based on further assessments of perfusion, and timely antibiotics. However, even fluid resuscitation is now under debate and study.
The current fluid strategy promoted by the SSC, based largely on the EGDT bundle, is typically with total amounts of 50–70 cc/kg (eg, 5 L) in the first six hours of care.7 This liberal fluid approach may be pressor-sparing and limit complications from hypoperfusion. Alternatively, a restrictive fluid approach of <30 cc/kg (eg, ≤2 L) in the first six hours, which relies on earlier use of vasopressors, may prevent complications from tissue edema that interfere with oxygen delivery and organ function. However, such a change will need to consider any increased risk of digital or limb amputations, which may be associated with expanded use of vasopressors.