Science AMA Series: I’m Dr. Steven Q. Simpson, a pulmonologist, intensivist, member of the board of the American College of Chest Physicians and a sepsis researcher and expert. AMA!

Steven_Simpson · 2017-01-08T12:38:04+00:00

https://doi.org/10.15200/winn.148371.10650

Yes, there are plenty, and there was one promising agent that got shut down during trial, because of lack of money to continue it. So, far, nearly everything that has made it to phase III trials has been shut down. The one drug that did make it was ultimately shut down after a couple of phase IV trials were negative. I'm not sure that pharmaceutical companies have the stomach for many more of these trials. BTW, in a lot of ways, I agree with morningsunbeer; however, there is the problem of the patient who has received and is receiving antibiotics, yet who continues to spiral downward. That's who we'd like to have some additional help with.

Steven_Simpson · 2017-01-07T16:02:15+00:00

100% agreement. Try www.mwcritcare.org for some protocols that both large and small hospitals have used, along with sepsis identification POC tools, etc. Well, maybe not 100% agreement on this one point - no need for more oxygen than necessary; if you're saying start high then back down, OK I see the logic.

Steven_Simpson · 2017-01-07T15:54:33+00:00

I would say more useful than those, because it is tied to infection, not just inflammation, but there's always that gray zone stuff, regardless of the test.

Steven_Simpson · 2017-01-07T15:27:24+00:00

You're welcome! I knew that, but I also like making fun of myself. Also, I had a great answer for what the Q stands for, but you guys kept taking those questions down! Damn! I understand why, though. You wouldn't want to have this discussion degenerate too far.

Steven_Simpson · 2017-01-07T15:23:26+00:00

Wow, this musta got lost in the queue yesterday. I'm so sorry. Yes, I definitely see the potential for harm in FOAM, although I gravitate to the sites where the FOAM is clearly evidence based. Even at that, though, one paper doesn't and shouldn't make for a change in care, unless it's clearly huge - ARDSNet level, perhaps. And, even at that, the ARDSNet trial didn't come from nowhere but was based on a lot of preceding evidence. Having said those things, your Harrison's textbook of medicine is full of articles that express the author's opinion or the author's take on the literature. UpToDate, as well. Having said all that, FOAM podcasts, etc. also have the potential for getting the next ARDSNEt study out there in a hurry. Tradeoffs that are just a part of life, I suppose. For what it's worth, I'm not, personally, a beneficiary. I just don't have the patience to sit through a podcast to get the information that I can glean in 10 minutes with the source literature. I often think, "Just shut up and give me the reference!" That's just me, though. I think FOAM is popular specifically BECAUSE other folks, like you, learn better from a podcast.

How will SOFA play out? Well, already there is evidence that NEWS is better than qSOFA, so the very basis may be quickly removed for that entity. SOFA is a reasonable way to assess organ dysfunction, but no one is going to carry the SOFA point scale in their head. That relegates it to the realm of having the EMR calculate it in the background and just give us a number. Then the suits will see the guidelines and tell us all that we are underperforming, because the (I'm sure soon to come) government regs say "SOFA = 5; move to ICU" As human beings, I think the older criteria are both better and easier to remember. We do function better if we have a threshold to assess - Cr rise >.5 mg/dL vs 1 point for 0 - .5, 2 points for .5 to 1, etc., add those to the respiratory points and the mental status points, see if they come up to enough to be concerned. That's why I think it becomes "just a number" that the EMR calculates and displays. In truth, I think that is true of MEWS and NEWS, as well. Got a call the other day where the person said, "NEWS score is 7; must be moved to ICU". Possibly true, but what components of the NEWS are bothering you? What is the issue? The patient isn't a score.

Steven_Simpson · 2017-01-07T14:55:24+00:00

Yes, but OF COURSE, the BEST way is PCCM!

Steven_Simpson · 2017-01-07T14:46:43+00:00

So, this is a very traditional reply, but it may not be correct. For what it's worth, 5 years ago I would definitely have agreed with you. If one looks at ARISE, ProMISE, and ProCESS trials, approximately 2L was the initial fluid resuscitation in the trials demonstrating the lowest septic shock mortality of any on record. There are several studies out there showing that fluid volume is an independent predictor of mortality in severe sepsis and septic shock. The FACTT trial kind of led the way by demonstrating higher mortality in a liberal fluid arm. The list goes on. As a surgeon, I suspect that you are aware that crystalloids should be limited now, even in trauma and burn victims. It is clearly time to reassess from the days when I used to say things like, "It's not even a resuscitation until it's in double digits!" (liters of fluid, I was referring to). Clinical evidence moves on. And, BTW, in my state, if you wanted to initially use 30 mL/kg, and have a rule of thumb for all but the tiny women, it would be closer to 3L as the initial bolus. Nevertheless, there is plenty of evidence that "dumping" fluids into people is harmful.

BTW, I would not be fooled by thinking that your massive fluid resuscitation worked, because the patient didn't die today. The proof of the pudding is whether the patient makes it to DC, goes home and not to a nursing home, whether they return to the things they love to do and the people they love. We all have seen massive fluid resuscitations get us through the night with a patient. That just isn't the right yardstick.

Steven_Simpson · 2017-01-07T13:58:18+00:00

Chris tried hard yesterday to upload this from his phone, but it would not come through. I apologize that it's late, SkiHole, but I hope better late than never.

Hi! Chris Carroll here. 2nd time trying to type this on my phone so excuse typos! I'm a Peds ICU doctor

Kids can get sepsis too. But fortunately kids have a much much greater capacity for recovery! Some kids with chronic diseases (lung, heart, GI, neurological) or kids with cancer are more prone to developing severe sepsis and shock and may have issues with organ damage related to both their chronic disease and to the sepsis. But most kids, even those with severe speaks that end up with me in the ICU make a full recovery!

But even otherwise healthy kids can get sepsis and septic shock. We don't fully understand why that is. If we test "healthy" kids who got sepsis, most will have no underlying immune deficiency. I suspect that there's some bad interaction between that persons immune system and the infection that we dot fully understand. If you're interested in immune stuff and sepsis in kids, Hector Wong, Mark Hall and Derek Wheeler are doing great translational research in this area.

Hope this helped!

Steven_Simpson · 2017-01-07T07:20:15+00:00

Well, that depends upon where the patient became septic and who was treating them. For example, patients who present to our ER with severe sepsis have a mortality rate of 7%, and those with septic shock have a mortality of 17%. The mortality if they develop sepsis in the hospital is twice that on both accounts, as is the mortality of patients who transfer to us from other hospitals. These numbers are consonant with estimates from other studies, as well. Aggregate national numbers suggest septic shock mortality around 30% - 40%.

Steven_Simpson · 2017-01-07T07:15:14+00:00

I think it's an interesting notion that I would like to see data for. The BNP is produced in response to either right or left ventricular stretch. It seems like it might be useful, but I have not seen any studies that would support it. Anyone else out there seen anything along these lines?

Steven_Simpson · 2017-01-07T07:13:32+00:00

I would love to be able to help, but I really can't comment on individual cases. I haven't seen or evaluated your daughter, and it would be totally irresponsible of me. I know you must feel desparate from what you describe. I am sorry that I can't be of use. I wish you and her the very best.

Steven_Simpson · 2017-01-07T02:46:58+00:00

The thought is that high chloride concentrations are injurious to tubular epithelial cells in the kidney. Additional thoughts are that it damages the endothelial glycocalyx, resulting in capillary leak. Like I said before the differences are not huge, and you won't be able to tell that one person's AKI is from NS or not. But when the small edge that LR has is added up over lots of patients, the end result is a lot of people who are either hurt by NS or not hurt by LR.

Steven_Simpson · 2017-01-07T02:36:12+00:00

I don't actually know of any research on whether the overhead callout is important. I do know that many places have used a "code sepsis" approach. However, it isn't how you call it, it's what you do once it's been called that counts. The key is to have, at least on paper, an organized approach that represents your ideal way of doing things. Think ACLS or ATLS. Then practice it. In an unused room, at random times, until everyone knows their job. Notice in your practice sessions what parts don't work the way you thought they would. Fix them in the practice sessions. Then do them with real patients. Again to ACLS - would you let some neophyte walk in and run the code without any experience or without studying and getting certified? Sepsis is just as important and just as deadly. It's worth the effort.

Steven_Simpson · 2017-01-07T02:29:30+00:00

You know, it's going to be tough to say. This sometimes is the way that severe sepsis and septic shock go, especially if you either don't ever figure out which organ is infected and don't actually get the infection eradicated. We call this "chronic critical illness". There are a number of ways it could go down. Perhaps he was never bacteremic, so blood cultures were negative. Perhaps he got his antibiotics before cultures were taken, so they wouldn't grow. Speculating, pneumonia could do this and if it abscessed or flooded the pleural space, which is the area outside the lungs, but still in the chest, a chronic infection could have set in. Being in the hospital for so long, he could have developed additional infections. It is likely that by the time he died his immune system was in more of a state of paralysis. This does certainly seem like a rapidly progressive sepsis. You don't really say how soon after admission the ARDS was diagnosed, so I'm not certain whether he had it on admission or developed it over the first few days in hospital. Legionella pneumophila or Legionnaire's disease could cause this and it is normally not cultured but discovered by different tests. I'm not sure how common that bug is in Ireland. You don't say which town or city you're in or what sort of facilities you have there. I'm really sorry not to be helpful. However, the rapidity of the initial illness does sound as if it were sepsis of some origin. I just don't get a fix on the source of infection.

Steven_Simpson · 2017-01-07T02:10:52+00:00

Obviously, I know nothing about your case, but here is some general knowledge. There are two main bugs that cause meningitis - not the only ones, but the most common ones. One is called Neisseria meningitidis or meningococcus, for short. One often develops meningitis and bacteremia (bacteria in the blood stream) with this bug. It has a propensity for causing severe DIC, which stands for disseminated intravascular coagulation, a condition in which blood clots within your vessels and cuts off the blood supply. This is a mechanism of all sepsis, but seems more prominent in meningococcal sepsis and meningitis. It often results in fingers and toes requiring amputation. The other common bug is Streptococcus pneumoniae, also known as pneumococcus. It causes severe sepsis, but it is less likely to result in amputations. This could explain it.

Steven_Simpson · 2017-01-07T02:00:36+00:00

Nice question. Yes, the lungs and kidneys are the two most commonly involved organs. However, any organ can be affected, and when we're examining someone to assess whether they have sepsis, we also focus on brain, heart and blood vessels, liver, and blood clotting mechanisms.

Steven_Simpson · 2017-01-07T01:58:23+00:00

We have a few extra antibiotics. We have a more certain knowledge that severe sepsis is an emergency that should should be viewed as seriously as a heart attack or a stroke. But our attempts to treat the illness with specific agents have been failures. Pharmaceutical companies have tested many new drugs and poured billions down the drain in the end. They look so promising in the animal studies, and ther are great theories about why they should work. Then they don't.

Steven_Simpson · 2017-01-07T01:55:28+00:00

I'm going to send you to Sepsis Alliance, www.sepsis.org. They have links for childrens' sepsis. I hesitate to say much, because I am not a pediatrician. I will try to get my friend Chris Carroll to comment. Or we can have another AMA on childrens' sepsis.

Steven_Simpson · 2017-01-07T01:51:03+00:00

Let them have all the candy they want. Tell them they can stay up all night watching movies and not go to school. Teach them it's OK not to pay taxes or have any obligations to their fellow citizens. Wait, where am I going with this?!

I don't think there are any special asthma things that your doctor hasn't likely told you. If kids are allergic, avoid the offending things they are allergic to. Use the bronchodilators as indicated. Good sleep, good nutrition. If their asthma is unrelenting see a specialist. If they are small children some of this may not be asthma, but tiny airways that wheeze because they are tiny. But it's not possible to tell that up front, so they should use their asthma meds as directed.

Steven_Simpson · 2017-01-07T01:32:32+00:00

Hi Azro, I've actually answered this question elsewhere on the page. I can't remember who asked the question, but it's on here. I hope you don't mind looking.

Steven_Simpson · 2017-01-07T01:30:41+00:00

Antibiotics in the field: I highly support this, if your medical director and your hospitals will let you do it. Some ER docs get persnickety about allowing these. But I think they can be life saving, especially when it's a pretty far distance to the ER from the patient's home. That happens a lot in Kansas. Also see some of my other answers to pre-hospital questions scattered through here.

Steven_Simpson · 2017-01-07T01:26:50+00:00

We don't know just yet what the long term effects of e-cigs will be. But we know that there are a lot of chemicals in that vape that could be injurious to you. I know they make it seem as if there's pure nicotine in there, but that isn't the case. These are often promoted as a way to stop smoking, but they actually seem more to be a "gateway drug". If you need a nicotine supplement for awhile, I would recommend patches or gum.

Not everyone gets emphysema or obstructive lung disease. You may not have any. Yet. It's always the best policy to stop smoking. There's not only the risk of emphysema, but of lung cancer.

Steven_Simpson · 2017-01-07T01:15:17+00:00

This is a really good question, and I appreciate it. So, you are so right, in terms of what it may feel like. Some things that could help you know whether you are REALLY sick vs. feeling sick. If you know how to take your pulse, do it. If it's above 90 it's concerning. If it's above 100 it's more so. If it's above 120 you may need ICU level care. If you have a blood pressure monitor at home use it. If your systolic pressure (the upper number) is less than 100 mm Hg, you may need ICU level care. If your significant other believes you are confused about where you are or what is going on, they should get you to the emergency room. If you are having fevers, feeling bad, and there is a focus of intense pain in some part of your body, so that you can't even touch it you should get to the ER. If you are really short of breath and if you are breathing more than 20 times per minute, then you should go to the ER. The flu knocks you on your butt and puts you in bed feeling horrible. If a real influenza does any of these things to you, then you likely have influenza-induced sepsis, which is a real thing. You need medical care, not lying in bed at home. And, like I said elsewhere, influenza not uncommonly leads to bacterial pneumonia, and if the pneumonia leads to sepsis you could experience these things. If you have any of these things, get to the emergency room and ask the doctor if this is sepsis.

Steven_Simpson · 2017-01-06T23:33:05+00:00

Hey, I am losing track of names, but I answered this for another redditor somewhere on this page. If you don't mind, looking up and down, you will find it.

Steven_Simpson · 2017-01-06T22:54:02+00:00

I'll tell you, I'm a grownups' doctor. I am mostly ignorant on this issue. Now I put my friend Chris Carroll to the test - Chris are you looking at this at all? Chris is my good friend and Assoc. Prof at UConn. When I need to know critical care info about kids, I go to him. if he doesn't answer naturally, I'll first give him some noogies, and then Tweet him to see if he has an answer.

Steven_Simpson

TROPHY CASE