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SEPSIS
morpheus
we have all dealt with sepsis in our clinical experience... generally i find it is the most simple to diagnose and the most difficult to treat right atleast in a busy ED.
why i say that is because of the overly simplified diagnostic criteria mentioned in the EGDT for sepsis program
now i am sure you share my sentiment when i say that the diagnostic criteria for SEPSIS often overdiagnose, or in other words catch a far more false positives... with the goal of avoiding false negatives.
but still my question is
are
TEMPERATURE <36 OR > 38
HEART RATE >90/MIN
RESPIRATORY RATE >20/MIN
WBC COUNT >12000 OR <4000
the only criteria that should be considered while diagnosing sepsis...
are there more criterias or changed criterias you think would better the false positive rate of the above criteria...
would like to know your experiences on the same.
regards
And leave footprints in the sands of time.......
 
maroju
You obviously do realise that the four parameters you mentioned only do suggest SIRS (Systemic Inflammatory Response Syndrome).

Sepsis has been diagnosed according to the consensus guidelines established in 1991 as an infection in addition to the symptoms of systemic inflammatory response syndrome (SIRS).

Amendments to these criteria were initiated by convening an international conference in 2001 in response to a survey revealing that 71% of responding clinicians considered the existing definitions insufficient (Just like how you feel!!!). The 2001 conference added several new diagnostic criteria for sepsis in addition to the previous criteria. Of particular interest was the inclusion of the biomarkers procalcitonin (PCT) and C-reactive protein (CRP), despite the overall conclusion that it was premature to use biomarkers for sepsis diagnosis.

Implementation of the PIRO (Predisposition, Infection, Response, and Organ dysfunctions) taging system was one of the major recommendation of the panel to determine optimum treatment for individual patients by stratifying their individual symptoms and risks.

The focus of the PIRO system on individualized patient treatment acknowledges the concerns of authors who have previously identified the need for individualized diagnostics and treatment. However, the PIRO outline fails to address the necessity of prompt diagnosis.

Given that swift diagnosis is crucial in permitting timely treatment, the majority of current research has focused on the search for a magic bullet biomarker as a provision for confirmed pathogen presence. In an effort to improve diagnostic efficiency and ultimate survivability, it is suggested that real-time protein detection technologies be used to monitor a panel of sepsis-related biomarkers. As to how feasible this process is, only time will tell...
Edited by maroju on 05-09-2008 04:27
 
morpheus
oh yes maroju i absolutely do.. and i meant to do that..
since most of the time
sepsis for us in ED as per definition is
SIRS + suspected or proven infection = Sepsis
And like you said there is a problem.
if i have a cough... well with sputum production, i am suspected to have a lower respiratory infection. My sputum culture will be reported after 48 hrs... so no way to confirm an infection.... and i have early mycoplasma pneumonia so my xray is relatively clear.
now i have a fever of a 102 F and i run a mile before i reach the hospital, ( just to trick the doctors)
now i am not very healthy so i obviously have a high heart rate and a high respiratory rate....
so i land up in sepsis... and have all the necessaryl EGDT goals to be fulfilled.
i know about the CRP and the procalcitonin things...
CRP hmmm not much experience in adults i should say... in children... its high even if they have loose stools sometimes...
procalcitonin my personal experience has been mixed...
people with a normal lactate sometimes have a higher procalcitonin...
and vice versa...
i do understand that procalcitonin is supposedly the magic bullet marker...
but then you get its result only after about 2 hours in most places....
so is it valid as a marker of detection?????
or should it be kept as a marker of prognosis and confirmation, as it is treated today!!!
isnt there any other clinical index that can be added to the SIRS criteria to make it better for understanding sepsis????

And leave footprints in the sands of time.......
 
morpheus
i am not aware of the PIRO system though
could you please send some details of the same... or tell me where to look exactly...
the web search turned up weird results...
And leave footprints in the sands of time.......
 
maroju
For details of PIRO staging criteria, please check these refs:

1. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D et al. 2001 SCCM/ESICM/ACCP/ATS/SIS. International Sepsis Definitions Conference. Crit Care Med 2003;31:1250-6

2. Marshall JC, Vincent JL, Fink MP, Cook DJ, Rubenfeld G, Foster D et al. Measures, markers and mediators: towards a staging system for clinical sepsis. A report of the Fifth Toronto Sepsis Roundtable, Toronto, Ontario, Canada, October 25-26, 2000. Crit Care Med 2003;31:1560-7

All said, I am sure one can make a good diagnosis of sepsis from a good history and clinical examination supported by basic investigations in a majority of cases. As mentioned earlier, CRP and PCT do not give anymore info than merely suggesting inflammatory response.

I do agree that for specific management however, pathogen identification is crucial, which in mopst cases is the weakest link...
Hence the need to develop 'point of care testing' systems like traditional ELISAs (2-3 h), Immunoluminometric PCT assays (3 h) and DNA detection by PCR (5-6 h) which provide more rapid results than culture testing (24-48 h).
 
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