With a view to raising awareness of this life-threatening condition, clinical negligence specialist Lyndsey Banthorpe discusses the symptoms of sepsis and the common diagnostic pitfalls with Professor Robert Masterton, former Professor and Director of the Institute of Healthcare Associated Infection at the University of West Scotland.
Sepsis can be difficult to diagnose but, if left untreated, can lead to shock, multi-organ failure, limb amputation or even death. It is a medical emergency requiring urgent attention.
Also known as blood poisoning or septicaemia, sepsis is the body’s own immune system overreacting to an infection. Think of sepsis as a Western Australian bushfire; if the source of the fire is not isolated and brought under control, the fire will spread uncontrollably destroying the entire forest. Essentially, what should have been the body’s protective mechanism kicking in to fight off an infection, it instead causes damage to its own healthy tissues and organs, causing the patient to deteriorate and become seriously unwell.
A recent review of the impact of sepsis in the UK conducted by The Sepsis Trust reported some stark and shocking findings. It found that in 2017, hospitals in England treated over 200,000 episodes of sepsis, accounting for approximately 5% of emergency admissions annually. This makes sepsis a more common reason for a hospital admission than heart attacks. The Sepsis Trust estimated that 52,000 deaths per year were attributable to sepsis, claiming more lives than breast cancer, lung cancer, prostate cancer and bowel cancer combined.
Some individuals may be more likely to develop an infection which could lead to sepsis, including young babies (particularly premature babies), people over the age of 75, people with diabetes, people with a weakened immune system (such as those undergoing chemotherapy), those who have recently undergone surgery or women who have recently given birth.
Sepsis may begin as a simple bacterial infection such as an infection of a surgical wound, a urinary tract infection or pneumonia. Group B Strep is one of the most common causes of sepsis in maternal and neonatal sepsis. The infection may be acquired in the community or whilst a patient is in hospital.
Sepsis can present differently in children and adults. Children with sepsis may experience fast breathing and fits or convulsions. They may have mottled, bluish or pale skin or a rash that does not fade when pressed. They may also appear lethargic or difficult to wake and feel abnormally cold to touch. Parents who notice their child acting differently or being disinterested in food or normal activities should not delay in seeking medical attention.
An adult with sepsis may initially present as feeling generally unwell and may start to develop slurred speech or confusion with extreme shivering or muscle pain. They may notice a reduction in urinary output and experience diarrhoea, severe breathlessness and mottled or discoloured skin.
Because the treatment of sepsis is so time sensitive, guidelines issued by the National Institute for Health and Care Excellence (NICE) require a patient to be referred to hospital as an emergency (usually via ambulance after calling 999) where sepsis is suspected and to be treated with the same level of urgency as someone suffering a heart attack. Upon admission to hospital, blood tests should be performed in order to identify the infective organism and appropriate antibiotics prescribed within one hour of diagnosis. Patients should be monitored carefully and urgent action should be taken if there is no improvement within an hour of commencing antibiotics.
Prevention of the evolution of an infection into sepsis requires early and prompt diagnosis. The warning signs listed above should not be underestimated and are key to aiding the swift identification of the infection source. Maintaining good hygiene practices, particularly among those most vulnerable to infection, is also key to sepsis prevention.
A delayed diagnosis can have a significant impact on the prevention of deterioration, patient survival rates and long-term effects and outcome. The fourth part of this sepsis series will look at the long-term effects of sepsis and the impact of post-sepsis syndrome.
A diagnosis of sepsis is often missed or delayed because the symptoms may initially appear similar to those of other less serious conditions such as the flu or a stomach bug.
Common issues arising in clinical negligence claims involving sepsis include the failure to diagnose and treat a wound infection resulting in a deterioration into septic shock, a failure to refer patients to A&E for specialist treatment or a failure to adequately treat the infection with appropriate antibiotic therapy.
Professor Masterton has over 25 years’ experience acting as an expert witness in clinical negligence claims concerning sepsis. He provides the following commentary on some of the key issues he experiences in his practice:
“In my opinion, the most common difficulty encountered with sepsis in the medicolegal world is the widespread abuse of the term. ‘Sepsis’ is applied to cover everything from relatively minor infections up to death. This misuse applies to the general population, lawyers and – most embarrassingly – clinical professionals. The confusion that this causes is because patients invariably consider sepsis to be a very severe disease and so when they read the word in their records they adopt this meaning when the clinician might simply have been describing a suspicion of a basic infection. From an infection specialty perspective ‘sepsis’ has always had a precise definition. Before 2017, it was defined as the body’s systemic response to infection as manifested by two or more of the SIRS (systemic inflammatory response syndrome) criteria, eg raised temperature, pulse or breathing rate. This was then subdivided into various categories of sepsis from uncomplicated up to full multiorgan dysfunction. In 2017, a new international definition was adopted to simplify and give greater consistency. The new definition is that sepsis is a life-threatening condition caused by multiorgan failure arising from immune system dysregulation due to an infection ie ‘sepsis’ now is a disease at the furthest end of the spectrum of infection severity. I would encourage everybody to adopt the proper use of the word.
“The second most common difficulty in my experience with ‘sepsis’ in medicolegal practice is the misunderstanding of ‘the golden hour’ ie if antibiotics are not administered within the first hour of attendance, this is a breach in the duty of care that flows through into the outcome. Intuitively we would all accept the rational conclusion that the earlier infection management is started, the better the outcome. From a legal perspective, the desire is to pin this down to a specific time in the patient’s clinical pathway. From a clinical perspective, however, the ability to do this definitively is usually recognised to be impossible with time windows of variable durations applying. The principal science lying behind this issue is generally acknowledged to be the 2006 Kumar paper which showed that each hour of delay in antimicrobial administration was associated with a consistent average decrease in survival of 7.6% per hour over the ensuing six hours. While this was an excellent study on a large scale, it also had significant limitations eg it was retrospective without any case controls and only assessed antimicrobial treatment. The starting point in the study was the beginning of hypotension. Applying this in the legal world, we need to recognise that many of the cases are actually in established hypotension by the time treatment begins. We need to allow, as an inevitable delay, a period of admission, initial assessment and investigations – leading to the standard becoming one hour from a diagnosis of sepsis - and to reflect on the other interventions that are started as part of sepsis management. The immune system dysregulation referred to above is the body’s inflammatory response cascade and this process is driven not directly by the infection but by the release of cytokines and other mediators that cause the resultant damage. It is now known that the resolution of this inflammatory cascade that causes the sepsis is an active and not a passive process which depends upon multiple interventions eg oxygenation, intravenous fluid resuscitation and steroid administration are all known to reduce the impact of the inflammatory cascade. Thus, the principle of ‘the golden hour’ applies not just to the antimicrobial treatment element of the sepsis management but to all the other potential interventions as well. Accordingly, the Kumar 7.6% per hour approach cannot be simply applied blindly to every case and this requires a much broader and more nuanced assessment, which invariably results in a greater degree of uncertainty.
“This impact comes home particularly in the context of the ‘Sepsis Six’, which is an algorithm that is now widely deployed in clinical practice in the United Kingdom to assess, at admission, the potential of the presence of sepsis. The algorithm then provides the recommended interventions for the due times, including one hour for the antibiotics, eg investigations (lactate and blood cultures), antibiotic administration, oxygenation, fluid resuscitation and catheterisation for the assessment of renal function. However, while the algorithm has been very effective in highlighting the need to consider the presence of sepsis so that cases are not unreasonably missed, it is not particularly accurate in identifying those who are actually suffering from the life-threatening variant of this disease. As a consequence, it has caused a massive overdiagnosis of sepsis to the extent that up to 40% of patients initially diagnosed as having the disease have subsequently been found not to be suffering from this condition. The effect on clinical practice has been that in the last six years there has been approximately a 50% increase in diagnosed cases of sepsis with mortality up by 27%. Clinically nobody believes that this is actually what we are seeing and as a consequence there has been something of a backlash in the medical world to move away from a wholesale unfocused approach to the diagnosis and management of sepsis with a call to achieve more accurate identification of the condition.”
Kumar et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006; Jun;34(6):1589-96. doi: 10.1097/01.CCM.0000217961.75225.E9.
Singer et al. Sepsis hysteria: excess hype and unrealistic expectations. Lancet. 2019:394,1513-1514. DOI:https://doi.org/10.1016/S0140-6736(19)32483-3.
Continue to follow the Penningtons Manches Cooper sepsis series, with part 2 dealing with sepsis issues in the accident and emergency department.