Bringing sepsis care back to the emergency department: New prognostic tools and extended role of emergency physicians

Abstract

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). Despite recent advances in diagnosis and treatment, sepsis remains a significant common final pathway to death in patients with infection worldwide. The constant threat of sepsis to mankind has been amplified during the COVID-19 pandemic. Yet, the effort to fight sepsis is undermined by health inequalities. How to advance prevention, survival, and survivorship of sepsis and COVID-19 was the theme of the World Sepsis Congress 2021 in April 2021 (https://www. worldsepsiscongress.org). It highlights a number of key questions clinicians of our generation need to answer. Emergency departments (EDs) are at the forefront in combating community-acquired infection and sepsis. However, over the years, the role of emergency physicians has weakened with interventions hindered because of the most recent definition of sepsis that heavily relies on laboratory test results to confirm organ dysfunction (the Sepsis-3 definition), a lack of reliable sepsis screening and prognostic tools outside the intensive care unit (ICU), limited ED access to imaging studies to identify the source of infection and ED overcrowding. Technological advances such as novel sepsis biomarkers may help clinicians to make a more precise diagnosis, but the turnaround time, added cost and complexity are creating a force to move sepsis care away from the hands of emergency physicians, especially in resource-poor settings. There is a need to bring sepsis care back to the ED. To achieve this, we need better prognostic tools that are best based on routinely collected clinical or laboratory parameters. We also need to extend the role of emergency physicians in managing severe infection including bloodstream infection. A number of articles featured in this edition represent such endeavours to explore how emergency physicians can improve sepsis care in the ED. One of the key issues is to recognise tissue hypoperfusion quickly with easily available clinical or laboratory parameters in order to avert multi-organ failure and reduce sepsis mortality. In a systemic review and meta-analysis of 13 clinical studies that involved 940 patients, Wang et al. found that the venous-to-arterial carbon dioxide pressure changes and the arteriovenous oxygen content difference ratio (Pcv-aCO2/Ca-vO2), a marker for global anaerobic metabolism, is an important predictor for mortality in patients with sepsis or septic shock. A higher ratio of PcvaCO2/Ca-vO2 was associated with a higher 28-day mortality (risk ratio = 1.89, 95% confidence interval = 1.48–2.41) and a higher Sequential Organ Failure Assessment (SOFA) score (standardised mean difference = 1.58, 95% confidence interval = 0.88–2.28).1 Wang et al. recommended that the use of this ratio combined with lactic acid clearance and central venous blood oxygen saturation to guide the effects of early resuscitation treatment in sepsis patients. While clinicians often focus on white cell counts in the complete blood picture in making clinical decision, the value of red cell parameters in sepsis prognostication has not been fully explored in the literature. A study by Zhang et al. on 236 patients with sepsis or septic shock found that the red blood cell distribution width (RDW), a parameter reflecting the heterogeneity of red blood cell volume, is an independent predictor of 28-day mortality (hazard ratio = 1.311, 95% confidence interval = 1.119–3.011) in sepsis or septic shock patients. The area under curve (AUC) of RDW was comparable to that of procalcitonin (0.727 vs 0.768),2 making RDW a potentially valuable prognostic marker in settings with limited access to procalcitonin or other sophisticated sepsis biomarkers. Another interesting study by Gho et al. featured in this edition evaluated the use of electrical cardiometry (EC) in pneumonia. The study involved 368 ED patients and found that the thoracic fluid content (TFC), a measure of water contained in the lung and pulmonary vasculature, can reliably predict mortality and ICU admissions. EC is a non-invasive method that can measure cardiac output continuously at the bedside. The AUC was 0.72 (95% confidence interval = 0.71–0.74) for 28-day mortality and 0.73 (95% confidence interval = 0.62–0.82) for ICU admission.3 Finally, a local study by Cheung et al. reviewed and described the experience and outcome of 64 patients with bloodstream infection managed in the emergency Bringing sepsis care back to the emergency department: New prognostic tools and extended role of emergency physicians 1019870 HKJ0010.1177/10249079211019870Hong Kong Journal of Emergency MedicineEditorial editorial2021