Sepsis: Challenges of diagnosis and building a medicolegal case
What is sepsis?
One of the major conditions facing an Intensive Care Physician (Intensivist) is sepsis. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection.
Sepsis (also known as blood poisoning) is the immune system’s overreaction to an infection or injury. Normally the immune system fights infection, however sometimes it attacks the body’s own organs and tissues; the reasons for this are not fully understood. If sepsis is not treated immediately, it can result in organ failure and death. Yet with early diagnosis, it can be treated successfully with antibiotics. (More information about sepsis can be found here on the Sepsis Trust website.)
What diagnostic criteria are used?
In the hospital setting sepsis can be poorly managed. The qSOFA (quick Sequential Organ Failure Assessment) is used to give a probability of sepsis. It uses three criteria:
· Low blood pressure (SBP≤100 mmHg);
· High respiratory rate (≥22 breaths per min; and
· Altered mentation (Glasgow coma scale<15)
It assigns one point for each criterion met. The score ranges from 0 to 3 points. The presence of 2 or more qSOFA points near the onset of infection is associated with a greater risk of death or prolonged intensive care unit stay.
Early Warning Scores (EWS) are used to monitor patients on the general ward, and a rising score mandates referral to ICU. The most common EWS in use is the National Early Warning Score (NEWS) developed by the Royal College of Physicians.
The NEWS is based on a simple aggregate scoring system in which a score is allocated to physiological measurements, already recorded in routine practice, when patients present to, or are being monitored in, hospital. Six simple physiological parameters form the basis of the scoring system:
1. respiration rate
2. oxygen saturation
3. systolic blood pressure
4. pulse rate
5. level of consciousness or new confusion
What role does sepsis play in medicolegal cases?
The most common clinical negligence claim concerns a rising NEWS in a septic patient without intervention at the correct time. The NEWS requires critical care input when a score of 7 or higher is reached. Failure to intervene greatly increases the chance of death or significant morbidity.
What are the challenges sepsis presents in a medicolegal case?
Sepsis presents clinicians with a number of challenges, most notably that it cannot be assumed that sepsis is the root cause when a patient presents with the symptoms outlined above, because other diagnoses may mimic sepsis, such as acute autoimmune diseases (e.g. thyrotoxicosis), however it has to be part of the differential. Treating sepsis is also challenging. Blanket use of antibiotic will increase resistance and reduce its effectiveness. Therefore the route of administration needs to be optimal for the possible infection. In cases of sepsis, swift diagnosis and efficient treatment are crucial.
Why instruct an intensive care expert in a case involving sepsis?
Experience as an intensive care physician gives a far better understanding of severe sepsis or septic shock than a general physician. A general physician may see 1 or 2 severely septic patients a year, whereas an intensive care unit deals with 1,000 critically ill patients a year, most of whom have severe sepsis or septic shock during their ICU admission.