world sepsis day: september 13, 2012

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Editorial World Sepsis Day: September 13, 2012 Philip S. Barie T he stories appear all too often, sensationalized by the press. The clinicians involved are made to appear un- witting, or callous, or fools, or some combination thereof. Perhaps they come across as the whole package-uncaring, blithering idiots. There is also the portrayal of the family, bereaved (undoubtedly), sympathetic (unquestionably), vic- timized (that is for others to decide). The nexus, stated simply, is death from severe sepsis. The real story behind the scenes is more nuanced, but not always more positive. The case of Rory Staunton, deceased at age 12 years in New York City at a major academic medical center, received much media attention [1]. Your humble correspondent has no direct knowledge of the events as they transpired, expresses no opinion as to the propriety of actions taken or not, and casts no aspersions. Recounted here in encapsulated form are the events as reported by The New York Times [1]. Two days prior to admission, Rory cut his arm while playing basketball at school. His pediatrician evaluated him in the office the next day for complaints of fever, vomiting, and pain in his leg. According to the media report, in the pediatrician’s office Rory’s temperature was 102 o F, his heart rate was 140 beats/min; his respiratory rate was 36 breaths/ min, and his skin was mottled, whereupon he was sent to the emergency department of the academic medical center. The diagnosis: An upset stomach and dehydration! Fluid and odansetron was given, acetaminophen was recommended, and Rory was sent home. Seen and sent out.there is hardly another colloquialism in clinical medicine so laden with con- notation or fraught with peril. Seemingly just ordinary childhood woes, Rory’s condition was already dire. He was likely bacteremic at the time. Crucial information gathered by his pediatrician and during his first visit to the emergency department (marked leukocytosis with bandemia) may have been discounted or not considered when decisions were made about his disposition. His parents may not have been advised of, or may not have understood, the early signs to watch for at home that would have indicated he was deteriorating. There may have not been any proactive follow-up to determine how the child was faring at home. When his deterioration became profound (he turned ‘‘blue,’’ according to his parents as recounted by the media report) his family was instructed by the pediatrician to return to the ac- ademic medical center. He was diagnosed with and treated for Streptococcus pyogenes bacteremia and septic shock, but succumbed to multiple organ dysfunction syndrome three days later in the intensive care unit. By all accounts Rory was a good kid. Big for his age, and mature beyond his years, he was involved in student politics, knowledgable of world affairs, and already enrolled in flight school, determined to become a licensed commercial pilot. Legal counsel has been retained. To those of us who treat sepsis every day, it may be difficult to imagine that sepsis can go undiagnosed, or be diagnosed (too) late, but the experienced do recognize that sepsis has protean manifestations, some of which may be subtle at first, and not all of which may be present in an individual case. Sepsis can be a difficult diagnosis to make, and time is cer- tainly of the essence. Several organizations have developed educational programs and clinical tools to assist clinicians with the early diagnosis and expeditious treatment of sepsis, including the Surviving Sepsis Campaign [2,3]. Indeed, the mortality of severe sepsis and septic shock may be decreasing overall, confounding our ability to advance the field by clin- ical investigation [4,5]. Nonetheless, stories such as this re- mind us all to strive every day to do the best we can for our patients with sepsis in the realms of diagnosis, treatment, education, and quality. By way of example, the Greater New York Hospital Asso- ciation and the United Hospital Fund have partnered to create the STOP (Strengthening Treatment and Outcomes for Patients) Sepsis Collaborative [6,7]. A consortium of 56 hospitals par- ticipates in the New York region, including the center that treated young Staunton. The goals are focused on clinician performance: To reduce mortality in patients with severe sepsis and septic shock by developing a protocol-based approach to case identification and rapid treatment; and to enhance communication and patient flow between the emergency department and other areas of the hospital, in particular, the intensive care units [6,7]. The Global Sepsis Alliance (GSA) [8,9], of which the Sur- gical Infection Society is a Committed Member, is working to heighten sepsis awareness not only among practitioners, but also among policy makers and the public, crucial stakeholders Table 1. Global Goals of the World Sepsis Declaration: World Sepsis Day, September 13, 2012 1. Place sepsis on the development agenda 2. Ensure that sufficient treatment and rehabilitation facilities and well-trained staff are available 3. Support the development of international sepsis guide- lines 4. Mobilize stakeholders 5. Involve sepsis survivors and those bereaved by sepsis in planning From reference [9]. SURGICAL INFECTIONS Volume 13, Number 4, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/sur.2012.9905 185

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Editorial

World Sepsis Day: September 13, 2012

Philip S. Barie

The stories appear all too often, sensationalized by thepress. The clinicians involved are made to appear un-

witting, or callous, or fools, or some combination thereof.Perhaps they come across as the whole package-uncaring,blithering idiots. There is also the portrayal of the family,bereaved (undoubtedly), sympathetic (unquestionably), vic-timized (that is for others to decide). The nexus, stated simply,is death from severe sepsis. The real story behind the scenes ismore nuanced, but not always more positive.

The case of Rory Staunton, deceased at age 12 years in NewYork City at a major academic medical center, received muchmedia attention [1]. Your humble correspondent has no directknowledge of the events as they transpired, expresses noopinion as to the propriety of actions taken or not, and casts noaspersions. Recounted here in encapsulated form are theevents as reported by The New York Times [1].

Two days prior to admission, Rory cut his arm whileplaying basketball at school. His pediatrician evaluated himin the office the next day for complaints of fever, vomiting,and pain in his leg. According to the media report, in thepediatrician’s office Rory’s temperature was 102oF, his heartrate was 140 beats/min; his respiratory rate was 36 breaths/min, and his skin was mottled, whereupon he was sent to theemergency department of the academic medical center. Thediagnosis: An upset stomach and dehydration! Fluid andodansetron was given, acetaminophen was recommended,and Rory was sent home. Seen and sent out.there is hardlyanother colloquialism in clinical medicine so laden with con-notation or fraught with peril.

Seemingly just ordinary childhood woes, Rory’s conditionwas already dire. He was likely bacteremic at the time. Crucialinformation gathered by his pediatrician and during his firstvisit to the emergency department (marked leukocytosis withbandemia) may have been discounted or not considered whendecisions were made about his disposition. His parents maynot have been advised of, or may not have understood, theearly signs to watch for at home that would have indicated hewas deteriorating. There may have not been any proactivefollow-up to determine how the child was faring at home.When his deterioration became profound (he turned ‘‘blue,’’according to his parents as recounted by the media report) hisfamily was instructed by the pediatrician to return to the ac-ademic medical center. He was diagnosed with and treatedfor Streptococcus pyogenes bacteremia and septic shock, butsuccumbed to multiple organ dysfunction syndrome threedays later in the intensive care unit.

By all accounts Rory was a good kid. Big for his age, andmature beyond his years, he was involved in student politics,

knowledgable of world affairs, and already enrolled in flightschool, determined to become a licensed commercial pilot.Legal counsel has been retained.

To those of us who treat sepsis every day, it may be difficultto imagine that sepsis can go undiagnosed, or be diagnosed(too) late, but the experienced do recognize that sepsis hasprotean manifestations, some of which may be subtle at first,and not all of which may be present in an individual case.Sepsis can be a difficult diagnosis to make, and time is cer-tainly of the essence. Several organizations have developededucational programs and clinical tools to assist clinicianswith the early diagnosis and expeditious treatment of sepsis,including the Surviving Sepsis Campaign [2,3]. Indeed, themortality of severe sepsis and septic shock may be decreasingoverall, confounding our ability to advance the field by clin-ical investigation [4,5]. Nonetheless, stories such as this re-mind us all to strive every day to do the best we can for ourpatients with sepsis in the realms of diagnosis, treatment,education, and quality.

By way of example, the Greater New York Hospital Asso-ciation and the United Hospital Fund have partnered to createthe STOP (Strengthening Treatment and Outcomes for Patients)Sepsis Collaborative [6,7]. A consortium of 56 hospitals par-ticipates in the New York region, including the center thattreated young Staunton. The goals are focused on clinicianperformance: To reduce mortality in patients with severesepsis and septic shock by developing a protocol-basedapproach to case identification and rapid treatment; and toenhance communication and patient flow between theemergency department and other areas of the hospital, inparticular, the intensive care units [6,7].

The Global Sepsis Alliance (GSA) [8,9], of which the Sur-gical Infection Society is a Committed Member, is working toheighten sepsis awareness not only among practitioners, butalso among policy makers and the public, crucial stakeholders

Table 1. Global Goals of the World Sepsis

Declaration: World Sepsis Day, September 13, 2012

1. Place sepsis on the development agenda2. Ensure that sufficient treatment and rehabilitation facilities

and well-trained staff are available3. Support the development of international sepsis guide-

lines4. Mobilize stakeholders5. Involve sepsis survivors and those bereaved by sepsis in

planning

From reference [9].

SURGICAL INFECTIONSVolume 13, Number 4, 2012ª Mary Ann Liebert, Inc.DOI: 10.1089/sur.2012.9905

185

both. The founding members of the GSA, the World Federationof Societies of Intensive and Critical Care Medicine (WFSICCM),the World Federation of Pediatric and Intensive and Critical CareSocieties (WFPICCS), the World Federation of Critical CareNurses (WFCCN), the International Sepsis Forum (ISF), and theSepsis Alliance (SA) prepared the World Sepsis Declaration [10](Tables 1 and 2) to set targets to change the global burden ofsepsis by 2020. Professional associations from 69 countries, re-presenting more than 600,000 individual members, support theWorld Sepsis Day. Your editorial correspondent asks you, thereader to make your own personal commitment.

Every time you are confronted with a seriously ill patient,or by a clinical picture that confounds, ask yourself thequestion: Could this be sepsis? An answer in the affirmative,

or even equivocal, should lead to rapid diagnostic and ther-apeutic action that could save a life. Had Rory’s parents (orany loved one in a circumstance analogous) asked the ques-tion, would the outcome have been different? That is a bigpart of what World Sepsis Day is about.

References

1. http://www.nytimes.com/2012/07/12/nyregion/in-rory-stauntons-fight-for-his-life-signs-that-went-unheeded.html?_r = 1&pagewanted = 1&hp. Accessed August 17, 2012.

2. Barie PS. Surviving sepsis. Surg Infect (Larchmt) 2004;5:1–2.3. Marshall JC, Dellinger RP, Levy M. The Surviving Sepsis

Campaign: A history and a perspective. Surg Infect(Larchmt) 2010;11:275–281.

4. Ranieri VM, Thompson BT, Barie PS, et al.; PROWESS-SHOCK Study Group. Drotrecogin alfa (activated) in adultswith septic shock. N Engl J Med 2012;366:2055–2064.

5. Barie PS. The last Xigris� survivor. Surg Infect (Larchmt)2011;12:423–425.

6. http://www.gnyha.org/6653/Default.aspx. Accessed Au-gust 17, 2012.

7. http://www.uhfnyc.org/initiatives/quality_improvement/STOP_Sepsis. Accessed August 17, 2012.

8. http://www.globalsepsisalliance.org. Accessed August 17,2012.

9. Marshall JC, Reinhart K. The Global Sepsis Alliance: Build-ing new collaborations to confront an under-recognizedthreat. Surg Infect (Larchmt) 2011;12:1–2.

10. http://www.world-sepsis-day.org/cgi-bin/WebObjects/WsdCMS.woa/1/wa/default?path = %2FWSD%2Fen%2FOur + goals + by + 2020%2FThe + Declaration. Accessed Au-gust 17, 2012.

Table 2. Key Targets To Be Achieved by 2020:World Sepsis Declaration

1. Decrease the incidence of sepsis globally throughstrategies to prevent sepsis

2. Increase sepsis survival for children (including neonates)and adults in all countries through the promotion andadoption of early recognition systems and standardizedemergency treatment

3. Improve public and professional understanding andawareness of sepsis

4. Improve access to appropriate rehabilitation facilities forall patients worldwide

5. Improve the measurement of the global burden of sepsisand the impact of sepsis control and managementinterventions

From reference [9].

186 EDITORIAL