With respect, the problem with asking whether "the generally healthy college kid with SIRS criteria and a strep throat really needs a lactate and blood cultures" is that it presupposes a correct and benign diagnosis requiring only simple outpatient therapy. The question correctly implies a group at low risk, but we will undoubtedly make mistakes. A rare patient will return to be recharacterized as strep bacteremia or pneumonia with organ dysfunction, peritonsillar abscess, or meningococcal meningitis. In some of these cases, perhaps, earlier hints of serious trouble were overlooked. We of course will be held responsible, and hold ourselves responsible, for our oversights. There would be fewer of them if we were more vigilant.
I am often reminded that expert opinion is regarded as the lowest quality of evidence. Even in groups at higher risk for severe sepsis, however, many of us assume our clinical judgments (which usually fall short of expert opinion) will distinguish those who are "really sick" from those who are not. I think this is an error. In all likelihood, some of us are better at this game than others, but undoubtedly we all have lapses. Few if any of us have data regarding the accuracy of our own clinical judgments, yet many if not most of us seem quite eager to overestimate our own abilities even when it is the patient and family who bear the risk. The purpose of a screen is to detect the maximum number of cases - and perhaps thereby protect patients from our sometimes faulty clinical judgment. SIRS &/or infection should often prompt an additional screen for organ dysfunction including an elevated lactate. The treating physician or nurse makes the screening decision, and all cases do not have to be directed to the ED. The cost of a lactate in our hospital is well below $1.00. A normal lactate does not exclude severe sepsis. An elevated lactate can seldom be dismissed. Some maintain that lactate is a better ED screen for severity of illness than many of the standard ED tests we run, and a better predictor of who should stay, length of stay, cost of stay, development of multi-organ failure, and death. Blood cultures are substantially more expensive, results are delayed, and so they may deserve a little more thought before ordering, but we've all seen patients called back to the hospital for positive blood cultures. Should we always follow SIRS &/or infection with a screen for organ dysfunction? "Always" and "never" are unforgiving rules that may not work well here. The answer may partially depend on where the patient is identified. Already hospitalized patients are in a special risk group with perhaps a better reason to screen in the great majority. I'd agree the answer is probably "no" for many low grade fevers, sore throats and runny noses in the ED or office. One practical issue is that EDs or offices could become overcrowded with people at low risk waiting for their organ dysfunction screens to return while delaying necessary attention from those who really need it. Should rare mistakes result in "always" screening subsequent low risk patients with the identical clinical picture for evidence of organ dysfunction? Probably not, but it should lead to a more thorough search for those subtle hints of real trouble, reasons to complete the screening, and an early return visit or call for some of those considered safe for discharge. Just my $0.02 Ron Elkin, MD Pulmonary/Critical Care California Pacific Medical Center San Francisco On Fri, Dec 14, 2012 at 6:32 AM, Steve Chabala <[email protected]> wrote: > I think Sue's question gets at the larger question of the need for testing > of ALL patients with SIRS criteria and evidence of infection. All such > patients should be directed by their primary care doctors to come to the ER > for sepsis evaluation? Does the generally healthy college kid with SIRS > criteria and a strep throat really need a lactate and blood cultures drawn? > Probably not. I'm curious to know if there is any literature to address > this sort of issue. When does sepsis screening yield to common sense? > > Steve Chabala D.O., F.A.C.E.P. > _______________________________________________ > Sepsisgroups mailing list > [email protected] > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org >
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