I echo Ron's position on this. The value of screening tools (which typically
are much more sensitive than specific) on a population needs to take into
account the risk of the population for the particular disease. Hospitalized
patients and those that present to an ED definitely characterize higher risk
populations. I think some of the confusion in the application of the data has
to do with extrapolation of population data to inidividual cases - the "always"
and "never" dilemma Ron had described. Number needed to treat is a statistic I
have found very useful in making these decsions for inidividual patients.
Ron, any data on the number needed to treat for ALL patients presenting in the
ED with SIRS to prevent one severe sepsis/septic shock morbidity or mortality?
Ramon Anel, MD
Nephrology/Critical Care
Franciscan Haelth System
Tacoma WA
________________________________
From: Ron Elkin <[email protected]>
To: Steve Chabala <[email protected]>
Cc: "[email protected]" <[email protected]>
Sent: Sunday, December 16, 2012 5:43 AM
Subject: Re: [Sepsis Groups] flu and sepsis screening
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.
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