Severe sepsis, discussed in detail in another CDS chapter, is the combination of the following: acute infection, evidence of the systemic inflammatory response syndrome (SIRS), and indications of end-organ hypoperfusion or hypotension. More than 750,000 cases of severe sepsis were estimated to have occurred in the United States in 2001, and the incidence of severe sepsis cases continues to rise. Hospitalizations for severe sepsis in the United States increased to 343 per 100,000 individuals in 2007, compared with 143 in 2000. Hospitalization rates for patients with sepsis or septicemia also increases with age, according to a 2011 National Center for Health Statistics Data Brief, with a substantial increase in incidence starting at age 65. In addition, multiple studies have demonstrated a commensurate decline in short-term mortality from severe sepsis.
The composite result of these trends is an increasing number of older patients being diagnosed with, and surviving, severe sepsis during inpatient hospitalizations. Studies have demonstrated that survivors of severe sepsis have decreased quality of life, often develop cognitive and functional disabilities, and require considerable ongoing care. As a result, the concept of “sepsis survivorship” has been devised to characterize those in whom the acute episode of severe sepsis has passed but the sequelae become important to subsequent well-being and functioning. A landmark study estimated the magnitude of the population burden of older adults with disability after severe sepsis at more than 100,000 “sepsis survivors” with moderate to severe cognitive impairment and approximately 500,000 with functional disability. These figures approximate those of breast cancer survivorship.
Older survivors of severe sepsis have been shown to have higher health care use in the year following discharge. “Sepsis survivors” demonstrated a remarkable increase in health care use relative to their prior resource use due to an increased number of days in inpatient health care facilities. Survivors of severe sepsis also had a significantly higher 1-year mortality than matched controls.
Another study of older “sepsis survivors” demonstrated a significant increase in the odds of both physical and cognitive dysfunction. Moderate-to-severe cognitive dysfunction was found to increase three fold in “sepsis survivors.” New functional losses have been established in patients with severe sepsis initially admitted to a general floor, even with good baseline function. Additionally, decreased quality of life indicators have been documented in sepsis survivors, as well as a higher number of admissions for severe sepsis, have been found to result in discharge to a long-term care facility.
Additional information regarding organ-specific complications of severe sepsis that may further impact prognosis and the likelihood and extent of functional and/or cognitive decline should also be expected. Sepsis-induced atrial fibrillation and its potential consequences, along with sepsis-related acute kidney injury are among many examples that have, and will continue to receive, research focus in coming years.
II. Identify the Goal Behavior
The spectrum of sepsis disorders is primarily managed by hospitalists and general internists. A substantial proportion of patients admitted with severe sepsis are managed entirely on general medical wards; for patients admitted to higher acuity units (“step-down” and intensive care), hospitalists are involved in the escalation of care to such units, care of patients in these higher acuity units, and receipt of sepsis survivors being sent out of these units to general medical floors. As such, awareness of the concept of “sepsis survivorship” and a working knowledge of the potential consequences of a severe sepsis diagnosis is essential to everyday practice. The application of this information is most necessary when hospitalists are requested by patients and family members to make estimates regarding prognosis, and the timing and setting of disposition.
III. Describe a step-by-step approach/method to this problem.
During the hospitalization of a patient of age 65 or older, the hospitalist should consider the following steps:
Exploration, clarification, or confirmation of goals of care with respect to life-prolonging interventions, which may have changed as the result of a severe, prolonged, or complicated hospitalization. The discussion may include (but should not be limited to) a patient’s willingness to: be re-hospitalized, receive invasive procedures, obtain care in high-intensity medical units, undergo ACLS interventions or intubation/mechanical ventilation for cardiorespiratory arrest, receive non-invasive positive-pressure ventilation, and hemodialysis.
Discussion of patient and family understanding regarding the potential effects and subsequent prognosis following a hospitalization for severe sepsis.
Provision of information, if desired, regarding the risks for potential cognitive impairment, functional decline, and need for long-term nursing care.
Information, if appropriate and if desired, regarding advanced directives (living will and durable health care power of attorney) and financial power of attorney.
IV. Common Pitfalls.
The concept of “sepsis survivorship” is relatively new, and the evidence-base regarding the prognosis regarding life expectancy, organ function, and cognitive/functional impairment following hospitalization for severe sepsis is expected to increase significantly in coming years. It is therefore essential for the practicing hospitalist to anticipate and monitor this expanding pool of knowledge. At present, it is critical to avoid the assumption that “sepsis survivors,” specifically those patients age 65 and older, are uniformly expected to return to their cognitive, functional, and organ-specific baselines.
V. National standards, core indicators and quality measures.
No national standards/benchmarks established yet
What's the Evidence?
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Hall, MJ, Williams, SN, DeFrances, CJ, Golosinskiy, A. “Inpatient care for septicemia or sepsis: A challenge for patients and hospitals. NCHS data brief, no 62”. 2011.
Kumar, G, Kumar, N, Taneja, A. “Milwaukee Initiative in Critical Care Outcomes Research Group of Investigators. Nationwide trends of severe sepsis in the 21st century (2000–2007)”. Chest. vol. 140. 2011. pp. 1223-31.
Stevenson, EK, Rubenstein, AR, Radin, GT, Wiener, RS, Walkey, AJ. “Two decades of mortality trends among patients with severe sepsis: A comparative meta-analysis”. Crit Care Med. vol. 42. 2014. pp. 625-31.
Iwashyna, TJ, Cooke, CR, Wunsch, H, Kahn, JM. “Population burden of long-term survivorship after severe sepsis in older Americans”. J Am Geriatr Soc. vol. 60. 2012. pp. 1070-7.
Prescott, HC, Langa, KM, Liu, V, Escobar, GJ, Iwashyna, TJ. “Increased 1-year healthcare use in survivors of severe sepsis”. Am J Respir Crit Care Med. vol. 190. 2014. pp. 62-9.
Iwashyna, TJ, Ely, EW, Smith, DM, Langa, KM. “Long-term cognitive impairment and functional disability among survivors of severe sepsis”. JAMA. vol. 304. 2010. pp. 1787-94.
Karlsson, S, Ruokonen, E, Varpula, T, Ala-Kokko, TI, Pettil€a, V. “Long-term outcome and quality-adjusted life years after severe sepsis”. Crit Care Med. vol. 37. 2009. pp. 1268-74.
Storgaard, M, Hallas, J, Gahrn-Hansen, B, Pedersen, SS, Pedersen, C, Lassen, AT. “Short- and long-term mortality in patients with community-acquired severe sepsis and septic shock”. Scand J Infect Dis. vol. 45. 2013. pp. 577-83.
Odden, AJ, Rohde, JM, Bonham, C. “Functional outcomes of general medical patients with severe sepsis”. BMC Infect Dis. vol. 13. 2013. pp. 588
Winters, BD, Eberlein, M, Leung, J, Needham, DM, Pronovost, PJ, Sevransky, JE. “Long-term mortality and quality of life in sepsis: A systematic review”. Crit Care Med. vol. 38. 2010. pp. 1276-83.
Rohde, JM, Odden, AJ, Bonham, C. “The epidemiology of acute organ system dysfunction from severe sepsis outside of the intensive care unit”. J Hosp Med. vol. 8. 2013. pp. 243-47.
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