Dr. Hallie Prescott is an Assistant Professor in Pulmonary & Critical Care Medicine at the University of Michigan and staff physician at the Ann Arbor Veterans Affairs Hospital. She leads grants on post-sepsis morbidity and hospital performance measurement from the US National Institutes of Health and the US Department of Veteranâ€™s Affairs. She is an expert in long-term outcomes and recovery after sepsis. She is a vice-chair of the Surviving Sepsis Campaign guidelines, council member of the International Sepsis Forum, and a former ANZICS Intensive Care Global Rising Star fellow.
Back-end of sepsis: de-escalating & de-resusciating
SMACC INTENSIVE CARE UPDATES
Sepsis clinical practice guidelines focus on the early management of sepsis during the first 24 hours after hospital presentation. However, with advances in critical care, most patients survive the early phases of sepsis, most survive hospitalization, and many go on to experience poor longer-term outcomes. Greater antibiotic exposure and volume overload have been associated with worse long-term outcomes-specifically with recurrent sepsis and disability. On the flip side, there is increasing data that shorter antibiotic courses are effective. Nonetheless, many patients receive prolonged treatment with broad-spectrum antibiotics and are not treated with diuretics despite frank volume overload in the aftermath of sepsis. Both clinical and biomarker trajectories may be used to guide antibiotic de-escalation and fluid de-resuscitation.
Uncertainty at the Centre of Sepsis
Sepsis is a common and deadly condition, but diagnosis in not always knowable in real-time. The optimal treatment during times of diagnostic uncertainty differs across patients. Despite this reality, sepsis performance is uniformly assessed and reported for a population knowable only in retrospect – the patients ultimately judged to have sepsis at hospital discharge. This limits effective audit and feedback to incentivize clinician behaviour. Personalized, real-time assessments of a patient’s risk of death and likelihood of infection could instead be used to guide treatment recommendations and performance assessment. Clinicians and health systems could be judged on whether their responses are appropriately calibrated given the urgency of the situation. Were antibiotics prescribed at an appropriate time given the urgency of the patient’s clinical status? With the information available, were the best treatment decisions made? Did treatment plans change as new data became available? Organizing treatment recommendations and performance assessment by risk of death and likelihood of infection could optimize sepsis care.