Every year, sepsis affects more than 50 million people worldwide and leads to more than 10 million deaths (Citation1, Citation2). The overall sepsis mortality rate ranges from 10–20%, but reaches 50–60% for septic shock, making sepsis a health issue of the utmost importance (Citation3). Consequently, early recognition and diagnosis, severity assessment, and treatment are essential to improve sepsis survival (Citation4). This journal frequently publishes on the prehospital detection and management of sepsis, with two articles in the current issue.
Although defining and detecting sepsis severity in adults are easier since the 2016 Sepsis-3 conference, managing children with sepsis can be challenging, especially in the prehospital setting (Citation5). In the current issue of this journal, Kadish et al. report that pediatric sepsis guidelines are positive factors pertaining to recognition and management of pediatric sepsis, but may be counterproductive when complicated or non-existent (Citation6). From video conferences conducted with 38 EMS professionals in six focus groups, the authors identified nine environmental factors, 21 negative factors, and 14 positive factors pertaining to recognition and management of pediatric sepsis. Six of the positive factors, mainly concerning education, were identified that could improve prognosis: awareness of pediatric sepsis, increasing pediatric education, receiving feedback on prehospital encounters, increasing pediatric exposure and skills training, and improving dispatch information. Undoubtedly, future studies should focus on these factors likely to improve prognosis through earlier recognition of sepsis, though not only in pediatrics.
After sepsis recognition, diagnosis, and severity assessment, international guidelines recommend earlier treatment, which should be initiated within the first hour for the most severe form, septic shock (Citation4). From in-hospital studies, evidence-based medicine concludes that both early antibiotic therapy and hemodynamic optimization allow sepsis-related mortality to decrease (Citation5, Citation7–11). Considering the prehospital setting, care begins before hospital admission, by as much as 15 to 170 min (Citation12), and 70% of sepsis signs are already present before hospital admission (Citation13). Consequently, the question of implementing hospital-like care in the prehospital setting is legitimate and opens a new window within the first hour of care for saving lives to the most at-risk patients, suffering from the most severe forms of sepsis. In-hospital hemodynamic optimization relies on fluid volume expansion and early norepinephrine infusion (Citation4, Citation7, Citation11, Citation14), with a target mean arterial pressure of at least 65 mmHg (Citation14), and a shortened delay to correct hypotension is associated with improved outcomes (Citation15, Citation16). Conversely, in the prehospital setting, such care is not always systematically performed by EMS, perhaps because inadvertent prehospital initiation of hemodynamic optimization and antibiotic therapy may induce unintended harms for patients with noninfectious shock (Citation17).
In the current issue, Miller et al. report that fewer than 50% of prehospital sepsis patients cared for by their EMS system had intravenous therapy attempted, among which nearly half met the fluid volume goal (Citation18). Female sex and congestive heart failure were negatively associated, whereas systolic blood pressure lower than 90 mmHg and abnormal temperature were positively associated, with receiving at least 500 ml intravenous fluid in the field. These results are in line with a previous study involving a different EMS system, which had reported that prehospital fluid resuscitation is mainly performed using crystalloids with quantitative fluid expansion lower than recommended, that was finally associated with increased mortality (Citation19).
Beyond these considerations, we must keep in mind that a single treatment cannot be alone responsible for outcome improvement, and the greater impact on septic shock outcome remains more from global implemented treatments and strategies, rather than from the prehospital EMS organization itself (Citation16, Citation20). Further prospective studies are needed to clarify the usefulness and the effectiveness of optimized prehospital care for septic shock patients.
Service de Médecine Intensive Réanimation, Hôpital Universitaire Ambroise Paré, Assistance Publique - Hôpitaux de Paris, Paris Saclay University, Gif-sur-Yvette, France
[email protected], [email protected]
Papa Gueye
SAMU 972 Centre Hospitalier Universitaire de Hôpital de Martinique, Université des Antilles, Pointe-à-Pitre, Guadeloupe
Félix Djossou
Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Guyane and Laboratoire Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne, French Guiana
Benoît Vivien
SAMU de Paris, Service d’Anesthésie Réanimation, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
Disclosure statement
The authors have no conflicts of interest to declare.
References
- Fleischmann C, Scherag A, Adhikari NKJ, Hartog CS, Tsaganos T, Schlattmann P, Angus DC, Reinhart K, International Forum of Acute Care Trialists. Assessment of global incidence and mortality of hospital-treated sepsis. Current estimates and limitations. Am J Respir Crit Care Med. 2016;193(3):259–72. doi:10.1164/rccm.201504-0781OC.
- Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, Colombara DV, Ikuta KS, Kissoon N, Finfer S, et al. Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study. Lancet. 2020;395(10219):200–11. doi:10.1016/S0140-6736(19)32989-7.
- Luhr R, Cao Y, Soderquist B, Cajander S. Trends in sepsis mortality over time in randomised sepsis trials: a systematic literature review and meta-analysis of mortality in the control arm, 2002–2016. Crit Care. 2019;23(1):241. doi:10.1186/s13054-019-2528-0.
- Chen AX, Simpson SQ, Pallin DJ. Sepsis guidelines. N Engl J Med. 2019;380(14):1369–71. doi:10.1056/NEJMclde1815472.
- Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017;45(3):486–552. doi:10.1097/CCM.0000000000002255.
- Kadish CB, Lloyd JK, Adelgais KM, Ward CE, Lo CB, et al. Prehospital recognition and management of pediatric sepsis: a qualitative assessment. Prehosp Emerg Care. 2023;1–11. doi:10.1080/10903127.2023.2210217.
- Leisman DE, Doerfler ME, Ward MF, Masick KD, Wie BJ, Gribben JL, Hamilton E, Klein Z, Bianculli AR, Akerman MB, et al. Survival benefit and cost savings from compliance with a simplified 3-hour sepsis bundle in a series of prospective, multisite, observational cohorts. Crit Care Med. 2017;45(3):395–406. doi:10.1097/CCM.0000000000002184.
- Naucler P, Huttner A, van Werkhoven CH, Singer M, Tattevin P, Einav S, et al. Impact of time to antibiotic therapy on clinical outcome in patients with bacterial infections in the emergency department: implications for antimicrobial stewardship. Clin Microbiol Infect. 2021;27(2):175–81. doi:10.1016/j.cmi.2020.02.032.
- Peltan ID, Brown SM, Bledsoe JR, Sorensen J, Samore MH, Allen TL, Hough CL. ED door-to-antibiotic time and long-term mortality in sepsis. Chest. 2019;155(5):938–46. doi:10.1016/j.chest.2019.02.008.
- Seymour CW, Gesten F, Prescott HC, Friedrich ME, Iwashyna TJ, Phillips GS, Lemeshow S, Osborn T, Terry KM, Levy MM, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017;376(23):2235–44. doi:10.1056/NEJMoa1703058.
- Sterling SA, Miller WR, Pryor J, Puskarich MA, Jones AE. The impact of timing of antibiotics on outcomes in severe sepsis and septic shock: a systematic review and meta-analysis. Crit Care Med. 2015;43(9):1907–15. doi:10.1097/CCM.0000000000001142.
- Jouffroy R, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Bounes V, et al. Impact of prehospital antibiotic therapy on septic shock mortality. Prehosp Emerg Care. 2021;25(3):317–24. doi:10.1080/10903127.2020.1763532.
- Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche J-D, Coopersmith CM, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA. 2016;315(8):801–10. doi:10.1001/jama.2016.0287.
- Scheeren TWL, Bakker J, De Backer D, Annane D, Asfar P, Boerma EC, Cecconi M, Dubin A, Dünser MW, Duranteau J, et al. Current use of vasopressors in septic shock. Ann Intensive Care. 2019;9(1):20. doi:10.1186/s13613-019-0498-7.
- Maheshwari K, Nathanson BH, Munson SH, Khangulov V, Stevens M, Badani H, Khanna AK, Sessler DI. The relationship between ICU hypotension and in-hospital mortality and morbidity in septic patients. Intensive Care Med. 2018;44(6):857–67. doi:10.1007/s00134-018-5218-5.
- Jouffroy R, Gilbert B, Gueye P-N, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B. Prehospital hemodynamic optimisation is associated with a 30-day mortality decrease in patients with septic shock. Am J Emerg Med. 2021;45:105–11. doi:10.1016/j.ajem.2021.02.060.
- Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign Bundle: 2018 update. Intensive Care Med. 2018;44(6):925–8. doi:10.1007/s00134-018-5085-0.
- Miller NS, Patel MD, Williams JG, Bachman MW, Cyr JM, Cabanas JG, et al. Prehospital fluid administration for suspected sepsis in a large EMS system. Opportunities to improve goal fluid delivery. Prehosp Emerg Care. 2023;1–6. doi:10.1080/10903127.2023.2203526.
- Jouffroy R, Saade A, Muret A, Philippe P, Michaloux M, Carli P, Vivien B. Fluid resuscitation in pre-hospital management of septic shock. Am J Emerg Med. 2018;36(10):1754–8. doi:10.1016/j.ajem.2018.01.078.
- Prekker ME, Puskarich MA. Emergency department sepsis care: could it matter who is in the ambulance? Ann Am Thorac Soc. 2018;15(12):1398–400. doi:10.1513/AnnalsATS.201808-554ED.