Sepsis is an overwhelming inflammatory response to infection. Left unrecognized and untreated, it can lead to irreversible damage to organs such as the kidneys, lungs or brain, as the body goes into shock. Bleeding often occurs as well. With severe sepsis, about 40-50% of patients will die. In the U.S., there are over 1 million cases of sepsis each year, and the numbers have been increasing.
Patty Duke died Tuesday from sepsis caused by “a ruptured intestine according to a statement from Mitchell K. Stubbs & Associates, the agency that represented her.” No further details were given, but this can be a complication of diseases like diverticulitis, appendicitis, inflammatory bowel disease, cancer or C. difficile infections, for example.
Duke was 69. She was perhaps best known for her portrayal of Helen Keller in The Miracle Worker, for which she won an Academy Award for Best Supporting Actress. She was also a staunch mental health advocate, having herself suffered from bipolar disorder. She wrote a book on it in 1992 to educate others on mental illness.
Perhaps Ms. Duke’s untimely death can help prevent other deaths from sepsis. Here’s what you should know about sepsis.
Who’s at risk?
Anyone can become septic from an infection, but those at highest risk are the elderly, babies and very young children, people with weakened immune systems (think cancer or immunosuppressive medicines) or those with chronic illnesses, such as diabetes, AIDS, cancer and kidney or liver disease. Sepsis is increasing as we have more vulnerable patients, and also with worsening problems with antibiotic resistance.
Occasionally, even a minor cut or scrape can lead to septic shock. Tragically, this happened to a 12-year-old boy, Rory Staunton, who died after delays in recognizing and responding to his sepsis.
Symptoms
Often, early symptoms are nonspecific, and might include diarrhea and vomiting as well as general aching and weakness. It can be confused early on with influenza or other viral syndromes.
The CDC has this mnemonic for suspecting sepsis, if a person complains of the following symptoms:
They also stress telling your doctor or healthcare worker specifically, “I AM CONCERNED ABOUT SEPSIS.” I’m curious how much of an impact that would have, but I would generally find the reminder helpful, especially during harried times. Again, early symptoms are nonspecific and can be missed, and speeding the response time is critical to saving lives.
Diagnosis
Sepsis is detected by symptoms, signs on physical exams and lab tests. I learned a lot, having been a principal investigator on a number of sepsis clinical trials over the years. Here are some suggestions from my experience, which you won’t commonly see.
Tips from the trenches: Have a real person count your breathing rate; hospital monitors are notoriously inaccurate about respiratory rate, which is an early sign. The same applies to temperatures. Some electronic thermometers are worthless. If you think you have a fever and it is not being detected, ask them to take your temp by another route.
One of the earliest, most sensitive signs of organ failure, I learned, is a drop in urine output. Docs might routinely order “I & Os,” measurement of intake and output, but that is not good enough, as it’s measured one time each eight hour shift. Placing a urinary (Foley) catheter in a patient’s bladder and measuring hourly urine output is an excellent way of detecting sepsis early so it can be more aggressively treated. (Addendum post publishing: Not everyone agrees as to whether Foley catheters should be used in this way.)
A change of mental status (confusion or decreased responsiveness) is also an important barometer for sepsis, and is emphasized in new criteria that were released in February in JAMA.
Treatment
Sepsis requires aggressive treatment with appropriate antibiotics, based on the likely cause of infection and knowledge of local antibiotic resistance patterns. This is critical, as receipt of an effective antibiotic within the first hour of hypotension (low blood pressure) was associated with an 80% survival. In contrast, in a disturbing study, each hour delay decreased survival by 7.6%. Discouragingly, 50% of the septic shock patients received effective antimicrobial therapy within the initial six hours.
Sepsis also requires supportive care with aggressive fluids, medicines for blood pressure support and monitoring/treating respiratory failure. Many patients with septic shock end up requiring to be put on a ventilator (a.k.a. breathing machine, mechanical ventilation) to help with oxygen delivery. Some will end up needing dialysis for kidney failure.
I participated in many clinical trials of novel medicines over the years. Although none of these experimental therapies were found to work, our mortality dropped from the expected ~50% to 10-15%—simply from earlier recognition and far more aggressive supportive care. This attention to basics was similarly seen even to help reduce the mortality in Ebola last year.
Post-sepsis syndrome
Even after recovery from severe sepsis, many patients are troubled by long-term sequelae. Called post-sepsis syndrome, this is somewhat analogous to PTSD, with insomnia, nightmares, decreased functioning, depression and pain, in addition to any residual problems from kidney or other organ damage. This may require a prolonged recovery period.
Conclusion
Rory Staunton’s death on April 1, 2012 triggered an extensive educational effort by his parents, through the Rory Staunton Foundation for Sepsis Prevention. New York adopted Rory’s Regulations, to require hospitals to adopt protocols that would lead to screening and earlier recognition of sepsis, as well as to improve a hospital’s communication with the parents and primary care provider. Perhaps these will be widely adopted through his parents’ efforts.
Hopefully, Patty Duke’s death from sepsis won’t just be another tragedy, but will help as well with sorely needed awareness of sepsis so that we can reduce deaths that would have been preventable. As the Sepsis Alliance says, “Suspect sepsis. Save lives.”
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