Of the 120 million patients presenting to the emergency department (ED) in the United States per year, 2.9% or over 600,000 carry a diagnosis of severe sepsis and septic shock in the United States. The overall hospital mortality for sepsis, severe sepsis, and septic shock is 15%, 20%, and 45%, respectively. Sepsis is responsible for 9% of the deaths or 210,000 deaths per year in the United States. By comparison, 180,000 persons die of acute myocardial infarction and 200,000 die of lung or breast cancer annually. Many patients with severe sepsis and septic shock present to the ED where there are often long delays before transfer to an intensive care unit (ICU) bed. Sepsis is the most expensive diagnosis admitted to hospitals accounting for over $50 billion in health care costs each year. It is because of these aforementioned factors that the ED has become a logical focal point for sepsis diagnosis and treatment. It is during the first 6 hours that sepsis management can improve outcomes in one of every six patients who present with the disease.1
Risk factors and comorbidities that increase the incidence and mortality include age, gender, race, multidrug-resistant organisms, severity of chronic illnesses, and overcrowding of the EDs.2 Because ED visits increase with age, a higher proportion of patients will come from this population. The incidence of sepsis in adult patients over age 85 is 26.2/1,000 versus 0.2/1,000 in children.3 Over 115 million patients present to the ED per year and 2.9% of these patients have sepsis that accounts for over 600,000 annually, with a mean stay of 4.7 hours. Approximately 20.4% of the patients stay longer than 6 hours.4 The ED accounts for 50% of all hospital admissions for sepsis. Because of ED overcrowding and long lengths of stay, the ED becomes a significant portal of entry to realize improved outcomes.5
A series of pathogenic events are responsible for the transition from simple infection or sepsis to severe sepsis and septic shock. When an organism enters the body, the reaction is a systemic response that creates a systemic inflammatory response syndrome (SIRS). This reaction may be self-limited or may create a generalized systemic response. SIRS is the result of a release of proinflammatory and anti-inflammatory mediators. There is also a release of apoptotic proteins and an activation of the coagulation cascade. These processes can lead to malignant microvascular injury, thrombosis, and diffuse endothelial disruption, resulting in impaired tissue oxygenation. Furthermore, there is an imbalance between oxygen delivery and oxygen consumption. When organ dysfunction accompanies this response, this marks the onset of severe sepsis. Global tissue hypoxia and cytopathic (cellular) hypoxia develops, leading to multiple organ dysfunction and irreversible shock.
The American College of Chest Physicians (ACCP), the Society of Critical Care Medicine (SCCM), and International Sepsis Definitions Conference (ISDC) provided the definition of SIRS. SIRS is the systemic inflammatory response that is seen in a variety of ...