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Tuesday, October 18, 2022

The Sepsis Episode

Episode 74

 
Dr. Nick Gilpin (00:04):

Coming to you from Beaumont, this is your house call. When an infection happens, there are a few possible outcomes. Often, the infection can improve on its own, and this commonly happens with very mild viral or bacterial infections. In the case of more serious infections, treatment is often necessary, and this often includes antibiotics or other medications to help eliminate the offending agent. And in the most serious infections, the body's overwhelming response can be so severe that it triggers a cascade of inflammation and tissue damage, and this is what we call sepsis.

(00:46):

Sepsis is a life threatening medical emergency, and the best treatment is timely recognition and timely management. Keep it here. The HouseCall Podcast is talking all about sepsis awareness. Hello, and welcome to The Beaumont HouseCall Podcast. I'm Dr. Nick Gilpin. And my goal is to help you and your family live a smarter, healthier life. Today it's all about sepsis. This is certainly a topic that's near and dear to my heart. We also have a couple of outstanding guests with us to discuss this important topic. I have Dr. Paul Bozyk and Jennifer Pipta. Dr. Bozyk is a pulmonary critical care physician at Royal Oak Beaumont. He's also the section head of pulmonary and critical care. Paul has been a brother in arms during the COVID pandemic and he is certainly no stranger to the challenge that is sepsis.

(01:38):

Jennifer is a nurse specializing in quality improvement and she's currently the sepsis coordinator at the Beaumont Dearborn campus. And she does a lot of work educating providers and the community about timely recognition and management of sepsis. So with that, welcome to the podcast, Jennifer and Paul.

Dr. Paul Bozyk (01:54):

Thank you very much, Nick.

Jennifer Pipta (01:55):

Thank you.

Dr. Nick Gilpin (01:56):

Before we jump in, couple of things. First off, I always like to kind of put a timestamp on some of this information. But the reason why we're talking about sepsis, or one of the reasons we're talking about sepsis today, and we're a little bit late to the party on some of this, is that September was Sepsis Awareness Month. And so this is something that started about a decade or so ago to help raise public awareness of sepsis and its implications and to try to help the public get their arms around this. Paul and Jen, tell us why we need a month dedicated to sepsis awareness.

Dr. Paul Bozyk (02:25):

Yeah. And I think the first thing that I'd say, Nick, is that a month is not enough. For as many people as sepsis impacts, for the death it can cause, for the problems of the survivors that it can cause, for the cost of healthcare, it is a serious, serious condition that all of healthcare needs to take very seriously. Additionally, Jen and I are passionate about this not only because of all those things and because of the patients we treat with sepsis every day, but we both have seen sepsis in our families.

Jennifer Pipta (02:56):

Yes. In April 2015, before I actually took on the role of sepsis coordinator at Beaumont Dearborn, I lost my father to sepsis after he was in the intensive care unit at my hospital for two weeks. I was a nurse and I was blind to the symptoms that my dad had, mostly because he was sick and he didn't want me to know that he was sick. But ultimately, after two weeks in the ICU, we lost him to septic shock. Paul.

Dr. Paul Bozyk (03:32):

Yeah. So pre pandemic, I remember my dad called middle of the night saying that he was having what he described as back pain, flank pain, having a hard time with it, just didn't feel right. Pain was really is only symptom, to the point where he decided to come to the emergency department and called me on the way. And I saw him there, and fortunately, he made the smart decision to come in because he had a very, very severe infection of his gall bladder. And with that, he saw some of the untoward effects of that infection manifesting as sepsis. He has some kidney dysfunction at the time. And he didn't look quite right. My dad's a very super smart, sharp guy, lot of sarcastic humor, things like that. And he looked very kind of stoic, stone faced, somewhat withdrawn. And we're very thankful of the quick action on the part of the team at Beaumont Royal Oak that got him the antibiotics, and the surgeon that he needed to remove the infected gall bladder. And he made a complete and full recovery thereafter, thank God.

Dr. Nick Gilpin (04:41):

Wow. Thank you both for sharing that. I think that illustrates why sepsis is important not only for the community to early recognize and early treat and be able to get people to the hospitals for that advanced level of care, also very important for our healthcare providers to know what sepsis is and to know how to recognize and treat it in our hospitals as well. The second thing I want to do is, Jennifer, I want to ask you to clarify something. When I introduced you a moment ago, I introduced us as the sepsis coordinator. So do you want to talk a little bit about what that role is and how you landed there?

Jennifer Pipta (05:17):

So yes, I am the sepsis coordinator at Beaumont Dearborn. And my role is to make sure that we are providing sepsis care through treatment protocols and guidelines to patients in a timely manner. Sepsis treatment is broken down into the early treatment phases, and then throughout the patient's care, I make sure that they're educated on what sepsis is and different treatment choices or things that they can do to prevent sepsis from happening again.

Dr. Nick Gilpin (05:45):

So hospitals are becoming much more dialed into the management of sepsis.

Jennifer Pipta (05:49):

Yes.

Dr. Nick Gilpin (05:50):

Is this a position that is becoming increasingly common at other hospitals? Do all hospitals have a sepsis coordinator, many hospitals?

Jennifer Pipta (05:58):

Many hospitals do, and a lot of hospitals are trying to bring more sepsis coordinators on. We are very fortunate in the Beaumont Health System to have coordinators or quality improvement nurses at each eight of our hospitals that are working toward sepsis care and awareness as well.

Dr. Nick Gilpin (06:17):

Perfect. So let's pivot now to talking about sort of the scope of sepsis. I want to lay some statistics out, which are going to give the public some idea of why we're talking about sepsis today. So according to the CDC, sepsis affects 1.7 million Americans and takes about 350,000 adult lives every year. So for perspective, this is more deaths annually than can be attributed to prostate cancer, breast cancer, opioid overdoses, all of those things combined. This is a serious health problem. And sepsis also affects more than 75,000 children in the United States, so it's not just an adult problem, it's certainly also a pediatric problem. And about 6800 of these children die, which is more than can be attributed to certain pediatric cancers. It is the second leading cause of pregnancy related death in the United States. And it's also the number one cost of hospitalization in the United States at about $62 billion annually.

(07:14):

So in spite of these staggering numbers, the numbers I just laid out, fewer than 15% of US adults can readily identify the symptoms of sepsis, so that's heavy stuff. So let me get your reaction to some of that and tell me: What are our next steps here in making the public more aware?

Dr. Paul Bozyk (07:33):

Well, Nick, I absolutely agree that the numbers are staggering. The effects of sepsis are staggering at a macro level across the country, across the globe, but absolutely to the individual that is admitted with sepsis. And I think the definition of sepsis is something that's been unclear to a lot of folks out there that hear it. They know it's a word that's scary, can be associated with lots of bad symptoms or even death at times. But being able to pinpoint exactly what it is has always been a challenge. And that's one of the reasons that we want to come on this podcast and talk to your listeners today, so they can help identify sepsis because as Jen was mentioning, early identification and treatment is the absolute best way to avoid the complications of sepsis.

Dr. Nick Gilpin (08:20):

So give us the layperson's definition of what sepsis is.

Dr. Paul Bozyk (08:24):

So first, I think it's important to discuss infection. Right?

Dr. Nick Gilpin (08:28):

Yeah.

Dr. Paul Bozyk (08:28):

So let's start there. Sepsis and infection are two different things. Infection is the breach of an organism into the body that causes us to feel unwell. And we've all experienced infection at some point in our life. We've had that sore throat. It could be a virus or a bacteria that causes that sore throat. We might've felt little achy, we might've had a little fever, and those are normal responses to an infection. Sepsis is not that. Sepsis is an abnormal response to infection, and because of that abnormal response, the body creates chemicals which actually can be injurious to the different parts of the body. And so we get this thing called organ dysfunction, which is very scary, and it is.

(09:09):

Organ dysfunction means what it sounds like. It means that there are organs in our body that are not functioning properly. And this could happen to any organ in the body. This could relate to abnormal kidney function. This could relate to abnormal heart function. This could cause people shortness of breath and have difficulty getting enough oxygen into the body. And one thing that we often forget that is so important, this could affect the brain as well. And one of the common symptoms of sepsis is actually an abnormal response in the brain that makes people not think as clearly as they otherwise would. So just to recap on that, an infection is part of sepsis, but beyond that, sepsis is the abnormal organ response to that infection.

Dr. Nick Gilpin (09:56):

Right. It's sort of a continuum. Right?

Dr. Paul Bozyk (09:58):

Yeah.

Dr. Nick Gilpin (09:58):

So you have infection, a mild infection on the one end of the continuum, and then you have of course the most severe clinical manifestations of an infection. You have sepsis, you have septic shock on the other end. And a person can sort of live anywhere on this continuum. And when you get to that point where you're starting to see that tissue injury or that robust inflammatory response, that's when you start tipping into the realm of sepsis. Right?

Dr. Paul Bozyk (10:23):

Yes.

Dr. Nick Gilpin (10:24):

So now let's talk about the difference between, and this is one of the greatest hits that I hear a lot on the floors with the patients, my doctor said I have sepsis. Right? Does that mean I have a blood infection? Let's differentiate some of these common misnomers. Right?

Jennifer Pipta (10:40):

Yes.

Dr. Nick Gilpin (10:40):

You want to take that one, Jen?

Jennifer Pipta (10:42):

That is one of the ones that I hear the most when I start talking to people about sepsis. And they're like, "Oh, yeah, I know what that is. That's a blood infection." And I have to dial it back and say, "No, sepsis can be caused from an infection in the blood, but sepsis can happen from any infection."

Dr. Nick Gilpin (11:01):

That's right.

Jennifer Pipta (11:01):

So that's the one thing that I think that most people get wrong, is they think that sepsis is the infection itself when it's not. It's not contagious. You can't get sepsis from somebody else, but you can contract an infection that could cause sepsis from somebody else.

Dr. Nick Gilpin (11:19):

Yep, good point. And I think also to put a finer point on that, or maybe restate what you've just said about any infection can cause it, heck, even COVID. Right? We've seen oodles of patients in the hospital with clinically sepsis. Right? They have a robust, overwhelming inflammatory response. They're having difficulty breathing. They're having fevers. They're having signs of organ dysfunction. And it's all secondary to COVID, so you can get sepsis as a consequence of COVID. You can get sepsis as a consequence of a urinary tract infection. You can get sepsis as a consequence of a skin infection. I mean, there's all kinds of things that can cause sepsis.

(11:57):

So let's try to crystallize this now with a real world scenario. So say I have an elderly relative who's prone to getting recurrent urinary tract infections, so this is another common clinical scenario that we might see play out in one of our hospitals or in our community. What are the things that should prompt me to take this person to an emergency room as opposed to just calling my primary care doctor and saying, "I think my mom has another urinary tract infection"? What am I looking for?

Jennifer Pipta (12:26):

Really, the number one thing I see in that type of a scenario is my mom just isn't acting right. And that kind of plays on when you said that the brain can be affected. My mom just hasn't been acting right for the last couple of days and I don't actually know why. And so I usually tell people if that's what you're seeing, you definitely need to get it looked at. There are multiple different things that it could be, but one of the things that it could be is sepsis.

Dr. Paul Bozyk (12:52):

And I'd say things that are typical of infection should clue you into whether or not we need to have a heightened awareness of: Could this be progressing to sepsis? Some things are easily identifiable. Is there fever? And again, that may be a normal response to infection, but could progress to sepsis. One of the things that's been found is that people's respiratory rate and respiratory effort can change with sepsis. So if you notice your loved one may be breathing a little bit harder, even when they're sitting in the chair watching television, or breathing a little bit more quickly, or claim that they have shortness of breath themselves, that should be a red flag indicator that you'd want them to be looked at.

(13:30):

Sometimes people monitor their blood pressure and their heart rate at home, also helpful information. That's what we do if you come to the doctor's office or to the hospital. Right? And if you notice deviations from your loved one's normal, that's important. Same thing with blood pressure. If the blood pressure is normal on most days, and now we see that it's less than normal, or it's trending in a downward direction, that's very important and you want to have your loved one seen immediately.

Dr. Nick Gilpin (13:55):

Definitely. Red flag symptoms and things that I like to highlight for patients, first of all, in the setting of an infection, known or unknown, say you've got a cut or a scrape on your skin, or you think you've got a urinary tract infection, in addition to that, you have high fevers, significant body discomfort or aches, cool, clammy skin, shortness of breath, like you mentioned, Paul, diminished consciousness, or altered mental status, changes in your heart rate or your blood pressure, those are significant red flags. And any combination of those or more than one of those things could indicate a serious problem and you need to get help right away. That becomes a medical emergency.

(14:34):

So then you're going to haul this person into the emergency room, so now let's start to kind of develop a bit of a timeline here. So we're going into the emergency room to get seen and evaluated. What are we doing now?

Jennifer Pipta (14:46):

So when a patient comes into the emergency room, there has been a lot of education with the staff about it's all about time. Time equals tissues with anything that we're looking at, whether it's a stroke, or a heart attack, and sepsis, so we want them to start those early treatment protocols. And we take within the Beaumont system, a take two, give two, kind of approach to everything.

Dr. Nick Gilpin (15:09):

Talk about that.

Jennifer Pipta (15:09):

So with every sepsis patient, we want to take two things from them in the form of blood cultures, where we do a lab test to look to see if there is an infection that's going on in the blood. And then we also want to take a laboratory test called a lactic acid. After those things have been obtained, the other thing that we want to do is we want to get antibiotics on as quickly as possible. Studies have also shown that the more that we delay getting those antibiotics, the more detrimental it is to a patient. And then we also want to give those patients some fluids.

Dr. Nick Gilpin (15:43):

So real time, rapid diagnostic testing, things like blood cultures, you mentioned lactic acid, which is an indicator of how well a person is perfusing their tissues. Right? If that number is elevated, then that means that we're not getting enough blood flow to certain organs. And then obviously, you mentioned getting antibiotics in as quickly as possible. What else?

Dr. Paul Bozyk (16:02):

So I think also, when they're drawing that lactic acid and they're getting those blood cultures, we also send for a wide variety of labs at the time. And the patient wouldn't understand this, the person getting the blood drawn would just see an extra tube or two being sent off to the lab. But importantly, with those labs, we're looking at things that help us understand whether we have that organ dysfunction and help us discriminate between infection and sepsis. So we're looking at the liver function. We're looking at the kidney function. We're looking at the white blood cell count, which can help us understand if we're having a robust effect response to infection. All of these things come together in helping the physician or the advanced practice provider kind of understand that sepsis is happening and take all those really urgent, if not emergent actions that Jennifer was just describing because again, early identification and aggressive early treatment is the name of the game.

Dr. Nick Gilpin (16:55):

Talk about the other component to this, which is sort of the fluid management of the patient, where if there's evidence that the person is behind in fluids or dehydrated, we're giving them a lot of fluids. We're helping resuscitate the patient. Can you talk a little bit more about that, Paul?

Dr. Paul Bozyk (17:11):

Yeah, absolutely, Nick. So one of the abnormal responses to infection that we see in sepsis relates to the amount of fluid within the bloodstream. Let's look at it this way. We've got a hose, and that hose is about, let's say a half an inch in diameter. And it's there, and it's there to water your lawn. And you turn on the faucet and it does just fine. During sepsis, a few things happen. Number one, that hose goes from about a half an inch to let's say an inch. Yet, the faucet's turned the same amount. So the fluid is going to move much more sluggishly through the bigger diameter hose. Secondarily, that hose is going to get some holes in it along the way. And so what happens is your lawn is no longer getting all the water that it would've gotten under normal circumstances with a normal sized functioning hose with the faucet turned the same amount.

(18:05):

One of the things that happens when that fluid doesn't get to the organs, and that fluid in the body is carrying important things like red blood cells, and those red blood cells are carrying the oxygen that the tissues need, one of the things that happens if that's not done effectively is that the tissues don't get the oxygen that they need, and that's one of the contributors to organ dysfunction. So we give fluids to try to supplement that. We're trying to, if you will, we're turning the faucet a little bit further to try to support the blood pressure and support the flow of that vital red blood cell and the oxygen it's carrying to get to those tissues. And so one of the things that you may see in a patient being treated with sepsis is fluids that are being administered, and not an insignificant amount of fluid.

Dr. Nick Gilpin (18:51):

I like the metaphor, I like the visual of the hose. And I think the other side of that is by giving those early antibiotics, that idea of a leaky hose, that's inflammation that's causing all that leakage, so we're trying to stop the source of the original infection, which is the source of that inflammation, and thereby sort of plug all those holes within that hose and slow that down, so that the water can, or the blood rather, can flow the way it normally should, so that's a helpful visual, Paul. I do appreciate that.

(19:22):

Certain populations of patients, we know from other infections, from dealing with things like COVID and such, certain populations are more at risk for sepsis. So I'm thinking about the immunocompromised hosts, including patients that are on certain medications, cancer patients, patients that have chronic medical conditions. I'm thinking about elderly patients, children less than a year old, pregnant women. Another statistic that I mentioned early on in the pod was sepsis is a leading cause of death among pregnant women because they are relatively immunocompromised. Also, people who are frequently, or recently hospitalized, or in nursing homes, we know that these patients tend to be more likely to harbor unusual or more aggressive bacteria, and that can potentially be a source of infection.

Jennifer Pipta (20:10):

Another one that I had heard was patients who have had sepsis in the past are at higher risk of developing it again. It's not uncommon for me to see patients who have come in every year getting an infection, and they have sepsis again. So just having sepsis once puts you at a higher risk of developing it again.

Dr. Nick Gilpin (20:30):

Excellent point. And I think it's a story I certainly hear from patients. Every time Mom gets a UTI, she ends up with sepsis, she ends up in the hospital. And so this can certainly become sort of a cyclical problem for a lot of patients, and we do everything we can to try to break that cycle with early recognition, early management. And the other thing I think we have to mention here is that communities that have historically lacked access to high quality healthcare, including communities of color, individuals who are experiencing poverty, these are areas where sepsis is still unfortunately and will continue to cause a lot of problems, so making sure that we're increasing awareness and making sure that we're arming the hospitals and the healthcare settings in those communities with the tools that they need to manage sepsis is going to be really critical in this fight.

(21:16):

So Paul, I think this one's probably more for you. So some of our patients with sepsis will require higher levels of care. They may require ICU level care. So can you talk a little bit about what we're doing in our ICUs to help support these patients with sepsis and what that experience looks like for the patients?

Dr. Paul Bozyk (21:33):

Well, if that organ dysfunction is bad enough, or to use the leaky hose analogy, if we can't get enough fluids to support a blood pressure, then someone's going to require ICU level care. When we can't sustain a blood pressure despite all the fluids that we're giving someone, and we have markers like that lactic acid elevation that Jen was talking about, that's called shock. And when someone's in shock, the only real way to make them better is in an ICU environment with special medications that we can only use in an ICU. And those medications are designed to increase the blood pressure so we get better forward flow of the blood, so that the tissues can be supported and the organ dysfunction can heal.

(22:20):

And it's a scary time because those special medications sometimes even require special IV lines to be put in, but they're done with a team. You have an ICU doctor usually working with other doctors, nurses. In an ICU, you get good geographic care, so the doctor's usually within three minutes of anyone at any given time. So it's a safe as an environment as we can make it, though understandably scary for someone that needs to be there.

Dr. Nick Gilpin (22:48):

And I think this might be a good time to just point out that sepsis, as scary and as complicated of a problem as it is, is something that our hospitals really are pretty well equipped at. Right? Our doctors are pretty good at recognizing sepsis, our ICU attending physicians understand the medicine and the protocol behind this.

Dr. Paul Bozyk (23:09):

Yeah. Absolutely. I'd say that once sepsis is identified, the care plan is very clear.

Dr. Nick Gilpin (23:15):

Yes.

Dr. Paul Bozyk (23:16):

It's very clear. And as Jen was mentioning, we're watching the clock.

Dr. Nick Gilpin (23:20):

So good segue then to talking about what we can do in addition to that early recognition component and early management component. What else can our patients be doing to lower their chances of getting sepsis? I'm talking about making sure that your underlying medical problems are under control, if you have diabetes, making sure your diabetes is well controlled. Jennifer, what else is out there?

Jennifer Pipta (23:43):

We try to educate all of our sepsis patients that one of the biggest things that they can do to help reduce their chances of getting any infection that can lead to sepsis is hand hygiene, making sure that they ... If you can't get to somewhere where you can wash your hands, that you're at least using hand sanitizer of some sort. We also encourage patients to get vaccinations. We know that we're going to be coming up on flu season, and flu is another one of the big ones that can lead to sepsis. So those routine vaccinations and staying up on those routine vaccinations is another big way that we can help prevent infections that lead to sepsis.

Dr. Nick Gilpin (24:22):

Agree. Control the things that you can control. Manage your chronic medical conditions. Get your vaccinations. Prevent the preventable. Paul, anything you want to add to that?

Dr. Paul Bozyk (24:32):

I agree, Nick, with everything you mentioned about taking care of underlying medical conditions. We do know that folks that have underlying medical conditions are more prone to sepsis, so as one considers if somebody's at risk, think about sepsis in someone that has odd symptoms, but you know they have a history, let's say of COPD. Taking care of ourselves, generally good nutrition, avoidance of things that could do our bodies harm in general, and being as well as we can.

Dr. Nick Gilpin (25:03):

Well said. Let's leave it there. I want to thank Dr. Paul Bozyk and Jennifer Pipta for joining me on the podcast. Thank you, both.

Jennifer Pipta (25:10):

Thank you very much for having us.

Dr. Paul Bozyk (25:11):

Really appreciate it, Nick. Thank you.

Dr. Nick Gilpin (25:13):

For more information on sepsis, please visit www.beaumont.org/sepsis. And I also want to remind you to send along any questions or suggestions to podcast@beaumont.org. And I will leave you today with this healthy thought. Sepsis, the body's overzealous response to an infection, can be a severe, life threatening emergency. Almost any infection can potentially lead to sepsis. If not treated promptly, sepsis can trigger a cascade of inflammation that leads to organ damage and even death. Fortunately, with early recognition and management, sepsis is highly treatable. Know the signs and symptoms of sepsis. If you or a loved one is experiencing an infection and things are getting worse, be sure to get prompt medical care immediately. Thank you.

Speaker 4 (26:04):

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