A recent study found over 50% of severe COVID-19 patients suffered from sepsis, which means it’s all the more important to stay cognizant of the condition, diagnosis, and treatment.
By Lisa Spear
During the novel coronavirus COVID-19 pandemic, when medical resources throughout the globe are strained, caring for sepsis patients may become more complicated. Nevertheless, it is all the more important to stay cognizant of this devastating condition and informed of how to treat and identify sepsis in COVID-19 patients as well as other critically ill patients who come through the intensive care unit.
“The extra attention that we normally give to sepsis care, it is very important that we continue to do that,” said Chirag Choudhary, MD, MBA, a critical care physician, who leads the Cleveland Clinic’s sepsis management team in Ohio.
One study, published in JAMA,1 found that a significant number of critically ill COVID-19 patients developed septic shock and organ dysfunction. These patients were at higher risk of dying from the coronavirus. To help educate healthcare providers on how to properly monitor and treat sepsis in the era of COVID-19 the Surviving Sepsis Campaign (SSC) recently released Guidelines on the Management of Critically Ill Adults with Coronavirus.2 A coronavirus subcommittee of experts from around the world formed to develop a set of best practices to support hospital clinicians managing critically ill adults with COVID-19 in the intensive care unit.
“I think that COVID-19 is going to continue to hang out with us for at least the foreseeable future, so we need to figure out how to continue to practice medicine and at the same time, continue to improve the way that we take care of patients,” said Choudhary.
For COVID-19 patients who are experiencing septic shock as well as acute respiratory distress (ARDS) syndrome, the SSC recommends a conservative approach to IV fluids. This differs from the SSC’s previously released sepsis care guideline that recommends 30 mL/kg of IV crystalloid fluid, which is not intended for COVID-19 cases.
“In the absence of data demonstrating a benefit of the use of liberal fluid strategies in critically ill patients with sepsis or ARDS, and considering that the majority of COVID-19 patients in the ICU develop ARDS, we suggest an initial conservative approach to fluid resuscitation in patients with COVID-19 and shock,” the guidelines say.
Clinicians may worry that taking this approach to fluid administration in these patients might lead to adverse affects, including acute kidney injury, but research shows more positive outcomes when limiting IV fluid therapy in ARDS patients. This approach is supported by a randomized study published in the New England Journal of Medicine,3 which found that a conservative strategy of fluid management improved lung function and shortened the duration of mechanical ventilation and intensive care without increasing nonpulmonary-organ failures.
The researchers compared a conservative and a liberal strategy of fluid management for seven days in 1,000 patients with acute lung injury. In this sample there was no significant difference in the outcome of 60-day mortality. The patients who were given a conservative amount of fluid spent fewer days on mechanical ventilation and fewer days in the ICU.
“This approach is beneficial, not from a survival perspective, but beneficial from a perspective of getting them free from the ventilator sooner,” said Choudhary. “…If you kept patients drier, not only did they not require extra renal replacement therapy, but you were also able to get them off the ventilator, on average, about three days sooner than patients who had extra fluid on board.”
Sepsis kills millions worldwide every year. An immune system response to a bacterial infection of the blood, it preys on those who are already the most vulnerable in our society, including the elderly, and is a condition that is all too familiar to those who work in intensive care units.
According to data from the US Centers for Disease Control and Prevention (CDC), 1-in-3 patients who die in hospitals have sepsis, often a result of multiple organ failure. However, these numbers could be drastically higher since sepsis-related fatalities may be attributed to the primary source of an infection, such as pneumonia.4
The body’s response to the novel coronavirus and its response to sepsis can have similar presentations, so critical care providers should continuously monitor their coronavirus patients for signs of co-occurring bacterial infections.
While it may not be a primary feature in COVID-19, sepsis is always something critical care providers are concerned about, said Philippe Bauer, MD, PhD, a pulmonologist and critical care specialist at the Mayo Clinic in Minnesota. Many of the steps clinicians take to monitor their sepsis patients will remain the same during the pandemic, Bauer said. Common metrics of tracking a patient’s stability, including blood oxygenation, metabolic function, and others can inform care in sepsis patients whether or not they have the virus.
Additionally, irrespective of whether a patient has a bacterial infection or COVID-19, they may experience shortness of breath, fever, tachycardia or low blood pressure. When evaluating patients, balance both of these diagnoses in your mind, Choudhary said. “It is very important to determine what is driving the clinical deterioration. Is it COVID-19 or is it a bacterial infection?”
If there is any suspicion of sepsis, start the patient on antibiotics to take care of any underlying bacterial infection that may or may not manifest. And don’t forget to take all the necessary precautions to protect yourself and other healthcare workers, including wearing the appropriate personal protective equipment.
For healthcare workers performing aerosol-generating procedures like tracheal intubation or non-invasive positive pressure ventilation (NIPPV) on patients with COVID-19 in the ICU, the SSC recommends using fitted respirator masks, as opposed to surgical masks. The SSC also suggests performing aerosol-generating procedures on patients with COVID-19 in negative pressure rooms.
Negative pressure rooms are engineered to create negative air pressure in the patient’s room to keep the pathogen inside and avoid its diffusion to other hospital facilities and patients. This helps protect healthcare workers and patients in hospital settings by avoiding the accidental release of pathogens, according to the SSC. The World Health Organization recommends that the use of negative pressure rooms for certain COVID-19 patients with a minimum of 12 air changes per hour or at least 160 L/second/patient in facilities with natural ventilation.
Over the first 24 to 72 hours after a patient is admitted to the emergency room, lab work can guide clinicians to appropriate care. Clinicians should regularly take blood cultures and monitor severe COVID-19 patients for high levels of lactic acid. Providers can also check the patient’s procalcitonin levels, which is a marker of an underlying bacterial infection. If an underlying bacterial infection is detected, monitoring procalcitonin levels can help indicate when to decrease antibiotics.
In a typical year, at least 1.7 million adults in America develop sepsis and nearly 270,000 Americans die as a result of the infection, according to the CDC. New research released in January showed that twice as many people than previously believed are dying of sepsis worldwide. The study, led by researchers at the University of Pittsburgh and University of Washington schools of medicine and published in The Lancet, found that sepsis accounted for 1-in-5 deaths worldwide.5
“We are alarmed to find sepsis deaths are much higher than previously estimated, especially as the condition is both preventable and treatable,” senior author Mohsen Naghavi, MD, PhD, MPH, professor of health metrics sciences at IHME at the University of Washington School of Medicine, said in a statement.
Since severe cases of COVID-19 may make the body more susceptible to sepsis, these numbers could go up if the coronavirus continues to spread. It remains unknown just how many of COVID-19 patients succumb to, or even develop, sepsis. One small study from China, published in The Lancet, found sepsis was a common complication in patients who had the poorest outcomes from COVID-19 infection. The authors wrote that further research is needed to investigate the pathogenesis of sepsis in COVID-19. “In the current climate of dealing with the pandemic, I think it will take us a few weeks, if not a few months, to go back and evaluate our data,” said Choudhary.
“…We also haven’t seen a demographic variability in patients with COVID-19 and developing sepsis. Again, it might be too soon. This is going to take some time to look back and get a much better sense of the manifestations of sepsis in COVID-19.”
Lisa Spear is associate editor of RT Magazine. For more information, contact editor@RTmagazine.com.
- Murthy S, et al. Care for Critically Ill Patients With COVID-19. JAMA. 2020;323(15):1499-1500. Accessed at https://jamanetwork.com/journals/jama/article-abstract/2762996
- Alhazzani W, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med (2020). Accessed at https://link.springer.com/article/10.1007/s00134-020-06022-5
- The National Heart, Lung, and Blood Institute ARDS Clinical Trials Network, et al. Comparison of Two Fluid-Management Strategies in Acute Lung Injury. NEJM. Accessed at https://www.nejm.org/doi/full/10.1056/NEJMoa062200#article_Abstract
- Rudd KE, et al. The global burden of sepsis: barriers and potential solutions. Crit Care 22, 232 (2018). Accessed at https://doi.org/10.1186/s13054-018-2157-z
- Rudd K, et al. Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study. The Lancet (2020). Accessed at https://doi.org/10.1016/S0140-6736(19)32989-7
- Zhou F, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet (2020). Accessed at https://doi.org/10.1016/S0140-6736(20)30566-3