Report details the deadly toll of sepsis cases in hospitals

MEDICAL MATTERS

Medicine & Science

October 27, 2003|By Judy Foreman | Judy Foreman,SPECIAL TO THE SUN

IT WAS the second semester of freshman year at Salve Regina University in Newport, R.I., and John Kach, then 18, and a member of the basketball team, was in great shape.

Until one night, when he developed a fever of 104 to 105 Fahrenheit and flu-like symptoms. His girlfriend wanted to take him to the hospital, but he said no.

After all, Kach was a guy and, as he puts it, "a guy's not going to go to the hospital for a high fever." But by 5 a.m., he was fading in and out of consciousness. By the time they got to the hospital, he could barely breathe. The pain in his back was excruciating as his kidneys shut down. His white blood counts were sky high - like his fever, a sign of rampant infection.

Kach had bacterial meningitis, and it was rapidly turning into severe sepsis, a reaction to infection that causes runaway inflammation, blood clots and organ damage in 750,000 Americans every year, killing an estimated 215,000.

Kach barely survived. His circulation got so poor he developed gangrene. Doctors had to amputate his right leg below the knee, part of his left foot and all his fingers. (This summer, because of nerve damage, he had the other leg amputated below the knee.) He needed dialysis because of his failing kidneys. His heart was pumping so hard his bed shook.

According to a recent report in the Journal of the American Medical Association, sepsis after surgery is the most common medical "injury" in hospitalized patients. Of all medical "errors," sepsis is associated with the greatest increases in length of stay, costs (on average, $57,727) and in-hospital deaths.

Indeed, sepsis is the second leading cause of death in noncoronary intensive care units and the 10th leading cause of death overall in the United States, according to a New England Journal of Medicine report in April. Although the death rate is falling, sepsis still kills 20 percent to 50 percent of those who get it.

Septic problems can begin with infection anywhere in the body. As soon as the immune system detects infection, it starts pumping out white blood cells, which secrete chemicals called cytokines. Some of these keep the aggressive immune response going. Others do the opposite - dampen the response.

In the early stages, the right antibiotic can often halt sepsis. But often, the inflammatory response spirals out of control, revving up the whole body - raising fever, increasing white blood cells, respiration, cardiac output and heart rate.

This "overexuberant" response soon begins destroying tissues, notes Dr. Mitchell Levy, director of the medical intensive care unit at Rhode Island Hospital, a teaching hospital of Brown University.

In the lungs, cytokines trigger chemicals that damage delicate air sacs. They make blood vessels leaky, allowing fluid to leak into the lungs, kidneys and other tissues. As blood vessels dilate and leak, blood pressure drops, forcing the heart to beat faster.

Thanks to recent studies, doctors now have a much more precise idea of how to use ventilators so as not to further destroy lung tissue. They can reduce death by another 15 percent to 20 percent by giving steroids (which dampen immune response) at lower doses for longer periods. And they are armed with better antibiotics, too.

But perhaps the most excitement - and controversy - centers on Lilly's anti-sepsis drug, Xigris (drotrecogin). It can reduce the death rate by 6 percent, though it can also cause abnormal bleeding.

But Xigris is so expensive - nearly $7,000 for a several-day treatment - that some hospitals now ration it. That means many septic patients still die because they don't get state-of-the-art care. Doctors probably use up-to-date sepsis therapy only 10 percent to 40 percent of the time, says Dr. Peter Provonost, associate professor at Johns Hopkins Medical Institutions.

Judy Foreman is a lecturer on medicine at Harvard Medical School.

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