Wednesday, 22 July 2020

There, I've Said It: There is No Such Thing as Early Sepsis

Words are really important when it comes to communication.  Certainly, non-verbal communication counts for a lot, but words are very powerful ways of getting a message across.  We should be responsible about how we use them.

Diagnostic error in paediatrics is a very emotive issue.  If a clinician is wrong (always in retrospect) and a child is involved, it can be difficult to be objective.  No-one is right all the time though, and diagnoses  that are later apparent are sometimes easy to miss or even too elusive to reasonably detect in their early stages.

There is one important exception to this: sepsis, because there is no such thing as early sepsis.  This is really important because clinicians are both criticised and self-critical when a child has been diagnosed with sepsis and there was an earlier clinical contact.

You're going to want me to back this one up no doubt.  I haven't got any academic references, but I don't need them since it's a case of simple logic.  I'm going to Spock the heck ot of the idea of early sepsis.
Starting with the terminology that we are working with, there is already difficulty with the definition of sepsis.  Ever since the word ceased to mean infection in any form and came to be used for an effect of the infection, sepsis has remained impossible to decisively define.

The best definition that we have of sepsis "a life-threatening organ dysfunction caused by a dysregulated host response to infection," comes from the 2016 Third International Consensus Definitions for Sepsis and Septic Shock.  This definition is inherently subjective.  There is no formula and no test.  Note also the lack of attempt to define early sepsis at this event.
Why do I care if people use the term early sepsis?  Because words.

The term early sepsis implies that there is a clearly definable and therefore recognisable entity which has therefore earned its own name.  Implications are more dangerous than overt statements because they go unchallenged and become part of the profession's assumption that because a term is used, it must be valid.

The harm of the term being given validity is that (again with the logic) if it is a definable entity, whenever a child is diagnosed with sepsis and they had an earlier contact with a clinician, that person has failed to recognise early sepsis.  In reality, they will have seen a child with features that are attributable to sepsis.  These features are also commonly found in children who are febrile but not sepstic.

How damaging is that?  Apart from the medicolegal implications, the negative impact on a clinician's confidence and reputation is potentially huge.  Using the term early sepsis risks leaving a string of second victims in its wake.

Just to be clear, I am 100% behind the idea of recognising sepsis early.  Swapping those words around is all it takes to make them functional again.  I'm also all for anything that improves the early recognition and treatment of sepsis.  So far, no strategy has proved successful in achieving earlier diagnosis of sepsis in children.  Awareness, careful clinical assessment are key, as is treating every illness as dynamic.  That is why appropriate observation and good safety-netting are key interventions.  Whether the child is managed at home or in a health-care setting, no illness is 100% safe until the child is better.

The focus on sepsis over the past decade or so has improved the timely treatment when sepsis is diagnosed, but making that decision in the first place remains a complex business.  Here's a nice oversimplifiaction of that process:
The red and green patients are relatively easy in terms of decision making.  The amber patients represent a small uncertainty which needs to be managed expertly.  In the small proportion that later become red and therefore relatively easy to define as having sepsis, retrospectively calling the preceding illness "early sepsis" defies logic and undervalues the difficulties of managing a large volume of moderately unwell children.

Next time you hear someone talk about recognition of early sepsis, politely challenge them and explore whether they mean early recognition of sepsis.  Sepsis is a thing.  The point when an illness goes from not sepsis to sepsis is not sudden and therefore easily missed.  Implying that there is a clearly definable and recognisable thing called early sepsis risks the vilification of front line clinicians in both primary and secondary care.

Edward Snelson