Saturday, November 6, 2010

Survival from severe sepsis: The infection is cured but all is not well


Severe sepsis is a syndrome marked by a severe infection that results in the failure of at least one major organ system: For example, pneumonia complicated by kidney failure. It is the most common non-cardiac cause of critical illness and is associated with a high mortality rate.

But what happens to those who survive their hospitalization for severe sepsis? An important study published in JAMA from Iwashyna and colleagues provides answers and tells us all is not well. When the patient leaves the hospital, the infection may be cured, but the patient and family will need to contend with a host of major new functional and cognitive deficits.

Iwashyna examined disability and cognitive outcomes among 516 survivors of severe sepsis. These subjects were Medicare enrollees who were participants in the Health and Retirement Study. The average age of patients was 77 years.

When interviewed after discharge, most survivors were left with major new deficits in their ability to live independently. On average, they had 1.5 new functional limitations, compared to their pre-sepsis baseline. These were major limitations that would have a profound effect on the ability to live independently. Examples of problems included requiring the help of a caregiver to manage finances, take medicine, bathe, or get dressed. In addition, there was a spike in cognitive impairment among survivors with a tripling of the risk for moderate or severe cogntive impairment.

Infection and sepsis are usually viewed as acute problems, with the assumption that the patient returns to normal if you "fix" the infection. But this study shows that among older persons, all is hardly normal once the infection is better. Many elders will go home to a different life. They will be less able to take care of themselves, and will be more reliant on family members and caregivers.

It would be interesting to note how often these new needs of sepsis survivors were recognized and anticipated by their hospital providers. But clinical experience suggests that most hospitals are structured in a way that made post-discharge care plans woefully inadequate. It is likely that infectious disease care was outstanding, but care directed at helping patients and their families manage new functional and cognitive impairment was poor.

These findings accentuate the need for better models of hospital and post-discharge care for elders admitted with serious illness. This care model needs to recognize that most of these elders will have a marked and often permament increase in disability. Our models of care need to help these elders live well with this disability and provide assistance to family members and other caregivers that help the elder stay at home.

by: Ken Covinsky

7 comments:

Mary Poole said...

Also highlights the need for education to prevent sepsis eg early detection of UTI

Anonymous said...

This really has been on my mind lately. In the ER, we are basically mandated to invasively manage those who meet criteria for severe sepsis, putting in a central line, transducing CVP and getting them to ICU. I frequently wonder about which patients I should help "opt out" of this fairly extreme regimen. Hospice patients usually yes, but what about those with significant dementia, stage 4 cancer (not hospice), relatively short life expectancy etc. Is grandma really better off in the unit or can I resuscitate her and send her to the floor where she might get a bit of sleep and less sundowning? We know that not only sepsis, but also invasive monitoring and ICU stays, are all actually hazardous to your health. For whom isn't is worth it?

Laura said...

Sounds like this study could be used to make the argument for outpatient palliative care programs with a home and nursing home focus. We have so many patients and families that fit the discription from the article that would so benefit from palliative care. Hope i get to be apart of making that a reality!

Christopher Langston said...

I agree this was an important article - JAMA has had a lot of good stuff recently.

It was also really impressive to see two Beeson scholars collaborating.

It was an important demonstration of the need for outcomes research - particularly long-term outcomes in older adults.

The commentator really seemed to take the findings seriously. Now that we know about this effect, I hope people can begin to explore preventative or rehabilitative strategies. I know that Wes Ely is working on an ICU rehab - I don't know if it applies beyond delirium.

Marian Grant said...

I think this adds to the body of evidence that problems like sepsis, delirium, and loss of function after a hospitalization have long-term consequences that are not typically made clear to families while the patient is in the hospital. This data may help families make better decisions about life support and other aggressive care if they realize the longterm outcome is not going to be a full return to baseline function.

Anonymous said...

Yes, I totally agreed with this website research. Most medical healthcare professionals only fixed the infection sepsis and after recovery, discharged the patient. Then left the family to care and worry for the recovered family member, to cope with reduced IADL and ADL. When approached the follow up doctors, they said patient is elderly so is like this after a sepsis. I could not agree to that explanation. I still trying to get help for my father after 1 year and he is not improving but has higher risk of dementia now. Doctor insisted is depression but we do not agree as he does not fully show all symptoms of depression. Please advise how to find my way to get help for my dad, geriatric doctor or psychartric doc?

Flona Hildenbrand said...

We have not reached the discharge point yet but I agree that early diagnosis is paramount when dealing with sepsis. My husband and I fought a new family doctor for seven months that all was not well with him. I watched his health deteriorate rapidly while she sat by telling him it was his pain meds that were causing his problems. If he stopped taking the pain meds he takes for chronic neuropathic pain in his legs from cellulitis and learned to live with the pain all would be well. By the time he was admitted to hospital for the second time in a month he was in severe septic failure and renal failure. They didn't give me a lot of hope he would survive the night. After surgery they discovered he had a perforated bowel that we know had to have been leaking into his system for some time. Unfortunately his doctor wasn't interested in sending him for testing to find out what was wrong and it almost cost him his life. He has been six months in hospital at this point with no sign of being able to come home anytime soon. To complicate matters he has not walked in six months and has critical care myopathy in his feet and legs. I can't help but wonder what is in store for our future. His mind seems to be clearing and he remembers most of what went on all but his stay in critical care and the first few weeks after. I consider it a blessing he has his memory restored at this point. That being said however his concentration is somewhat compromised. He was an avid reader before this happened and is finding he doesn't have the ability right now to focus on a story. I hope it all comes back for him. This has been a nightmare for our family but most especially for him.