Reviewing the literature on Sepsis and COVID-19
As scientists work overtime to study the disease and release information, many publications bypass the peer review process. Other scientists review the scientific effort to ensure it was done correctly and with appropriate rigor, to release them quickly. While we're getting information quickly, it does mean that the sciences' perfection may not yet there. That being said, here are few studies we've reviewed:
This study, a meta-analysis of other previously public studies, summarizes how COVID-19 clinically presents. COVID-19 patients admitted to the hospital present with fever, shortness of breath, bilateral pneumonia, tachycardia, and tachypnea – they develop Sepsis – they meet the criteria based on SIRS and often qSOFA. Still, they behave differently than most sepsis patients.
This study reviewed 113 patients that died from COVID-19. Of the 113, all 113 had Sepsis, but only 41% developed septic shock. The primary cause of death in this group was ARDS – 100% of patients in the study had ARDS. The study's conclusion is, "Severe acute respiratory syndrome coronavirus 2 infections can cause both pulmonary and systemic inflammation, leading to multi-organ dysfunction in patients at high risk."
So in this group of patients, this is different than a lot of other patients that die from Sepsis. The main causes of death are massive alveolar damage and progressive respiratory failure.
Now, let's review the two main hospitalized groups with COVID-19 + Sepsis: (1) patients admitted for observations and (2) critically ill patients.
1. Admitted for observation
The leading cause of death for this group will be respiratory failure, and it should be the primary focus for clinicians. Early studies from Italy indicate that a crucial phase of the disease is a decrease in oxygen saturation (<93%); there may be a rapid deterioration of respiratory functions. Non-invasive ventilation therapy has success, and some patients will improve, but others will collapse and require rapid intubation and mechanical ventilation. Patients can show rapid improvement, which may prompt a clinician to wean them off ventilation, but they see a new worsening of respiratory conditions after 24-48 hours. Thus, it is suggested to have mechanical ventilation for 1-2 weeks. Their message for those treating COVID-19 patients is to follow clinical performance focusing on the value of saturimetry rather than typical P/F values suggestive of ARDS.
Another study of 249 patients hospitalized with COVID-19 compared the patients under hospital observation that ended up in the ICU versus those that did not end up in the ICU. They reviewed a variety of factors, including lactate. Initial lactate testing was normal, and abnormal lactate was not associated with ICU admission.
So what can we gather from these studies?
- The primary observations of value are respiratory rate, O2 saturation, and physical examination. Even though these patients may have Sepsis and evidence of organ dysfunction, it is primarily their respiratory status that needs to be observed.
- When their O2 level drops below 93%, the monitoring frequency of VS checks and physical exam checks should be increased.
- Do not over-rely on other measures of organ dysfunction. For this reason, it is not recommended to conduct lactate screening. Lactate testing may lead you to a false sense of security.
The leading cause of death in this group will be respiratory failure, so it is key to pay attention to respiratory status.
2. Critically Ill Surviving Sepsis Campaign Guidelines
The Surviving Sepsis Campaign released recent guidelines on how to manage critically ill patients with COVID-19. Here we'll focus on the recommendations that differ from recommendations for patients that Sepsis is not from COVID-19.
- For the acute resuscitation of adults with COVID-19 and shock, it is suggested to use a conservative fluid strategy. Fluids are problematic for this population because of the great difficulty oxygenating them even after they're intubated.
- They only suggest antibiotics once patients are intubated. As of today, we don't have an effective antimicrobial strategy.
Literature is Continually Evolving - Sepsis and COVID-19 Resources
Science is rapidly changing, and we expect these practice guidelines to change as we discover more. Researchers are still investigating the relationship between COVID-19 and sepsis, and appropriate care for sepsis in patients with COVID-19 remains vital.