Is Fever the New Hotness in Sepsis?

Background: With the introduction of sepsis 3.0, came the quick sepsis related organ failure assessment (qSOFA) score. The purpose of this score is supposed to be a bedside tool to help predict which patients are at the greatest risk of poor outcomes.  There are three components to this score: Low systolic blood pressure (≤100mmHg), high respiratory rate (22 breaths per minute), and altered mental status (Glasgow coma scale <15).  Interestingly, nowhere in this score is fever.

What They Did:

  • Observational cohort study from the Swedish national quality register for sepsis
  • 30 ICU’s in Sweden
  • Divided patients into four categories
    • <37 C
    • 37 – 38.29 C
    • 3 – 39.5 C
    • ≥39.5 C

Outcomes:

  • Primary: In-hospital Mortality

Inclusion:

  • Enrolled in the Swedish National Quality Sepsis Register (NQSR)
  • >17 years of age
  • Admitted to the ICU with a diagnosis of severe sepsis or septic shock within 24 hours of arrival to the ED

Results:

  • 2,225 adults admitted to the ICU within 24 hours of hospital arrival with a diagnosis of severe sepsis or septic shock
  • Overall mortality: 25%

CRITICAL RESULTS:

  • In-hospital mortality decreased >5% for every increase by °C from 35°C up to >41°C

  • Of the clinical signs, body temperature had the highest predictive value for in-hospital mortality followed by respiratory rate >heart rate > O2 saturation > systolic blood pressure
  • Difference persisted despite variance in compliance with sepsis guidelines reflecting a possible lower quality of care.

Strengths:

  • Multicenter study
  • Evaluated the relationship between body temperature and in-hospital mortality stratified by age, lactate level, bacterial etiology, or sepsis bundle achievement
  • 1st study to investigate the prognostic significance of fever upon ED arrival in patients subsequently admitted to the ICU for sepsis
  • Lack of severity scores (i.e. SOFA) not allowing to adjust for disease severity
  • Information about antipyretics or immune-modifying drugs prior to arrival to ED were also lacking
  • Analyses were adjusted for quality of care, but it is possible that other differences in treatment were not captured in the database
  • The Swedish NQSR does not capture all eligible patients in Sweden and only comprises hospitals where infectious disease physicians are present

Limitations:

  • Lack of a uniform way to measure temperature (TM, Oral, Rectal) could have resulted in measurement errors
  • A large proportion of patients in this study had missing data (Only 58% of patients had complete information on all variables)
  • Almost 10% of the population did not have temperature documented
  • Missing values were more prevalent in patients without fever (i.e. lower quality of care)

Discussion:

  • Quality of care, measured by sepsis bundle achievement improved with rising temperatures. Treatment limitations were almost twice as common in the lowest compared with the highest temperature category.  The authors of this paper however adjusted for sepsis bundle achievement and still found a statistically significant difference in mortality associated with temperature (i.e. better care alone did not explain fever-mortality association)
  • At this time, it is unclear if treating fever with antipyretic medications is beneficial or harmful in critically ill patients. The HEAT Trial, which included 700 ICU patients with probable infection randomized patients to IV acetaminophen or placebo and showed no differences in ICU-free days or 30d mortality.
  • Currently, researcher Paul Young (The lead author of the HEAT Trial) has just initiated the Randomised Evaluation of Aggressive Control of Temp vs. ORdinary temp mngmt (REACTOR) Trial. In the REACTOR trial patients will be randomized to active prophylaxis and treatment of fever vs standard care. #REACTORtrial

Author Conclusion: “Contrary to common perceptions and current guidelines for care of critically ill septic patients, increased body temperature in the emergency department was strongly associated with lower mortality and shorter hospital stays in patients with severe sepsis or septic shock subsequently admitted to the ICU.” 

Clinical Take Home Point: It is the patients with severe sepsis and septic shock who DO NOT have fever, that we must pay more attention to.  Currently, the qSOFA score does not use temperature as a predictor of mortality and in this study, temperature was the vital sign that had the best prediction of in-hospital mortality. 

References:

  1. Sunden-Cullberg, J et al. Fever in the Emergency Department Predicts Survival of Patients with Severe Sepsis and Septic Shock Admitted to the ICU. Crit Care Med 2017. 45: 591 – 99. PMID: 28141683

For More Thoughts on This Topic Checkout:

Post Peer Reviewed By: Matt Astin (Twitter: @mastinmd)

The post Is Fever the New Hotness in Sepsis? appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.

EM Mindset: A Woman in the Emergency Department – by a Feminist

Author: Hilary E. Fairbrother, MD, MPH, FACEP (Assistant Professor and Director of Undergraduate Medical Education, Dept of EM, NYU School of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Sitting down to write this, I cursed myself for volunteering in the first place. Yes, I am a woman, yes I am a feminist, yes I am a physician, yes I am in academic leadership for a well-known emergency department… The yes’s are many, but what do I have to say that is so meaningful or useful that www.emdocs.net would want to publish it in EM Mindset series?

I write today because I wanted to share some of my perspective on how to 1) be happy as a woman in EM and 2) how to “make it” as a woman in EM. I know that I have achieved #1.  I am definitely a work in progress when it comes to #2, but aren’t we all?  I hope that my experiences will help guide others to achieving their personal and professional goals. It is my experience that in achieving goal #1, goal #2 is inevitable. “Making it” is different for each woman, and I encourage you to define it for yourself, as you will know what to aim for.

So the answer to the million dollar question: how to be happy as a woman in EM?  Or in medicine in general.

When I speak to women in EM about career and life happiness, I come across multiple themes and my favorites are: the struggle of finding work/life balance, the inequalities facing women in EM, and the rocky pathway to leadership opportunities.

Work/Life Balance

How many times will we discuss the difficulties of being a mother/caregiver or simply having a life, and being a successful EM physician? Whatever this means to the individual, this is the core of most personal and professional satisfaction. To some this means being able to successfully raise a family as both a present and loving mother/spouse and to have a successful career. To others this means having the time to take care of family members or other loved ones without losing a leadership opportunity. To still others this is the ability to sustain and enjoy meaningful outside interests and passions while still being able to succeed as a professional. Whatever the struggle, there is a balance that we individually find and define as we progress through our clinical careers. If there is no balance, happiness and career aspirations suffer for it.

For women, this balance is inherently more difficult to both find and then maintain than it is for men. If a woman is single, it is difficult to find a partner while working a clinical schedule full of nights/weekends/holidays that does not match the majority of others’ work schedules. It is tough in residency and often just as tough as an attending to find the time to nurture a relationship. And let’s be honest, the expectations for a woman in a relationship are classically very different than for a man. How many of my friends have proudly bragged about their successful male partners who have demanding and prestigious jobs, often taking them away from the social obligations of a couple? All of my relationships during residency ended with my partners citing some version of “you don’t have the time to make our relationship a priority.” I continue to struggle with this balance in my marriage.  Bless my husband for being the understanding, patient, and loving man that he is. I miss a lot of holidays and dinner parties. I know that all of you do too.

Conversely it seemed that the more unavailable my male colleagues were, the more attractive they were as partners. This never became clearer to me than during medical school and residency when my male colleagues would wear their scrubs to the gym. (First of all, eww, gross… followed by a full eye roll). I asked a male colleague in medical school why he did this, and he told me that it was a great way to pick up women. That women assumed that he was a doctor when they saw the scrubs, and that was a huge turn on. This tactic doesn’t work for women. Naively in the first year of graduate school, I used to proudly tell men that I was a medical student when asked what I did. And then I used to watch them run away. My girlfriends and I quickly realized that we got A LOT more lasting attention by telling men that we were airline stewardesses. Why isn’t the woman in medicine more attractive? Obviously this indicated that I was smart, driven, and successful.  Who wouldn’t want to be with a woman like that? The reality is that these are not the characteristics most people in their 20’s seemed to look for in a partner.

So how did I find my partner? Well first of all, I didn’t do it in my 20’s, and I didn’t do it in residency. So for all of you lady doctors out there in residency feeling very single… I recommend that you just invest in yourself right now, and then once you are an attending, find a partner. Second, I needed a partner that not only loved me for the strong, independent, and intelligent human that I am, but who was also seeking this out before meeting me, and that is difficult. Difficult… but so worth it. Female physicians are extraordinary partners, but we need someone who is going to hold up the slack when we don’t make it to the birthday party or dance recital. Someone who will order food/make dinner for us rather than vice versa. The reality is that we are still likely to do more than 50% of the family obligations, etc., but we need someone who will dig in and help out on a consistent basis.

So whatever you do or have outside of work in the ED 1) it is super important, and you need to grow it and take care of it because work is not everything, and 2) look for partnerships that are truly reciprocal in nature, don’t settle, and be ready to be a consistent defender of the “stay at home parent” or the partner who has the more flexible job. For female physicians with male partners, this flies in the face of generations of social stigma. Many of you will be the breadwinner for your family and support-team husbands of any fashion are often disrespected by men and women alike.

The inequalities facing women in EM

When I name these I get really angry. As a woman I earn less than my male equivalent. I am less likely to get promoted as quickly in academic and administrative leadership. I am less likely to be a medical director, program director, chair, vice president… the list is never ending.1 This flying in the face of the fact that since 2012, almost half of all residents are female.2 Progress has been made, but women still lag behind for a multitude of reasons. I actively work to decrease this trend by insisting on equal pay, and by only working in institutions that actively promote leadership of both men and women equally. I would recommend this to you as a starting point as well.

One of the most constructive things a department can do to help all employees is to offer supportive maternal and parental leave policy. A policy that allows for both women and men to take time off when a child is born demonstrates a commitment to families and work/life balance for all staff, regardless of gender. As our families become more diverse, policies such as this become even more important in creating equality and opportunity for all members of a department.  A maternal leave policy with payment and real time off allows for women to physically have a child without being punished professionally.

Currently, imagine a woman in the running for a leadership position or interviewing for a new job. During her interviews, she states that she is actively trying to start a family with her partner. It is common and almost expected that this information can be detrimental to the female candidate. Women hide the fact that they are trying to or actually in the process of starting a family all of the time in order to avoid or delay this stigma and its associated professional consequences. It is illegal to use pregnancy status as a factor for employment, but who wants to promote or hire someone who is then going to be “absent” in a few months? Meanwhile a man in the exact same position is not looked at negatively, and it is rare that this kind of information negatively affects a promotion or new job. If we promote a culture where all parents take time off after the birth of a child, then we begin to create a new environment in which all employees can prioritize their family.

The same goes for breaks during shifts. If there are established “physician breaks” during the otherwise chaotic ED shift, this allows all physicians to have a respite, and if a woman wanted to pump, she could then do so without asking for a special favor from her colleagues. Imagine the simple things that can be done to make it possible for new mothers to come back to work.

Finally, the role of the woman in her family does not end when a child is born or stops breast-feeding. Studies show us that women often carry a much larger than 50% of the caregiving/household running burden. While this may have worked in the 1950’s, it does not work for the modern female physician, and it continues to skew the playing field.3 Without recognition and attempted mitigation of this, female physicians are continually disadvantaged. In house day-care facilities, flexible scheduling, and easily accessed, non-punitive sick call are all progressive programs that allow for female physicians to balance their work and home commitments.

The rocky pathway to leadership opportunities

“The Answer to the Great Question… Of Life, the Universe and Everything… Is… Forty-two, said Deep Thought, with infinite majesty and calm. I think the problem, to be quite honest with you, is that you’ve never actually known what the question is.”
– Douglas Adams, The Hitchhiker’s Guide to the Galaxy

There is no silver bullet for this. I wish that I knew the answer, but if I did, I would likely have a best-selling book, and you would be hearing my spiel on Oprah rather than reading it on emdocs.net.  As ALANON would tell us, no one can give advice and we must acknowledge that “advice” is simply one person telling you their personal experience and successes. So here is my story.

I have followed my pathway to academic and organizational leadership a few different ways: 1) by being in the right place at the right time, 2) having diligence in my pursuit of leadership opportunities, and 3) finding mentors who could help me realize my dreams.

I hate it when people tell me that part of success is “being in the right place at the right time.” This is the equivalent to my mother saying that “I would just know” when I fell in love with the man I would marry. Unfortunately she, and they, are right. Being aware of your surroundings, getting as involved as possible in leadership opportunities, volunteering for projects that give you face time with leadership… all of these put you “in the right place.” Then when the right time hits, you need to notice it and be ready to take advantage. Women, be mindful that we are less likely to be invited to the social aspects of leadership development within a department (golf, paint ball, dinners, etc.) for a multitude of reasons. Some as innocent as learned behavior, some as ingrained as implicit bias, and some in the very social fashion that dictates the way men and women interact with each other. I remember as a young attending, my research mentor asked me to go kayaking with his family. I was young and single and he was married. There were more than a few eyebrows lifted about this kind of social interaction between colleagues. Those eyebrows would have stayed firmly lowered if I were a man, or if my gender matched that of my mentor.

To be consistently “in the right place,” you need to be diligent. I volunteered for the credentials committee, I mentored the residents, and I did a lot of work without reimbursement. I recommend that if possible, you plan to have this phase of your professional life in your first 5 years of practice. This is an unsustainable model and needs to translate into real leadership opportunities relatively quickly for it to work.  A.k.a. there needs to be a light at the end of the tunnel. Giant, huge, world shaking caveat… this is likely to happen during the years you are trying to have a child or when your children are quite young. I have not had the fortune of starting a family yet, so I have no great words of wisdom to the brave women that do all of what I did, with dependents.

What worked for me: make a contract with yourself to be diligent both in person and electronically at work. Make sure that you check your email at least once every day… yes, even on the weekends. In EM it can be difficult to have face time in the office, but make sure that you do it. Create a research project, and then when you are off on a Monday when you know the chair is working in the ED, make sure that that is the day when you go in to recruit patients. Make calendars and set deadlines, and then stick to those deadlines (the former is so much harder than the latter).

Finally, find mentors who will help you realize your dreams, and at least one of them needs to be a woman. One should be at your own institution, and one should be at an outside institution. One should be within 5-10 years of you on a similar path to where you would find yourself, and one should be at least 15-20 years out. In all, you hopefully find at least 4 mentors to fill these roles. Initiate contact with your mentors and then you are responsible for maintaining it. You need this way more than they do. So you are now the neighbor that ALWAYS has everyone over to your house for dinner. Life does not always reciprocate right away. Be diligent in both finding mentors and growing the relationships they offer. If in 6 months you can’t establish a relationship, graciously move on. You never want to beleaguer someone, and you never know in the future when a relationship might develop or become more important.

In conclusion, set yourself up for success, work hard, and be prepared to claw your way along the rocky path towards success. And do this all while nurturing your inner happiness and your work/life balance. No small feat. In her new book, “Why I Am Not a Feminist: A Feminist Manifesto,” Jennifer Crispin states that it is not enough for women to be accepted, or for individual women to break various glass ceilings. She postulates that being a feminist means reshaping society to make it better, to work on the systems that are in place that disenfranchise so many. In upending the system, we improve the world for all people, all genders, all race, etc. I like this vision. I hope to be a part of the revolution that leaves our profession better for all of us in it. I hope that the words that I wrote give some insight into my pathway, and I wish you luck!

 

References / Further Reading

  1. Westring AF, Speck RM, Sammel MD, et al. A culture conducive to women’s academic success: development of a measure. Acad Med 2012;87:1622-31.
  2. Welch JL, Jimenez HL, Walthall J, Allen SE. The women in emergency medicine mentoring program: an innovative approach to mentoring. J Grad Med Educ 2012;4:362-6.
  3. Sweeting H, Bhaskar A, Benzeval M, Popham F, Hunt K. Changing gender roles and attitudes and their implications for well-being around the new millennium. Soc Psychiatry Psychiatr Epidemiol 2014;49:791-809.

 

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