Reply: Severe Sepsis: Stay and Play or Scoop and Run?

From the Authors:

In their response to our article (1), Ligtenberg and colleagues suggest that time-sensitive conditions, such as severe sepsis, may benefit from systems of care similar to trauma or ischemic stroke, and that both future study and implementation of such systems will rely on accurate diagnosis of severe sepsis at the frontier of critical care—during the prehospital phase.

We agree wholeheartedly. Of course, the leveraging of the prehospital period to improve care relies in part on patient identification and stratification, a challenging task given the difficulty in recognizing and diagnosing sepsis. One approach is to integrate a quick history and physical with physiologic or serum biomarkers that can be deployed in prehospital care. Such biomarkers would require adequate evaluation, including assessment of their feasibility and their incremental value over existing approaches.

Ligtenberg and colleagues also suggest a suite of treatments that might be more effectively deployed if commenced in the prehospital setting. We certainly endorse evaluation of such interventions, again with attention to both feasibility and incremental value over current care. We would further add that, in addition to specific prehospital interventions, another key advantage of early identification and stratification is to determine where the patient should be taken. Many strategies for optimal early care of severe sepsis and septic shock may be better implemented at select centers of excellence. Yet, such centers make no sense if there is no mechanism by which to preferentially route patients.

Taken together, the many thousands of avoidable deaths from severe sepsis demand we explore innovative approaches to treatment. Should we solve the riddle of early and rapid diagnosis, many promising interventions at the patient and system level await study during prehospital care.