Investigating sepsis with biomarkers
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h254 (Published 28 January 2015) Cite this as: BMJ 2015;350:h254
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Sirs,
I read with interest the article by McLean et al, regarding the investigation of sepsis with biomarkers. However, I was interested to see the description of the urinary dipstick "showing the presence of leucocyte and nitrate".
The use of the term "nitrate positive" is widespread but incorrect. Many Gram negative bacteria convert nitrate to nitrite within urine and it is the nitrite that is detected by the reagents on the urine dipstick forming a red azo-dye giving the characteristic colour.
Yours sincerely
Andrew Chetwood
ST6 Urology
Competing interests: No competing interests
Dear Sir/Madam
I read the article by McLean et al (1) on "Investigating sepsis with biomarkers" with interest, especially with the role of lactate measurement. Whilst the authors note lactate itself is not a diagnostic tool it has a far more useful role in risk stratifying and prognosticating the septic and non-septic patient alike (2), and so has a recommendation to be measured on presentation in the Surviving Sepsis Guidelines (3) as well as the Sepsis Six bundles (4). It would have been worthwhile to have emphasised this in the article. Furthermore the use of point-of-care lactate machines in the emergency department, as well as in critical care, allows us access to and act upon lactate results within minutes without having to wait for formal laboratory results to return, a benefit over many of the other biomarkers mentioned.
I would also suggest that the authors note on Jones et. al's randomised control trial (5) not confirming the recommendation in using lactate clearance as a therapeutic endpoint misses an important message in the article. Jones et al. noted that lactate clearance as a measurement was non-inferior to ScvO2, which has important implications as many septic patients are not treated in critical care where ScvO2 can be measured (6). This allows us to easily measure response to treatment at ward level for this important group of patients. Serial lactate measurement can give clinicians an idea if treatment is effective and can be continued, or if modifications to management need to be considered. However further studies are needed to clarify what magnitude of lactate clearance is optimal (7).
I congratulate the authors on this excellent article, and I hope that my letter trying to emphasise the importance of lactate measurement in the acute management of sepsis stimulates some debate.
Yours Faithfully
Deepankar Datta
Emergency Medicine trainee, Emergency Medicine Research Group Edinburgh
MBChB BSc(Hons) MCEM
References
(1) McLean AS, Tang B, Huang SJ. Investigating sepsis with biomarkers, 2015, BMJ 2015;350:h254. doi: 10.1136/bmj.h254
(2) Datta D, Walker C, Gray AJ, Graham C. Arterial lactate levels in an emergency department are associated with mortality: a prospective observational cohort study. Emerg Med J 2015. doi:10.1136/emermed-2013-203541
(3) Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013;39:165-228.
(4) Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg Med J. 2011 Jun;28(6):507-12. doi: 10.1136/emj.2010.095067
(5) Jones AE, Shapiro NI, Trzeciak S, Arnold RC. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy—a randomized control trial. JAMA 2010;303:739-46.
(6) Gray AJ, Ward K, Lees F, Dewar C, Dickie S, McGuffie C. STAG steering committee, The epidemiology of adults with severe sepsis and septic shock in Scottish emergency departments., Emerg Med J. 30 (5) (2013) 397–401.
(7) Walker CA, Griffith DM, Gray AJ, et al. Early lactate clearance in septic patients with elevated lactate levels admitted from the emergency department to intensive care: time to aim higher? Journal of Critical Care 2013;28:832–7. doi:10.1016/j.jcrc.2013.02.004
Competing interests: No competing interests
Re: Investigating sepsis with biomarkers
I have read your interesting article. I just want to clarify the definition of SIRS. In your article, the SIRS was defined based on 4 criteria and not taking in account of hypothermia (temp <36degrees) and Leukopenia (WBC <4). Currently SIRS is defined as 2 or more of the below:
Temp >38.3°C or <36°C
Tachycardia >90 beats/ min
WBC >12 × 109/L or <4 × 109/L
RR >20
Altered mental state
Hyperglycaemia in the absence of diabetes
(http://www.survivingsepsis.org/SiteCollectionDocuments/Protocols-Sepsis-...)
Will it be possible to let me know the reasons for excluding the above?
Competing interests: No competing interests