Fighting Deadly Infections
Interviewed by Rasa Fournier
Wednesday - October 19, 2011
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Dr. Sam Evans
Intensivist at the Queen’s Medical Center
Where did you receive your schooling and training?
I did my Bachelor of Science at UC Santa Barbara in biopsychology and graduated in 1993. Then I went to American University of the Caribbean in the British West Indies and received a Master of Science in 1995. After that I went to Baltimore, Md., did two more years of clinical studies and received my MD in 1997. I came to the University of Hawaii in 1997 as an intern and then as a resident in the internal medicine residency program. I stayed another year as a chief resident at Queen’s Medical Center. Then I did my fellowship in pulmonary and critical care at UC Davis for three more years and came back home in 2004.
What is your specialty?
Pulmonary and critical care medicine. I am an intensivist, which is a critical care specialist and I’m also a pulmonologist a lung doctor.
What is sepsis?
Sepsis is a life-threatening disorder where the body has an infection and the body’s response to that infection is an overwhelming inflammatory cascade. Your organs become at risk for failure, your blood pressure drops and your mental status may become altered. Your lungs and kidneys can fail. It’s a whole-body, systemwide response and is life threatening.
Is the infection in the blood stream?
You may have the infection in the blood stream. Or you can have a simple infection elsewhere such as in the skin on your leg that could lead to this response.
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What causes sepsis?
Usually it’s an infection such as a bacteria, fungus or virus. It doesn’t always have to be an infection. You can have this systemic inflammatory response syndrome (SIRS) from another disorder such as pancreatitis, where you have some kind of inflammatory stimulus trigger the immune system to go off and affect the entire body.
How do you know it’s sepsis versus a milder infection?
We have basic criteria that we use to diagnose sepsis and severe sepsis. Most patients will have symptoms: fever, chills, sweating, altered mental status, trouble breathing, or they may tell you they’ve been coughing a lot and they’re bringing up green or bloody phlegm, which is a sign of pneumonia. You can do testing like Xrays, CAT scans and blood work. Blood work will usually show an elevated white blood cell count or acidemia, where the blood PH is unusually low, often from an elevated lactic acid level. When we see an elevated lactic acid level we get very concerned that the organs aren’t being perfused. Lactic acid levels will rise if there is a problem with organ perfusion.
What is the correlation between lactic acid levels and perfusion, and why is it important?
Lactate is produced when there is a deficit in organ perfusion or blood supply and oxygenation. If organs such as the kidneys or liver are not receiving enough blood and oxygen, your lactate levels start to rise.
The lactate level is prognostic: If the lactate is very high, your chances of multiorgan failure and ultimately survival are less.
Who is susceptible to sepsis?
Everybody is susceptible but some are more prone to sepsis than others patients with immunocompromise, such as those with cancer who are on chemotherapy or those with rheumatologic conditions or organ transplants requiring steroids. Our diabetic population with end stage renal disease also are highly susceptible.
How do you treat it?
The mainstay is to insert medical devices called central venous catheters and arterial catheters, and we’ll use those devices to measure how much fluid is in the body, what the exact blood pressure is, what the oxygen delivery is to the tissues, and then we’ll use medications to raise the blood pressure or increase the oxygen supply to the organs. Sometimes we’ll use transfusions, certainly antibiotics, occasionally antifungals and sometimes anti-inflammatory agents.
How prevalent is sepsis in Hawaii?
We have a pretty high prevalence and it’s mostly, I believe, because our population is older, and also because we have a lot of diabetic patients and a lot of kidney disease. They’re very prone to infection and sepsis.
What are the mortality statistics?
The average mortality nationwide is probably 3040 percent. That rate rises if you’re older. Sepsis doesn’t get enough attention in the media, yet we see a ton of it, especially here in Hawaii in our Intensive Care Units. I deal with it every day; sepsis takes a lot of lives.
Can you talk about the American College of Chest Physicians’ (ACCP) annual CHEST meeting coming up in Honolulu Oct. 2226 (accpmeeting.org)?
It’s pretty exciting for Hawaii to get a major national conference like this. The ACCP is a worldwide scholarly community of pulmonary and critical care physicians, but also respiratory therapists and other ancillary professionals who practice lung and critical care medicine. As many as 7,000 worldwide leaders, professors and researchers in pulmonary and critical care medicine may attend. We have many worldrenowned speakers coming and 10-15 distinguished local specialists who are speaking.
What is your role?
I am the governor of the ACCP Hawaii chapter. Each state and region in the U.S. and Canada has a governor representing its constituents, which are all the pulmonary critical care doctors for their region. I sat on the planning committee for the meeting, and also helped with planning some of the educational and outreach sessions. There’s a lot of community outreach that goes along with this meeting - outreach to schools on not to smoke, outreaches to shelters on smoking cessation. The new ACCP Centers of Excellence program will spotlight centers with innovative solutions on how we can all better deliver care to our nation’s critically ill patients.
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