Bone Lecture reviews significant advances in sepsis care

Emanuel Rivers, MD, MPH, FCCP, the 2020 presenter of the Roger C. Bone Memorial Lecture in Critical Care paid special tribute to the lecture’s namesake.

Emanuel Rivers, MD, MPH, FCCP
Emanuel Rivers, MD, MPH, FCCP

Dr. Rivers, from Henry Ford Hospital, who experienced firsthand the work done by Dr. Bone in sepsis care, talked about how things have changed for the better thanks to the foundation provided by Dr. Bone and others. The lecture, funded by the CHEST Foundation, featured a question-and-answer session moderated by Sai Haranath, MBBS, MPH, FCCP, and is still available for viewing by CHEST 2020 attendees.

The Bone Lecture recognizes career contributions to the field of critical care medicine. During the session introduction, CHEST President Steven Simpson, MD, FCCP, called Dr. Rivers one of the “giants” and “one of my personal heroes” in sepsis care.

Dr. Rivers has been a leader in sepsis care and research for two decades. His 2001 paper, “Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock,” was a landmark moment for expanding care throughout the hospital that has significantly improved outcomes for patients with sepsis.

During the lecture, Dr. Rivers gave plaudits to many mentors who shaped his career in sepsis and critical care but gave special emphasis to what he learned from Dr. Bone. The title of his lecture, “To SIRS with Love: Dr. Roger Bone’s Continued Influence on Early Sepsis Care,” was a homage to the similarities of Dr. Bone to the lead character in the movie “To Sir, with Love” played by Sidney Poitier.

Dr. Rivers said that, like the patient and gifted teacher played by Poitier in the movie, Dr. Bone brought sanity to sepsis care by finding ways to organize what was a chaotic situation in the later part of the 20th century.

“In a residency with Dr. Bone back in the late ’80s, and having done a critical care fellowship along with internal medicine and emergency medicine, sepsis became a passion of mine,” Dr. Rivers said.

Dr. Rivers noted that in 1997, sepsis care lacked several components: Screening criteria or early definition, a standard for antibiotics, risk stratification, or resuscitation standards. Improving sepsis care involved a systematic approach. That led Dr. Rivers to work on expanding sepsis care outside of the ICU into the emergency department and gave rise to the concept of early goal-directed therapy (EGDT).

Prior to adoption of EGDT at Dr. Rivers’ center, sepsis mortality was 51%. After EGDT introduction, mortality for patients in EDGT dropped to 30% compared with 46% in the control group. Today, mortality has decreased to 25%.

“And from a national and international perspective over the last two decades, we’ve seen an incremental decrease in sepsis mortality as a result of elevation of our standard of care,” Dr. Rivers said. “And this standard of care includes all of the things we just talked about but was observed by Dr. Bone years ago.”

The EGDT trial started enrolling patients in 1997, the year that Dr. Bone died from metastatic renal cancer. Dr. Rivers noted how Dr. Bone’s final work drew on his experiences as a patient with a terminal illness, including his own experiences with SIRS and MODS, and broadened and deepened the discussion about issues around patient preferences regarding intensive care. “In the last phases of his life, he had lemons delivered to him in terms of the cancer that he had, and he turned it into lemonade through various pieces in terms of describing and appreciating the concepts of life until the end,” Dr. Rivers said.