Dear Editor
Wise [1] describes a patient with pneumonia who fell. I believe if their standing systolic blood pressure (SBP) and heart rate (HR) had been tracked, clinicians would probably have been alerted earlier to the possibility of sepsis. It is when a patient goes from lying to standing there is the greatest contrast between the SBP and HR readings of a healthy patient and a patient with early sepsis. We need to learn to interpret those changes and look at ways of making interpretation easier. One potential way might be an ABCDS score [2], calculated by multiplying lying SBP/standing SBP by standing HR/lying HR. It has the advantage of being close to 1 in a healthy patient and mathematicians amongst you will notice a normal physiological rise by the same percentage in both variables would not elevate the score above 1. Studies are needed to assess whether a lying to standing ABCDS score less than 1.1 can be used to rule out sepsis.
Checking SBP and HR twice need not significantly lengthen a consultation. Evidence suggests readings are most informative when taken as soon as the patient changes posture [3]. When informing a patient they have a viral infection, consider checking their standing SBP and HR, just as you might do for a patient who you thought was dehydrated or keeps falling over. I find palpating the radial pulse volume in both postures during cuff inflation and deflation helps reduce the need to repeat abnormal results and helps stabilise the patient when they’re standing.
Does the patient or carer you’re speaking to by telephone have access to a BP machine? Do they feel dizzy, or appear drowsy or confused when they stand up? Perhaps it’s time to ask more of our patients to stand and be counted.
References.
[1] Wise J. Sepsis: Why the lack of progress? BMJ. 2023 Oct 27;383:2502. doi: 10.1136/bmj.p2502. PMID: 37890874.
https://pubmed.ncbi.nlm.nih.gov/37890874/
[2] Katona SJ. ABCDS calculator. JSCalc.io. 2018
www.abcds.co.uk
[3] Phipps D, Butler E, Mounsey A, Dickman MM, Bury D, Smith A, Bennett N, Arthur B, Marshall B. PURL: Best timing for measuring orthostatic vital signs? J Fam Pract. 2019 Nov;68(9):512-514. PMID: 31725137; PMCID: PMC6889980.
https://pubmed.ncbi.nlm.nih.gov/31725137/
It stands to reason.