Sepsis

• Severe sepsis is defined as the presence of organ dysfunction, hypoperfusion or hypotension.
• The pathophysiology of sepsis involves an initial phase where there are changes to vascular tone and endothelial function leading to vasodilation and increased capillary permeability. This leads to tissue oedema and reduced blood flow to vital organs such as kidneys and liver.
• Risk factors for developing severe sepsis include age over 65 years old, chronic illnesses such as diabetes mellitus, heart disease, renal impairment, alcoholism, malnutrition, immunosuppression, recent surgery, trauma, burns, catheterisation, intravenous drug use and hospitalisation.
• Sepsis is the body’s overwhelming response to an infection, characterized by coagulopathy issues such as micro emboli and the release of inflammatory mediators
• Sepsis affects an estimated 30 million adults and children each year, resulting in potentially six million deaths annually
• Sepsis accounts for approximately 20 percent of U.S. hospital admissions but is a factor in over 50 percent of U.S. hospital deaths
• In sepsis, the inflammatory and coagulation response is rapid and widespread, causing a dysregulated response that may overwhelm all of the body’s systems
• Bacterial infections are the most common cause of sepsis, but fungal, parasitic, or viral infections can also lead to sepsis
• The most common sources for infection in sepsis patients are pneumonia, urinary tract infection, gut & bowel infection, skin & wound infections, IV drug abuse injection sites, and surgical site infections
• Host factors that increase the risk of developing sepsis include age, gender, genetics, comorbidities, immunosuppression, and exposure risks
• Progression of sepsis: SIRS + Infection → Sepsis + End Organ Damage → Severe Sepsis + Refractory (unresponsive) hypotension → Septic shock
• Septic shock is a distributive shock characterized by massive vasodilation, increased capillary permeability, decreased systemic vascular resistance, and the formation of blood clots in the microvasculature
• Multiple Organ Dysfunction Syndrome (MODS) can be the end result of septic shock, involving altered organ function in various systems of the body
• The treatment bundle for sepsis includes reperfusion assessment and the SEP-1 core measure treatment bundle based on recommendations from the 2012 Surviving Sepsis Guidelines
• For patients with initial hypotension (SBP < 90 or MAP < 65), lactate ≥ 4, or septic shock, a 30mL/kg fluid bolus is required
• Persistent hypotension after the initial fluid bolus requires starting a vasopressor; norepinephrine (Levophed) is the preferred vasopressor
• If the initial lactate is > 2, a repeat lactate must be done to reassess tissue perfusion regardless of fluid resuscitation
• Blood cultures are crucial for source control in sepsis to identify and stop the infection
• Having two sets of blood cultures helps corroborate matching sets to confirm treatment of a true pathogen versus a contaminant, aiming to prevent culture negative severe sepsis (CNSS) and septic shock
• Source control is essential to stop the inflammatory response and systemic dysregulation in sepsis
• Antibiotics should be given as soon as possible after blood cultures are drawn, preferably after the second set; if the second set is delayed over 30 minutes, start antibiotics after the first set
• In sepsis, lactate is viewed as a marker of global tissue perfusion, with higher levels indicating increased mortality risk
• The pathophysiology behind lactate elevation in sepsis is due to hypoperfusion of end organs leading to anaerobic metabolism and lactate production
• The SEP-1 Bundle outlines time zero as the earliest chart documentation consistent with severe sepsis or septic shock elements, with specific requirements within 3 hours for severe sepsis and septic shock cases
• Severe sepsis is defined as sepsis with new organ dysfunction, requiring specific actions within three hours including drawing lactate, blood cultures, administering antibiotics, and fluid resuscitation
• Septic shock is severe sepsis with refractory hypotension or lactate ≥ 4 mmol/L, with similar actions to severe sepsis within three hours and additional steps within six hours
• The Society of Critical Care Medicine suggests isotonic saline or balanced salt solutions for initial fluid resuscitation in sepsis and severe sepsis cases
• Sepsis is a medical emergency with variable signs and symptoms, often presenting with fever as a common response to infection
• Delay in initiating treatment for sepsis increases the risk of mortality, emphasizing the importance of timely intervention
• Crystalloid fluids, antibiotics, and source control are crucial components in the management of sepsis to improve patient outcomes
• The goal in sepsis management is to stop the infection promptly through appropriate antibiotics and source control measures
• Surgical removal of infection may be necessary in some cases of sepsis, and delays in treatment should be avoided to reduce mortality risk
• The SEP-1 Bundle emphasizes the importance of documentation, timely interventions, and reassessment in the management of sepsis and septic shock
• Reassessment of tissue perfusion is essential in sepsis management to ensure appropriate treatment and improve patient outcomes
• The Society of Critical Care Medicine study highlights the importance of timely intervention in sepsis management to reduce mortality risk
• Understanding the pathophysiology of lactate elevation in sepsis is crucial for its interpretation as a marker of tissue perfusion and mortality risk
• Antibiotics are a critical component in the treatment of sepsis, with early initiation associated with improved patient outcomes
• Vasopressors like norepinephrine are recommended in cases of persistent hypotension in sepsis management
• Having two sets of blood cultures helps ensure accurate identification of pathogens in sepsis cases, reducing the risk of culture negative severe sepsis and septic shock
• Crystalloid fluids play a vital role in initial fluid resuscitation in sepsis and severe sepsis cases, with specific recommendations based on patient characteristics