INTRODUCTION
First, sepsis is a syndrome and not an individual disease. It is the 11th leading cause of death in the US. According to the Global Sepsis Alliance (GSA), “Sepsis is one of the most pressing healthcare challenges faced by the world today.” The CDC shows sepsis hospital admissions “have grown from around 200 per 1000 inhabitants in 2000, to 340 in 2008. Also, in 2008 the costs for hospital treatment were US $14.8 billion, but these have increased by an annual rate of 11 percent.” According to Dr. Reinhardt “the main way it can be prevented is if it is recognized early and the patient receives adequate measures of treatment. Treatments, like antimicrobials and intravenous fluids must be initiated when the first signs of organ dysfunction appear. If they are given in the first few hours the survival rate may be up to 80 percent, but studies suggest with each hour of delay the mortality rate increases by five to eight percent.” (GSA – Stop Sepsis, Save Lives)
DEFINITION
Sepsis is a potentially deadly medical condition characterized by a whole-body inflammatory state (called a systemic inflammatory response syndrome or SIRS) that is triggered by an infection. The body may develop this inflammatory response by the immune system to microbes in the blood, urine, lungs, skin, or other tissues. A popular term for sepsis is blood poisoning. Severe sepsis is the systemic inflammatory response, infection and the presence of organ dysfunction. Septic Shock is the combination of sepsis with abnormally decreased blood pressure.
(Also, here is another great video about SIRS from the same source.)
PATHOPHYSIOLOGY
At this point in time, the literature richly illustrates that no single mediator / system / pathway / pathogen drives the pathophysiology of sepsis (Am J Pathol. 2007 May; 170(5): 1435–1444. doi:10.2353/ajpath.2007.060872, Pathophysiology of Sepsis)
- The basic pathophysiology of sepsis, severe sepsis, and septic shock includes:
- Vasodilation
- Third spacing due to capillary leak
- Myocardial dysfunction.
- Vascular endothelium is both a source and target of injury in SIRS / sepsis. Injury may be due to toxins such as LPS (endotoxin) or from ischemia itself. Tissue factor release leads to amplification of the inflammatory response and to DIC via the thrombin pathway. Thrombin not only catalyzes fibrin formation but also causes leukocyte adhesion which leads to further endothelial damage. As DIC progresses, clotting factors are consumed and bleeding occurs.
- Clotting factors, pro-fibrinolytic, and anti-thrombin factors are consumed leading to loss of fibrinolysis & normal down-regulation of thrombin pathway. This phenomenon is both pro-inflammatory and pro-thrombotic.
- Protein C depletion has been associated with increased mortality. This has led to a series of clinical trials utilizing protein C, activated protein C (APC), antithrombin III (AT-III), and tissue factor pathway inhibitor to try and disrupt this cycle. Activated protein C has in fact been shown to reduce mortality in severe sepsis in adults. Bleeding problems seems to outweigh the benefits in children.
- Usually gram negative and usually originating in the urinary or respiratory systems
- Frequent microbial causes of sepsis
- Streptococcus pneumoniae
- Escherichia coli
- Streptococcus pyogenes (beta-haemolytic group A)
- Staphylococcus aureus including methicillin-resistant
- Staphylococcusaureus (MRSA)
- Less common
- Klebsiella spp and other coliforms/extended spectrum beta-lactamase (ESBL) producing organisms
- Beta-haemolytic streptococci groups C and G
- Candida albicans
- Anaerobes (Bacteroides fragilis, Clostridium spp)
IDENTIFYING SEPSIS
(Balk RA. Crit Care Clin 2000;16:337-52, Surviving Sepsis Campaign 2008 SSC Guidelines)
- Evaluation for Severe Sepsis Screening Tool
- Neurology
- Altered Consciousness
- Confusion
- Psychosis
- Agitated
- Signs of Meningismus (neck stiffness)
- Encephalopathy (Sepsis-associated encephalopathy -Sepsis-associated encephalopathy (SAE) is an early feature of infection in the
body and might appear before other systemic features of sepsis are obvious)
- Cardiology
- Tachycardia (Bradycardia is a late finding)
- heart rate > 90 bpm or >2 standard deviations (SD) for age
- Arterial hypotension (SBP 90<90 mm Hg; MAP 70<70 mm Hg; or an SBP >40 decrease 40 mm Hg in Adults or <2 SD below normal for age)
- Hypotension is a late finding
- Arterial Vasodilation (from nitric oxide synthase)
- Altered CVP (central venous pressure)
- Altered PAOP (pulmonary artery occlusion pressure)
- Inflamatory Cytokines cause a drop in SVR (systemic vascular resistance)
- Widended pulse pressure and bounding pulse
- Tachycardia (Bradycardia is a late finding)
- Respiration
- Dyspnea
- Tachypnea (potentially from metabolic acidosis progressing to respiratory acidosis)
- PaO2 < 70 mm Hg
- SaO2 < 90%
- PaO2/FiO2 <= 300
- Cough (especially if productive)
- Dullness on Percussion
- Pleuritic Chest Pain
- Bronchial Breath Sounds
- Localized Rales
- ARDS
- Gastrointestinal
- Abdominal Pain
- Nausea
- Vomiting
- Diarrhea
- Guarding or Rebound Tenderness
- Peritonitis and Abdominal Sepsis
- Urinary
- Oliguria
- Anuria
- Increased Creatinine
- Renal Vasoconstriction (via RAAS pathway)
- Pelvic or Flank Pain
- Vaginal or Urethral Discharge
- Rectal Tenderness or Swelling
- Costovertebral Angle Tenderness
- Adnexal Tenderness or Masses
- Hepatic
- Jaundice
- Increased Enzymes
- Decreased Albumin
- Increased PT
- Skin
- Temp >38° (fever) or < 36° (hypothermia)
- Palpable petechiae and purpura may be present
- Poor skin turgor
- Signi?cant edema or positive ?uid balance (20 mL/kg over 24 hrs)
- Pallor
- Crepitus in Necrotizing Infections
- Radiology
- Consider further radiologic studies based on patient’s presenting symptoms –
e.g. CXR if respiratory symptoms, abdominal CT if abdominal pain, etc.
- Consider further radiologic studies based on patient’s presenting symptoms –
- Labs
- ELEVATED LACTATE
Admission Lactate Mortality Rate % 0-2.5 mM 4.9 2.5-4.0 mM 9 > 4.0 mM 28 - Lactate in Sepsis
- Don’t take vitals, take a lactate
- Is It Septic Shock? Check Lactate Level
- Lactate Measures, When, Why, and How Much
- Trick of the Trade: Serial lactate measurements in sepsis?
- Dynamic lactate indices as predictors of outcome in critically ill patients
- In the first 24 hours following ICU admission, dynamic indices of hyperlactatemia have significant independent predictive value, improve the performance of illness severity score-based outcome predictions and are superior to simple static indices of lactate concentration.
- Whole blood lactate kinetics in patients undergoing quantitative resuscitation for severe sepsis and septic shock
- ELEVATED LACTATE
- Decreased Platelets
- Coag Panel – Increased PT/APTT
- Decreased Protein C
- Increased D-Dimer
- White Blood Cell Count > 12,000 cells/mm³ (leukocytosis), < 4000 cells/mm³ (leukopenia), or > 10% immature band
- Hyperglycemia (plasma glucose 140 mg/dL or 7.7 mmol/L) in the absence of diabetes
- Plasma C-reactive protein 2 SD above the normal value
- Plasma procalcitonin 2 SD above the normal value
- Critically evaluate the role of Procalcitonin (PCT) as a biomarker in the diagnosis and management of sepsis
- A peptide precursor of calcitonin
- Produced by
- parafollicular cells of the thyroid
- neuroendocrine cells of the lung and the intestine (extrathyroidal)
- It raises in a response to a proinflammatory stimulus especially of bacterial origin (mainly from the cells of lung and the intestine)
- Controversies in the of Procalcitonin to Diagnose Sepsis (Part 2)
- Procalcitonin algorithms for antibiotic therapy decisions: a systematic review of randomized controlled trials and recommendations for clinical algorithms
- Orientational Reference Values
< 0.05ng/ml Healthy individuals < 0.5ng/ml Probability of sepsis is low, local infection possible 0.5-2ng/ml Grey zone, recheck 6-12hrs later >2ng/ml Probability of sepsis is high
- Organ Dysfunction Variables
- Arterial hypoxemia (PaO2/FIO2 < 300)
- Acute oliguria (urine output 0.5< 0.5 mL/Kg hr or 45 mmol/L for at least 2 hrs, despite adequate ?uid resuscitation)
- Creatinine increase > 0.5 mg/dL or 44.2 mol/L
- Coagulation abnormalities (INR 1.5> 1.5 or a PTT > 60 secs)
- Ileus (absent bowel sounds)
- Thrombocytopenia (platelet count < 100,000)
- Hyperbilirubinemia (plasma total bilirubin >4 mg/dL or 70 mol/L)
Differentials
- Septic Shock Differential Diagnosis
- Best Practice – Sepsis Differential Diagnosis (BMJ Group)
- Differential Diagnosis For Acute sepsis syndrome: Infectious Disorders (Specific Agent)
TREATMENT
- Severe Sepsis Resuscitation Protocol: Non-Invasive
- Implement the Resucitation Bundle – Within the First 6 Hours of Care
- Implement the Management Bundle – Within the First 24 Hours of Care
- Early Goal Directed Therapy
- Broad-spectrum antibiotics (Think Vanc and 3rd Gen Cephalosporin or Clindamycin, or Zosyn)
- In multivariate analysis [including Acute Physiology and Chronic Health Evaluation (APACHE) II core and therapeutic variables], time to initiation of effective antimicrobial therapy has been shown to be the single strongest predictor of outcome. (Current Opinion in Infectious Diseases 2007, 20:345–352)
- Optimizing antimicrobial therapy in sepsis and septic shock.
- Improve Time to Broad Spectrum Antibiotics
- Emerging Drugs for the Treatment of Sepsis
- Source Identification and Control
- Aggressive fluid replacement
- Blood transfusions
- Vasopressors
- Patients with sepsis have a relative vasopressin deficiency state and it may therefore be very effective in increasing SVR. Vasopressin stimulates vascular smooth muscle V1 receptors (i.e. not alpha receptors) and increases MAP. In pediatrics dosing begins at 0.01 unit/kg/hr and can be titrated up to 0.04 units/min.
- Corticosteroids
- If systolic blood pressure remains less than 90mmHg despite appropriate fluid and vasopressor therapy, hydrocortisone at 200 mg/day for 7 days in four divided doses or by continuous infusion should be considered. (Current Opinion in Infectious Diseases 2007, 20:345–352)
- Meta-analysis: the effect of steroids on survival and shock during sepsis depends on the dose
- Corticosteroids in the treatment of severe sepsis and septic shock in adults: a systematic review
- Safety and efficacy of corticosteroids for the treatment of septic shock: A systematic review and meta-analysis
- UpToDate – Management of Severe Sepsis and Septic Shock in Adults
- Surviving Sepsis Guidelines Updated: Preview from SCCM Meeting
- Septic Shock Treatment and Management
DESPERATE MEASURES
These measures can help improve immunohomeostasis (pro/antiinflamatory mediators), improve coagulation response with decreased organ thrombosis, and provide mechanical support for organ perfusion during an acute episode, and may buy some time, but may or may not reduce mortality.
- ECMO (Extracorporeal membrane oxygenation) is an important though infrequent tool. It should be considered in patients with refractory shock despite maximal medical treatment, multi-system organ dysfunction and patients with severe respiratory failure. (What is next in sepsis: current trials in sepsis,Critical care paper review 2012)
- CRRT (Continuous renal replacement therapies) or CVVH (continuous veno-venous hemofiltration) has become an important tool for patients developing renal failure and fluid overload. The cytokine removal properties of CVVH are discussed extensively and remain investigational. (Principles of antibacterial dosing in continuous renal replacement therapy)
- Plasma exchange will remove cytokines, large von Willebrand multimers and other toxic substances. It is used increasingly to manage patients with severe shock though this indication is also still under investigation. (Plasma exchange as a source of protein C for acute onset protein C pathway failure)
NOVEL THERAPIES
- The Search for Effective Therapy for Sepsis Back to the Drawing Board?
- Hopefully more is still to come
QUALITY
- The GENESIS Project (GENeralized Early Sepsis Intervention Strategies) : A Multicenter Quality Improvement Collaborative (Journal of Intensive Care Medicine – DOI: 10.1177/0885066612453025 – PDF available via the EMCrit Blog)
- Institute for Healthcare Improvement – Sepsis
- Institute for Healthcare Improvement – Sepsis Care Enters New Era
- Institute for Healthcare Improvement – Sepsis Detection and Management
- National Quality Forum (Workgroup D – 0500) – Severe Sepsis and Septic Shock: Management Bundle (revised)*
- Nine-Hospital Collaborative Uses Patient Screening Criteria, Fast-Track Diagnosis, and Treatment Protocols to Reduce Sepsis Mortality by More Than 50 Percent
- Procalcitonin for Diagnosis and Management of Sepsis
- Procalcitonin-Guided Antibiotic Therapy
- Severe Sepsis Quality Indicators
- Sepsis: percent of patients with severe sepsis/septic shock who received a recommended broad-spectrum antibiotic within 24 hours following severe sepsis/septic shock identification
REVIEWS
- Annals of Intensive Care – Surviving Sepsis: going beyond the guidelines
- Severe sepsis bundles (doi: 10.4103/0972-5229.63028)
CLINICAL TRIALS
DR. RIVERS TALK
Dr. Emmanuel Rivers gave a talk on Severe Sepsis Management via the EMCrit Blog. The talk is broken down into the three links to each of the episodes provided below.
ADDITIONAL RESOURCES
In addition, here are some more great resources related to sepsis.
- Advances in Sepsis
- Crashing Patient Severe Sepsis
- Development and Implementation of a Multidisciplinary Sepsis Protocol
- EMCrit – Severe Sepsis Resources*
- EM Guidlines – Sepsis
- Global Sepsis Alliance
- International Sepsis Forum
- MedicineNet – Sepsis
- Medline Sepsis
- Sepsis Alliance
- Sepsis know from day 1
- Stanford SOM – Septris
- Surviving Sepsis
- The Surviving Sepsis Campaign (SSC) was developed by the European Society of Critical Care Medicine, the International Sepsis Forum,and the Society of Critical Care Medicine, to help meet the challenges of sepsis and to improve its management, diagnosis, and treatment. The agreement between the three founding organizations and funding for the campaign was concluded December 31, 2008. A generous grant has been received to continue the important work of the campaign. The grant funding extends through 2013. Assistance for US hospitals interested in implementing the bundles can be obtained through the Society of Critical Care Medicine’s Paragon program.
- Surviving Sepsis Protocol Checklist
Additional References
- 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis De?nitions Conference
- Cleveland Clinic – Sepsis
- Genetic Polymorphisms in Sepsis and Septic Shock:Role in Prognosis and Potential for Therapy
- New Approaches to Sepsis: Molecular Diagnostics and Biomarkers
- Role of oxygen debt in the development of organ failure sepsis, and death in high-risk surgical patients
- Oxidative stress as a novel target in pediatric sepsis management
- The Pathogenesis of Sepsis
- Rapid Treatment of Severe Sepsis
- Sepsis in cirrhosis: report on the 7th meeting of the International Ascites Club
- Thermo Scientific biomarker procalcitonin
- Time is tissue: Why emerging evidence on sepsis urges physicians to watch the clock
Early volume resuscitation can help avoid organ dysfunction—if you act quickly after making a diagnosis
CONCLUSION
Sepsis poses a significant burden upon the US healthcare system, resulting in an estimated 750,000 hospital admissions, 570,000 Emergency Department visits, 200,000 deaths and $16.7 billion in medical expenditures annually, according to, the online journal article in PLOS ONE, Chronic Medical Conditions and Risk of Sepsis. Mortality rates remain high in severe sepsis, and despite recent therapeutic breakthroughs much remains to be done to advance our understanding and treatment of sepsis. Currently, anti-sepsis initiatives focus on acute care, with ED staff employing the “sepsis bundles,” a series of steps that includes aggressive administration of antibiotics, IV fluids and blood pressure-boosting medications, and management. Additionally, the Surviving Sepsis Campaign 2012 guidelines will further suggest that in patients with elevated lactate levels as a marker of hypoperfusion, resuscitation should be targeted at normalizing lactate as rapidly as possible (grade 2C). Having said that, however, a normal lactate doesn’t indicate absence of shock. Other factors, such as the patient’s central venous oxygen saturation level, need to be considered as well. The Surviving Sepsis Campaign guidelines are sponsored by 27 medical organizations. Among them are the Society of Critical Care Medicine, ACEP, the Society of Hospital Medicine, the American College of Chest Physicians, the American Thoracic Society, the Infectious Diseases Society of America, the Surgical Infection Society, the Pediatric Acute Lung Injury and Sepsis Investigators, and a host of international groups. Hopefully, strategies will be developed to continue to improve and maximize our efforts towards ameliorating sepsis throughout the world.
- CDC – Inpatient Care for Septicemia or Sepsis: A Challenge for Patients and Hospitals
- An evaluation of the feasibility, cost and value of information of a multicentre randomised controlled trial of intravenous immunoglobulin for sepsis (severe sepsis and septic shock): incorporating a systematic review, meta-analysis and value of information analysis.
- Feasibility of modified surviving sepsis campaign guidelines in a resource-restricted setting based on a cohort study of severe S. aureus sepsis
- Cost-effectiveness of the Surviving Sepsis Campaign protocol for severe sepsis: a prospective nation-wide study in Spain
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