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Sepsis
Sepsis
Sepsis:
a severe, life-threatening condition that results from a dysregulation of
the patient's response to an infection, causing tissue and organ damage and
subsequent organ dysfunction [1]
o Diagnostic criteria
Persistent hypotension: Vasopressors are required to
maintain MAP ≥ 65 mm Hg.
Persistent lactic acidosis: lactate > 2 mmol/L (18 mg/dL)
despite adequate fluid resuscitation
10% immature bands
Sepsis: SIRS criteria PLUS a suspected or confirmed underlying infection [1]
Severe sepsis: sepsis PLUS dysfunction of at least one organ or system [1]
Multiple organ dysfunction syndrome (MODS)
o Progressive and potentially reversible failure in the physiologic function of
several organs and/or systems [6]
Used in critical care settings as a tool to identify organ failure and predict mortality
The score should be calculated after 24 hours of ICU admission and then every 48 hours.
Should not be used to diagnose sepsis
Etiology
Clinical features
Fever ,chills, and diaphoresis
Tachycardia
Tachypnea
Features of organ dysfunction (see SOFA score)
o CNS impairment: altered mental status
o Cardiovascular failure: hypotension
o Coagulopathy → disseminated intravascular
coagulation → petechiae, purpura
o Liver failure: jaundice
o Kidney failure: oliguria
o Respiratory failure: symptoms of acute respiratory distress
syndrome (ARDS)
Additionally in septic shock
o Hypotension (MAP < 65 mm Hg)
o Initially warm skin and normal capillary refill time (warm shock) →
cold cyanotic, pale, or mottled skin with prolonged capillary refill
time (cold shock)
Features of the primary infection
Generalized edema (capillary leak)
Management
Diagnostic and treatment measures should be conducted simultaneously in a patient suspected
of having sepsis. Success depends on early detection, early and effective resuscitation, and
early antibiotic therapy.
Sepsis is a medical emergency and clinicians should have a high index of suspicion.
Approach
1. Sepsis surveillance: Identify patients with potential sepsis.
o Quick SOFA criteria : [1]
Blood cultures
Serum lactate
IV fluids
Vasopressors
Antibiotics
Hour-1 bundle: lactate + cultures + fluids + vasopressors + antibiotics
Diagnosis
The main goals of the diagnostic workup in a patient with suspected sepsis are to determine the
presence and severity of organ dysfunction and to identify the source of infection. See
“Definitions” section for diagnostic criteria. [1][3][19]
Laboratory studies
In addition to serum lactate and blood cultures (at least two sets), the following laboratory
studies should be obtained to support the diagnosis and evaluate for organ dysfunction.
When possible, obtain the additional samples before starting antibiotic treatment, but DO NOT
DELAY ANTIBIOTICS if samples are not rapidly available.
Imaging
Direct decisions based on clinical suspicion. Examples of commonly performed imaging include:
IV fluids [7][19][21]
Monitor hemodynamic parameters [7][24]
o Vital signs: e.g., mean arterial pressure (MAP), heart rate
o Other clinical parameters: e.g.,urine output, capillary refill, signs of poor peripheral
perfusion
o Consider invasive vascular monitoring (if vasopressors are used).
o Biomarkers: e.g., serum lactate , base excess
o Cardiac function monitoring: e.g., devices that measure cardiac
index, echocardiography
Consider protocolized resuscitation targets
o Lactate guided fluid resuscitation strategy
o Early goal-directed therapy
Clinical reassessment should be a continuous and iterative process throughout the resuscitation
process.
First-line: norepinephrine
Second-line: if MAP persistently low
o Add vasopressin
o OR add continuous IV epinephrine infusion (off-label)
Third-line: consider as alternate vasopressors in select cases , or as an
additional vasopressor for refractory tissue hypoperfusion. [7]
o Dopamine [7]
o Dobutamine
Respiratory support
Address hypoxemia if present: Secure airway and start oxygen therapy as needed.
Consider mechanical ventilation (see “Indications for invasive mechanical ventilation”).
o See “High-risk indications for mechanical ventilation.”
o See “Hemodynamic compromise in mechanically ventilated patients.”
Maintain a high index of suspicion for ARDS to ensure early identification (see “Berlin criteria for
ARDS”).
Shock and metabolic acidosis are both associated with a high risk of peri-intubation mortality. [3][25]
Corticosteroids [7][26]
E.g., hydrocortisone
Consider as adjuvant therapy if hypotension is refractory to the first vasopressor.
Consider for patients with suspected adrenal insufficiency or patients taking long-
term steroids.
Infection control
General recommendations
Broad-spectrum antibiotics are part of the hour-1 bundle and should be started early
(ideally as soon as possible after blood cultures have been drawn).
Choice of empiric antimicrobial therapy should be guided by:
o Source of infection
o Local prevalence of common and resistant pathogens
o Prior infections, immune status , and patient comorbidities
o Presence of implanted devices (e.g., urinary catheter, central lines)
Therapy should be narrowed once the pathogen is identified. [3]
Control the source of infection as early as possible.
Ideally, specific measures to control the source of infection should take place a maximum
of 6–12 hours after the diagnosis is made.
Examples
o Abscess drainage
o Debridement of infected necrotic tissue (e.g., necrotizing fasciitis)
o Removal of infected devices
o Operative management of surgical pathologies (e.g.,
intraabdominal abscess, gastrointestinal
perforation, ischemic bowel, volvulus, cholecystitis, cholangitis)
o Nephrostomy/drain placement in obstructive pyelonephritis/abscess
Supportive therapy
Fluids, nutrition, and electrolytes [7][26]
surgery/invasive procedure
o FFP to correct coagulopathy in patients with active bleeding or a planned
invasive procedure
Other supportive measures [7][26]
o VTE prophylaxis
o Renal replacement therapy: e.g., for patients with concomitant severe acute
kidney injury
o Stress ulcer prophylaxis: on a case-by-case basis
Consult ICU early.
Consider interventions for infectious source control.
Supportive care (e.g., normoglycemia, nutritional support, VTE prophylaxis)
Conduct frequent clinical reassessments.
Differential diagnoses
The following is a list of noninfectious conditions that may mimic sepsis. [3][20]
Complications