Sepsis

Key Points

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Identification of the septic patient is the important first step. All other critical actions are missed if this does not occur.
Lactate measurement is critical to determining sepsis severity, response to therapy, and prognosis.
Early administration of appropriate antimicrobials and early goal-directed therapy are the mainstays of treatment.
Resuscitation of the critically ill septic patient should occur concurrent or before diagnostic evaluation.

Introduction

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Sepsis is now defined as “infection plus systemic manifestations of infection” (Table 34-1). Systemic inflammatory response syndrome is no longer a strict criteria. There are 3 sepsis syndromes (stages): uncomplicated sepsis, severe sepsis, and septic shock. Sepsis becomes severe sepsis when there is tissue hypoperfusion or organ dysfunction (Table 34-2). Septic shock is defined as a systolic blood pressure (SBP) <90 mmHg or 40 mmHg below one’s baseline blood pressure, despite two 20- to 30-mL/kg boluses.

Table 34-1.

Diagnostic criteria for sepsis.

Infection, documented or suspected, and some of the following:

General variables

Fever (>38.3 °C)
Hypothermia (<36 °C)
Heart rate >90 beats/min
Tachypnea
Altered mental status (delirium)
Significant edema or positive fluid balance (>20 mL/kg over 24 hrs)
Hyperglycemia (>140 mg/dL) in the absence of diabetes

Inflammatory variables

Leukocytosis (WBC count >12,000/μL)
Leukopenia (WBC count <4000/μL)
Normal WBC count with >10% immature forms
Plasma C-reactive protein >2 SD above the normal value
Plasma procalcitonin >2 SD above the normal value

Hemodynamic variables

Arterial hypotension (SBP <90 mmHg; MAP <70 mmHg; or an SBP decrease >40 mmHg in adults or >2 SD below normal for age)

Organ dysfunction variables

Arterial hypoxemia (PaO2/FIO2 <300)
Acute oliguria (urine output <0.5 ml/kg/hr for at least 2 hrs, despite adequate fluid resuscitation)
Creatinine increase >0.5 mg/dL
Coagulation abnormalities (INR >1.5 or a PTT > 60 secs)
Ileus (absent bowel sounds)
Thrombocytopenia (platelet count, <100,000/μL)
Hyperbilirubinemia (total bilirubin >4 mg/dL)

Tissue perfusion variables

Hyperlactatemia (<4 mmol/L)
Decreased capillary refill or mottling

Table 34-2.

Diagnostic criteria for severe sepsis.

Severe sepsis is sepsis with tissue hypoperfusion or organ dysfunction as defined by the following criteria:

Hypotension

Lactate greater than the upper limits of normal laboratory results

Urine output <0.5 ml/kg/hr for >2 hrs, despite adequate fluid resuscitation

ALI with PaO2/FIO2 <250 in the absence of pneumonia

ALI with PaO2/FIO2 <200 in the presence of pneumonia

Creatinine >2.0 mg/dL

Bilirubin >2 mg/dL

Platelet count <100,000/μL

Coagulopathy (INR >1.5)

Sepsis affects 751,000 patients per year, with an annual mortality that exceeds that of AIDS and breast cancer and approaches that of myocardial infarction. The lungs, abdomen, and urinary tract are the most frequent source of infection, but sepsis can come from anywhere in the body. In approximately 20% of cases, the etiology cannot be determined. Risk factors for the development of sepsis syndromes are extremes of age, immunosuppression (chemotherapy, organ transplantation, steroid use, HIV, etc.), severe comorbid disease, exposure to multiple drug-resistant organisms, vascular catheters and other indwelling devices, intravenous (IV) drug abuse, trauma, and burns.

Clinical Presentation

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History

Any patient presenting with an infectious syndrome should be considered for potential sepsis. Those at the extremes of age or the immunosuppressed may not mount a fever. Other patients may have defervescenced before triage vital signs. High clinical suspicion will be required in properly identifying these patients. Furthermore, patients with reduced physiologic reserve are at risk for rapid clinical deterioration.

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