Severe sepsis what is

Antimalarial compounds were prescribed for fever in China as early as bc and Hippocrates recognized the anti-infective properties of wine and vinegar around bc.

Despite clear advances in understanding infection and the immune response, sepsis was not recognized as a specific medical entity deserving of recognition and focused study until the s.

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Learn More. Sign in via OpenAthens. Sign in via Shibboleth. AccessBiomedical Science. AccessEmergency Medicine. Case Files Collection. Clinical Sports Medicine Collection. Davis AT Collection. Davis PT Collection. Murtagh Collection. About Search. It is vitally important to recognize sepsis promptly, particularly when severe, since delays will reduce the effectiveness of life-saving interventions. This may be challenging, particularly in the hospitalized patient, as the clinical presentation can vary widely and at times may be subtle, depending on the source of infection and host co-morbidities.

In sick patient populations, SIRS criteria have low diagnostic utility as they are overly sensitive and non-specific. In addition, in some particularly vulnerable populations, such as the elderly or those taking immunosuppressive medications, the clinical manifestation of both the infection and the SIRS response may be markedly attenuated despite overwhelming infection.

In these patients, among others, the signs of organ dysfunction e. This underscores the importance of maintaining a high degree of suspicion for the presence of sepsis as the underlying cause of any clinical deterioration in the critically ill patient. Given the adverse impact that delays in recognition may have on the effectiveness of some interventions, it is prudent to initiate treatment presumptively for severe sepsis, unless or until an alternative diagnosis has been established.

Recognizing the inherent challenges in diagnosing sepsis, a consensus conference was reconvened in to review the conventional definitions of sepsis see definition section. Although the definitions were not altered, the consensus panel added other clinical signs, associated commonly with sepsis, to the existing list of criteria that should raise the suspicion of sepsis.

When a patient is suspected of having sepsis it is important to establish both the etiology of infection and assess the severity of sepsis. If a specific source of infection can be found it supports the diagnosis of sepsis over other systemic conditions, informs the appropriate choice of antibiotics, and expedites source control.

The severity of sepsis dictates which interventions are indicated immediately and whether ICU transfer is indicated. In addition to a focused history and physical examination, cultures and directed radiographic imaging should be obtained to localize the source of infection.

If possible, all cultures should be obtained prior to antibiotic administration, to preserve their diagnostic sensitivity. However, even in the most acutely ill patients, pathogens will grow in blood cultures only in half the patients. Sepsis severity is readily established by physical examination and routine laboratory studies of organ function. Although some of these patients may be cared for on the general ward, when there is cardiovascular, respiratory, or central system dysfunction, more intensive monitoring and other life-saving interventions may be are indicated.

Given the similarly high mortality of cryptic septic shock as compared to full blown septic shock, and the effectiveness of these interventions in mitigating the risks of death, a serum lactate should always be obtained promptly in all patients with suspected sepsis, regardless of whether there are any other signs of organ dysfunction.

Another reason for measuring lactate in these patients is that even marginally elevated values i. Thus, one may consider using a lower lactate threshold in the decision to move a patient to the ICU, particularly in frail or vulnerable patients e. A limited set of disorders can mimic the warm shock low afterload state characteristic of well-resuscitated septic shock; however, in those patients presenting in cold shock, which is more common, one must consider a broader differential including disorders associated with a low cardiac output and high afterload.

This includes all the other categories of shock including hypovolemic, cardiogenic, and obstructive. Although this includes a long list of disorders, the initial findings on history and physical examination eg, clinical setting and absence of jugular venous distension and rales , usually allow one to readily exclude cardiogenic and obstructive shock from initial consideration.

See Table I. Interestingly, if these patients respond to treatment, resuscitation results in both a decline in the ScvO 2 , lactate. IV Fluids: Only crystalloids. Choose ABX based on nature of host, suspected sources, prior ABx use, prior culture data, institutional antibiogram, and allergies. To simplify, and ensure timely administration this is best accomplished by therapeutic algorithms and use of rapid response teams:.

Order and rate of administration: Always first infuse drugs against gram negative pathogens: Cefepime 5 min , Amikacin 30 min , Aztreonam 15 min , Levofloxacin 90 min , Meropenem 15 min. Start Vanco 60 min for 1 gm , simultaneously. Then caspofungin 60 min. Source control: Remove or drain focus of presumed infection ASAP includes tunnelled lines-if in shock. May need additional imaging once stable for transfer. Surgery consult for abdominal or soft tissue sources.

Insulin: Keep blood sugar levels , using insulin drip if necessary IV drip protocol. Inform them about high mortality rate and prognostic importance of response to therapy over next days extend to days with certain comorbidities e. Best predictor of prognosis is whether the patient is responding to therapy within a day period.

Lack of response or worsening after days, makes it very unlikely the patient will improve. Fluid resuscitation should begin with lactated ringers. This recommendation is based on the results of a recent RCT showing a mortality benefit in a retrospectively selected subset of patients with septic shock in the ALBIOS trial which included all patients with severe sepsis. Additional support for the use of albumin in septic shock patients comes from two prior meta-analyses and one large RCT, the SAFE trial.

Clearly, there is no role for colloids other than albumin. Repeated fluid boluses— mL of crystalloid should be administered through at least an 18 gauge IV given over 10 to 20 minutes—using a pressure bag.

Fluid boluses should continue, providing there is persistent shock with or without hypotension, and evidence of circulatory improvement using routine physical exam and laboratory parameters e. IVF should stop when either shock has resolved or there is evidence of harm. After an initial L of crystalloid are given, vasopressors should be used to reach the goal MAP, and continued IVF should be used to reach the goal of reversing hypoperfusion, with the caveats listed above about when to stop.

After the initial resuscitation goals have been achieved and shock has resolved, after a period of stability one should be encouraged to achieve a net negative fluid balance. Often times this occurs spontaneously, heralded by polyuria and negative fluid balance, however, diuretics may be required to affect this goal.

Careful monitoring of organ perfusion is essential during diuretic-induced fluid mobilization, to avoid secondary organ dysfunction. The goals of resuscitation include maintaining an adequate mean arterial pressure, to support cerebral and coronary perfusion, and improving oxygen delivery cardiac output to support systemic organ perfusion.

Both goals are best achieved initially through IV crystalloid resuscitation; however, vasoactive medications may be required after L of IVF and sometime sooner if hypotension is refractory or severely reduced. Studies show no improvement in organ perfusion when a higher MAP is targeted.

Regardless, the effectiveness and adverse impact of a given therapy should always be reassessed by following serial measurements of organ perfusion as therapy is titrated e. Based on the cardiovascular derangements in septic shock, including both vasodilation and a high incidence of cardiomyopathy, it is preferable to use a vasoactive agent with both vasopressor and inotropic actions.

The optimal vasopressor choice for septic shock based on RCT is norepinephrine, primarily because it is highly potent and has less arrythmogenic potential than dopamine. Nuances in patient presentation, requires that a firm grasp of the cardiovascular pharmacology of each potential vasoactive agent is known to be able to maximize the therapeutic role in a given patient see Table II. This is based on weak evidence favouring this combination of agents using a subset analysis of an RCT, however, given this approach has no risks compared to alternative strategies, we would favor this approach.

Finally, the optimal means to wean vasopressors is similarly unknown and requires further investigation. However, in the setting of a septic cardiomyopathy, if vasopressin has been added, one should not wean norepinephrine prior to weaning vasopressin to avoid the exclusive effects of increased afterload without inotropic support.

In contrast, the more recently published Corticosteroid Therapy of Septic Shock CORTICUS study failed to confirm a mortality benefit, although the patients enrolled differed significantly less ill from those in the original Annane trial. Both trials, however, did demonstrate a significant reduction in the time to shock reversal in patients receiving low-dose corticosteroids. Thus, at present, it is recommended that low-dose corticosteroids only be considered for patients with fluid and vasopressor-refractory septic shock, defined as failing low dose vasopressors.

The timely administration of effective broad-spectrum anti-microbial therapy is of paramount importance in the initial management of the patient with severe sepsis. This has been confirmed in several other studies.

In addition, several studies have shown that if the initial antimicrobial regimen is ineffective against the pathogen, mortality increases even if the appropriate antibiotic is given subsequently based on culture data. These studies provide the rational for the recommendation that broad spectrum anti-microbial therapy should be administered empirically, and within one hour of identification of severe septis or septic shock. In most patients, this would include vancomycin, a broad spectrum anti-pseudomonal agent and an aminoglycoside.

Double coverage with 2 new agents active against resistant gram negative pathogens is important, given the risk of a highly resistant strain in those patients with health care-associated septic shock.

When choosing an empiric antibiotic regimen, clinicians must also take into account prior culture results i. After 3 days of treatment, the antibiotic regimen should be de-escalated to the narrowest spectrum possible based on available cultures, or discontinued completely if an alternative diagnosis is established. However, if after days the patient fails to respond to the initial antibiotics, the drug regimen should be changed see section below on what to do if patient fails to improve , and a directed and systematic search for a localized source of infection should be initiated, e.

CT chest and abdomen or at least ultrasound if too unstable for transport. Definitive source control may require invasive procedures, including surgical intervention. Several recent studies of intensive insulin therapy failed to demonstrate a mortality benefit while simultaneously exposing an increased risk of hypoglycemia. Adults 65 or older. People with weakened immune systems. People with recent severe illness or hospitalization.

Sepsis survivors. Children younger than one. High heart rate or low blood pressure. Confusion or disorientation. Extreme pain or discomfort. Fever, shivering, or feeling very cold. Shortness of breath.

Clammy or sweaty skin. A medical assessment by a healthcare professional is needed to confirm sepsis. Fact Sheets Print Only. Get Email Updates. To receive email updates about this page, enter your email address: Email Address. What's this?