Updated: 3/1/2020

Sepsis

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Snapshot
  • A 44-year-old woman is brought to the emergency department by her husband for 2 days of generalize malaise, fatigue, and altered mental status. Her husband reports that she has been having a fever for the past 5 days with pain on urination and foul smelling urine. Medical history is significant for renal transplantation 4 years ago and is on tacrolimus and amlodipine. Her temperature is 101°F (38.3°C), blood pressure is 98/65 mmHg, pulse is 112/min, and respirations are 27/min. On physical exam, she is oriented to self but not place or time. Cardiopulmonary exam is unremarkable. Abdominal exam is notable for suprapubic tenderness upon palpation. She has costovertebral angle tenderness. She is immediately started on intravenous fluids and antibiotics and blood and urine studies are obtained. She is being transferred to the medical intensive care unit. (Urosepsis)
Introduction
  • Definition
    • a dysregulated host response to infection that results in organ dysfunction
      • if untreated, can result in septic shock
  • Epidemiology
    • most common bacteria include
      • Escherichia coli
      • Staphylococcus aureus
      • Klebsiella pneumoniae
      • Streptococcus pneumoniae
    • risk factors
      • admission to the intesive care unit 
      • bacteremia
      • advanced age (≥ 65 years of age)
      • immunosuppression
      • diabetes
      • obesity
      • malignancy
      • previous hospitalization
  • Etiology
    • gram-positive and -negative organisms are responsible for most cases
  • Pathogenesis 
    • pathogen results in the activation of the host's immune system, resulting in systemic inflammation and the release of pro-inflammatory mediators
      • increased heart rate => hyperdynamic circulation
        • low wedge pressure
        • cardiac output is high early in presentation and low as decreased preload outpaces cardiac compensation
      • decreased SVR
      • impaired tissue utilization of oxygenation => high SvO2 
        • from inability of tissue to extract oxygen + hyperdynamic circulation
  • Quick Sequential Organ Failure Assessment (qSOFA) score 
    • used to promptly triage infection in patients who may develop sepsis
    • the qSOFA score is:
      • respiratory rate ≥ 22/minute
      • altered mentation
      • systolic blood pressure ≤100 mmHg
  • Prognosis
    • increased mortality in patients who are not treated
Presentation
  • Symptoms
    • nonspecific and include
      • fever
      • symptoms from an infectious source, for example
        • cough and dyspnea in pneumonia
        • purulent exudate in abscesses
    • often associated with hyperventilation and altered mental status
  • Physical exam
    • arterial hypotension
    • tachycardia and tachypnea
    • warm and flushed skin (in early phases of sepsis)
    • cool skin (in the late phases of sepsis, where blood flow becomes redirected to core organs
Studies
  • Laboratory findings are nonspecific and can include
    • leukocytosis or leukopenia
    • elevated C-reactie protein
    • arterial hypoxemia
    • acute oliguria and worsening creatinine
    • elevated lactate
    • respiratory alkalosis with a metabolic acidosis
    • thrombocytopenia
    • hyperbilirubinemia
Treatment
  • Management approach
    • perform a detailed history and physical to properly triage patients to the intensive care unit (ICU) who require it and to determine the likely organism causing sepsis
    • initiate intravenous fluids and empiric antibiotic promptly and tailored to the patient
    • monitor the treatment response
      • can be accomplished by measuring mean arterial pressure, urine output, and trending lactate levels
  • Conservative
    • admit to the ICU
    • ensure we have a secure airway
    • establish venous access for fluid, obtain labs, and antibiotic administration
    • obtain an arterial blood gas
    • obtain cultures
    • remove source of infection (e.g., catheter)  
  • Medical
    • intravenous fluid administration
      • types
        • normal saline
        • Ringer lactate 
          • the preferred fluid for renal and mortality outcomes
      • central line for vascular access and if pressors needed
        • confirm placement with a chest radiograph 
    • empiric antibiotics
      • indication
        • administered preferably within the first hour once a presumed diagnosis of sepsis has been made
      • medications
        • carbapenem
        • piperacillin-tazobactam
        • vancomycin
        • third or fourth generation cephalosporins
Complications
  • Septic shock
  • Disseminated intravascular coagulation
  • Acute respiratory distress syndrome
  • Acute renal failure
  • Cardiomyopathy

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