Sepsis
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| Sepsis Classification and external resources | |
| ICD-10 | A40. - A41.0 |
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| ICD-9 | 995.91 |
| DiseasesDB | 11960 |
| MeSH | D018805 |
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Ongoing Trials on Sepsis at Clinical Trials.gov Clinical Trials on Sepsis at Google
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See also: Septic shock
Overview
Sepsis is a serious medical condition characterized by a whole-body inflammatory state caused by infection.
Traditionally the term sepsis has been used interchangeably with septicaemia and septicemia ("blood poisoning").[1] However, these terms are no longer considered synonymous; septicemia is considered a subset of sepsis.[2]
Differential diagnosis of underlying casues
- Anthrax
- Gangrene
- Gram negative bacteremia
- Necrotizing enterocolitis
- Lemierre syndrome
- Melioidosis
- Neisseria meningiditis
- Peritonitis
- Pseudomonas aeruginosa
- Vibrio vulnificus
Signs and symptoms
Symptoms of sepsis are often related to the underlying infectious process. When the infection crosses into sepsis, the resulting symptoms are that of systemic inflammatory response syndrome (SIRS): general inflammation, fever, elevated white blood cell count (leukocytosis), and raised heart rate (tachycardia) and breathing rate (tachypnea). A capillary leak syndrome can develop with severe swelling and edema and third spacing of fluids. General symptoms can include flu like symptoms as well as shaking chills or rigors.
The immunological response that causes sepsis is a systemic inflammatory response causing widespread activation of inflammation and coagulation pathways. This may progress to dysfunction of the circulatory system and, even under optimal treatment, may result in the multiple organ dysfunction syndrome and eventually death.
Epidemiology
In the United States, sepsis is the leading cause of death in non-coronary ICU patients, and the tenth most common cause of death overall according to data from the Centers for Disease Control and Prevention.[3] Sepsis is common and also more dangerous in elderly, immunocompromised, and critically ill patients. It occurs in 1%-2% of all hospitalizations and accounts for as much as 25% of intensive care unit (ICU) bed utilization. It is a major cause of death in intensive care units worldwide, with mortality rates that range from 20% for sepsis to 40% for severe sepsis to >60% for septic shock.
Definition of sepsis
Sepsis is considered present if infection is highly suspected or proven and two or more of the following systemic inflammatory response syndrome (SIRS) criteria are met:[4]
- Heart rate > 90 beats per minute
- Body temperature < 36 (96.8 °F) or > 38 °C (100.4 °F)
- Hyperventilation (high respiratory rate) > 20 breaths per minute or, on blood gas, a PaCO2 less than 32 mm Hg
- White blood cell count < 4000 cells/mm³ or > 12000 cells/mm³ (< 4 x 109 or > 12 x 109 cells/L), or greater than 10% band forms (immature white blood cells).
Consensus definitions however continue to evolve with the latest expanding the list of signs and symptoms of sepsis to reflect clinical bedside experience.[5]
The more critical subsets of sepsis are severe sepsis (sepsis with acute organ dysfunction) and septic shock (sepsis with refractory arterial hypotension). Alternatively, when two or more of the systemic inflammatory response syndrome criteria are met without evidence of infection, patients may be diagnosed simply with "SIRS." Patients with SIRS and acute organ dysfunction may be termed "severe SIRS."
Patients are defined as having "severe sepsis" if they have sepsis plus signs of systemic hypoperfusion; either end organ dysfunction or a serum lactate greater than 4 mmol/dL. Patient are defined as having septic shock if they have sepsis plus hypotension after an appropriate fluid bolus (typically 20 ml/kg of crystaloid).
The criteria for diagnosing an adult with sepsis do not apply to infants under one month of age. In infants, only the presence of infection plus a "constellation" of signs and symptoms consistent with the systemic response to infection are required for diagnosis (Oski's Pediatrics, 2006).
Treatment
The therapy of sepsis rests on antibiotics, surgical drainage of infected fluid collections, fluid replacement and appropriate support for organ dysfunction. This may include hemodialysis in kidney failure, mechanical ventilation in pulmonary dysfunction, transfusion of blood products, and drug and fluid therapy for circulatory failure. Ensuring adequate nutrition, if necessary by parenteral nutrition, is important during prolonged illness.
A problem in the adequate management of septic patients has been the delay in administering therapy after sepsis has been recognized. Published studies have demonstrated that for every hour delay in the administration of appropriate antibiotic therapy there is an associated 7% rise in mortality. A large international collaboration was established to educate people about sepsis and to improve patient outcomes with sepsis, entitled the "Surviving Sepsis Campaign." The Campaign has published an evidence-based review of management strategies for severe sepsis,[6] with the aim to publish a complete set of guidelines in subsequent years.
Early Goal Directed Therapy (EGDT), developed at Henry Ford Hospital by E. Rivers, MD, is a systematic approach to resuscitation that has been validated in the treatment of severe sepsis and septic shock. It is meant to be started in the Emergency Department. The theory is that one should use a step-wise approach, having the patient meet physiologic goals, to optimize cardiac preload, afterload, and contractility, thus optimizing oxygen delivery to the tissues.[7]
In EGDT, fluids are administered until the central venous pressure (CVP), as measured by a central venous catheter reachs 8-12 cm of water (or 10-15 cm of water in mechanically ventilated patients). If the mean arterial pressure is less than 65 mmHg or greater than 90 mmHg, vasopressors or vasodilators are given as needed to reach the goal. Once these goals are met the central venous saturation (ScvO2), i.e. the oxgyen saturation of venous blood as it returns to the heart as measured at the superior vena cava, is optimized. If the ScvO2 is less than 70%, blood is given to reach a hemoglobin of 10 g/dl and then inotropes are added until the ScvO2 is optimized. Elective intubation may be performed to reduce oxygen demand if the ScvO2 remains low despite optimization of hemodynamics. Urine output is also monitored, with a goal of 0.5 ml/kg/h. In the original trial, mortality was cut from 46.5% in the control group to 30.5% in the intervention group.[7] The Surviving Sepsis Campaign guidelines recommends EGDT for the initial resuscitation of the septic patient with a level B strength of evidence (single randomized control trial).[6]
Most therapies aimed at the inflammatory process itself have failed to improve outcome, however drotrecogin alfa (activated protein C, one of the coagulation factors) has been shown to decrease mortality from about 31% to about 25% in severe sepsis. To qualify for drotrecogin alfa, a patient must have severe sepsis or septic shock with an APACHE II score of 25 or greater and a low risk of bleeding.[8] Low dose hydrocortisone treatment has shown promise for septic shock patients with relative adrenal insufficiency as defined by ACTH stimulation testing.[9]
Standard treatment of infants with suspected sepsis consists of supportive care, maintaining fluid status with intravenous fluids, and the combination of a beta-lactam antibiotic (such as ampicillin) with an aminoglycoside such as gentamicin.
Prognosis
Prognosis can be estimated with the MEDS score.[10]
Related conditions/complications
- Infection is the invasion of normally sterile host tissues by a microbial pathogen.
- Bacteremia is the presence of bacteria in the blood. Bacteremia can occur in sepsis and other serious diseases such as infective endocarditis, bacteremic pyelonephritis or pneumonia and meningitis but it may also be a harmless and transient condition.
- Viremia is the presence of Viruses in the blood.
- Septic joint is an infection of a joint; it is associated with bacteremia and trauma.
- Disseminated intravascular coagulation (DIC) can be the result of sepsis
- Acute tubular necrosis (ATN) leading to acute renal failure, can be the result of hypoperfusion of the kidneys in sepsis (i.e. not enough blood gets to the kidney and they stop working properly)
- Arrhythmia is an abnormal heart rhythm; it can be the result of sepsis.
- Ileus or ischemic colitis can be the result (hypoperfusion) or cause of sepsis
- Multiple organ dysfunction syndrome can be the result of sepsis
- Meningitis, infection of the tissue that covers the brain and spinal cord, can be a complication or cause of sepsis
- Osteomyelitis is an infection of the bone; it can be the cause or result of sepsis
- Endocarditis, infection of the inner surface of heart which is in contact with blood, can also be a complication or cause of sepsis
- Pyaemia — causes abscesses
References
- ↑ Stedman's Medical Dictionary. URL: http://www.emedicine.com/asp/dictionary.asp?keyword=septicemia. Accessed on: June 30, 2007.
- ↑ Stedman's Medical Dictionary. URL: http://www.emedicine.com/asp/dictionary.asp?keyword=sepsis. Accessed on: June 30, 2007.
- ↑ Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003 Apr 17;348(16):1546-54. PMID 12700374 Full Text.
- ↑ Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992 Jun;101(6):1644-55. PMID 1303622.
- ↑ Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G; SCCM/ESICM/ACCP/ATS/SIS. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003 Apr;31(4):1250-6.
- ↑ 6.0 6.1 Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM; Surviving Sepsis Campaign Management Guidelines Committee. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004 Mar;32(3):858-73. Erratum in: Crit Care Med. 2004 Jun;32(6):1448. Correction of dosage error in text. Crit Care Med. 2004 Oct;32(10):2169-70. PMID 15090974.
- ↑ 7.0 7.1 Rivers E, Nguyen B, Havstad S, et al (2001). "Early goal-directed therapy in the treatment of severe sepsis and septic shock". N. Engl. J. Med. 345 (19): 1368-77. PMID 11794169.
- ↑ Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ Jr; Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001 Mar 8;344(10):699-709. PMID 11236773 Full Text.
- ↑ Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellissant E. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002 Aug 21;288(7):862-71. PMID 12186604.
- ↑ Shapiro NI, Wolfe RE, Moore RB, Smith E, Burdick E, Bates DW (2003). "Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule". Crit. Care Med. 31 (3): 670-5. doi:10.1097/01.CCM.0000054867.01688.D1. PMID 12626967.
See also
External links
- Septicemia in the Medical Encyclopedia, Medline Plus ("A service of the United States National Library of Medicine [NLM] and the National Institutes of Health [NIH]"). Updated October 27, 2005. Accessed August 31, 2007.
- Surviving Sepsis Campaign
- Sepsis Cleveland Clinic Medical Reference
- International Sepsis Forum
- Advances in Sepsis journal
- Sepsis.com
- Medscape Sepsis Resource Center
Health Science · Medicine · Medical specialities · Intensive care medicine / Critical care medicine and Critical care nursing | |||||||
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| General terms | Intensive care unit (ICU) · Neonatal intensive care unit (NICU) · Pediatric intensive care unit (PICU) · Coronary care unit (CCU) · Critical illness insurance | ||||||
| Conditions |
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| Diagnosis | Arterial blood gas · Arterial catheter · Blood cultures · Central venous catheter · Pulmonary artery catheter · Screening cultures | ||||||
| Life supporting treatments | Airway management · Chest tube · Dialysis · Enteral feeding · Goal-directed therapy · Induced coma · Mechanical ventilation · Therapeutic hypothermia · Total parenteral nutrition | ||||||
| Drugs | Analgesics · Antibiotics · Antithrombotics · Inotropes · Intravenous fluids · Neuromuscular-blocking drugs · Recombinant activated protein C · Sedatives · Stress ulcer prevention drugs · Vasopressors | ||||||
| ICU scoring systems | APACHE II · Glasgow Coma Scale · PIM2 · SAPS II · SAPS III · SOFA | ||||||
| Organisations | Society of Critical Care Medicine · Surviving Sepsis Campaign | ||||||
| Related specialties | Anesthesia · Cardiology · Internal medicine · Neurology · Pediatrics · Pulmonology · Surgery · Traumatology | ||||||
WikiDoc Research Resources for Sepsis | |
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| Articles on Sepsis | Most recent articles on Sepsis • Most cited articles on Sepsis • Review articles on Sepsis • Articles on Sepsis in N Eng J Med, Lancet, BMJ |
| Media (Slides, Video, Images, MP3) on Sepsis | Powerpoint slides on Sepsis • Images of Sepsis • Photos of Sepsis • Podcasts & MP3s on Sepsis • Videos on Sepsis |
| Evidence Based Medicine Regarding Sepsis | Cochrane Collaboration on Sepsis • Bandolier on Sepsis • TRIP on Sepsis |
| Cost Effectiveness of Sepsis | Cost Effectiveness of Sepsis |
| Clinical Trials Involving Sepsis | Ongoing Trials on Sepsis at Clinical Trials.gov • Trial results on Sepsis • Clinical Trials on Sepsis at Google |
| Guidelines / Policies / Government Resources (FDA/CDC) Regarding Sepsis | US National Guidelines Clearinghouse on Sepsis • NICE Guidance on Sepsis • NHS PRODIGY Guidance • FDA on Sepsis • CDC on Sepsis |
| Textbook Information on Sepsis | Books and Textbook Information on Sepsis |
| Pharmacology Resources on Sepsis | Dosing of Sepsis • Drug interactions with Sepsis • Side effects of Sepsis • Allergic reactions to Sepsis • Overdose information on Sepsis • Carcinogenicity information on Sepsis • Sepsis in pregnancy • Pharmacokinetics of Sepsis • |
| Genetics, Pharmacogenomics, and Proteinomics of Sepsis | Genetics of Sepsis • Pharmacogenomics of Sepsis • Proteomics of Sepsis |
| Newstories on Sepsis | Sepsis in the news • Be alerted to news on Sepsis • News trends on Sepsis |
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| Patient Resources on Sepsis | Patient resources on Sepsis • Discussion groups on Sepsis • Patient Handouts on Sepsis • Directions to Hospitals Treating Sepsis • Risk calculators and risk factors for Sepsis |
| Healthcare Provider Resources on Sepsis | Symptoms of Sepsis • Causes & Risk Factors for Sepsis • Diagnostic studies for Sepsis • Treatment of Sepsis |
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| International Resources on Sepsis | Sepsis en Espanol • Sepsis en Francais |
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Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
