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Definition

Sepsis is a systemic, deleterious host response to infection, manifested as multi system organ dysfunction plus hypotension, that is not readily reversible with fluid resuscitation.

Diagnostic Criteria For Sepsis (Documented/Suspected Infection Plus Inflammatory variables Plus One of The Organ Dysfunction)

General variables

• Fever > 38.3°C
• Hypothermia ( core temperature < 36°C )
• Heart rate > 90/min–1 or > 2 SD above the normal value for age
• Tachypnea
• Altered mental status
• Edema
• Positive fluid balance ( > 20 mL/kg over 24 hr)
• Hyperglycemia ( plasma glucose > 140 mg/dL or 7.7 mmol/L ) in the absence of diabetes

Inflammatory variables

• Leukocytosis ( WBC count > 12,000 µL–1 )
• Leukopenia ( WBC count < 4000 µL–1 )
• Immature WBCs forms are > 10% with normal count
• Plasma C-reactive protein > 2 SD above the normal value
• Plasma procalcitonin > 2 SD above the normal value

Hemodynamic variables

• Arterial hypotension after 30 ml/kg fluid bolus ( SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm Hg 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 or 44.2 µmol/L
• Coagulation abnormalities ( INR > 1.5 or aPTT > 60 Sec )
• Ileus ( absent bowel sounds )
• Thrombocytopenia ( platelet count < 100,000 µL–1 )
• Hyperbilirubinemia ( plasma total bilirubin > 4 mg/dL or 70 µmol/L )

Tissue perfusion variables

• Hyperlactatemia > 1 mmol/L
• Decreased capillary refill or mottling

Diagnostic Criteria for Severe Sepsis (sepsis induced hypoperfusion or organ dysfunction)

Includes any one of the following caused due to the infection:

• Sepsis-induced hypotension
• Lactate above upper limits laboratory normal
• Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation
• Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source
• Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as infection source
• Creatinine > 2.0 mg/dL (176.8 μmol/L)
• Bilirubin > 2 mg/dL (34.2 μmol/L)
• Platelet count < 100,000 μL
• Coagulopathy (international normalized ratio > 1.5)

Management

Characterize the symptoms: Fever Hypothermia Altered mental status Mottling Ileus oliguria

Examine the patient: Tachycardia Tachypnea Edema Hyperglycemia Hypotension after an initial 30 ml/Kg bolus Decreased capillary refill

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{{{Order labs: Random blood sugar (RBS) Complete blood count (CBC) Plasma C reactie protein (CRP) Plasma procalcitonin Pulse oximetry Urinalysis/Renal function tests PT/INR Liver function tests Serum lactate Central venous pressure (CVP) }}}

Consider alternative diagnosis: Infections Acute pancreatitis Diabetic ketoacidosis Lower gastrointestinal bleeding Myocardial infarction

Initial resuscitation: Goals to achieve in first 6 hours CVP 8-12 mm Hg Mean arterial pressure (MAP) ≥ 65 mm Hg Urine output ≥ 0/5 mL/Kg/hr Central venous O2 sat. 70%

Diangosis: 2 sets of blood cultures (aerobic and anaerobic) atleast, before starting antibiotics Drawn percutaneously Drawn through each vascular access device present for > 48 hours 1,3 beta-D_glucan assay, mannan, anti-mannan antibody assay if available Imaging studies as appropriate to locate a source