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YOUR INTENSIVE CARE HOTLINE - Sepsis

Sepsis

What is Sepsis?
Sepsis ( putrefaction and decay) is a potentially fatal or lethal whole-body inflammation (a systemic inflammatory response syndrome or SIRS) caused by severe infection. Sepsis can continue even after the infection that caused it is gone. Severe sepsis is sepsis complicated by organ dysfunction or sometimes Multi Organ Failure. Septic shock is sepsis complicated by a high lactate level or by shock that does not improve after fluid resuscitation and often goes hand in hand with low blood pressure(hypotension). Bacteremia is the presence of viable bacteria in the blood in is caused by a bacterial infection.

Signs& Symptoms of Sepsis
• Fever(hyperthermia) or low grade temperature(hypothermia)
• Rapid breathing(tachypnoea)
• Elevated heart rate(Tachycardia)
• Decreased Urine Output
• Elevated Blood sugar
• Confusion
• Metabolic acidosis(caused by high acid production in the body)
• Respiratory alkalosis(hyperventilation)
• Low blood pressure(hypotension), sometimes resulting in Shock
• decreased systemic vascular resistance
• higher cardiac output(caused by increased contractility of the heart muscle)
• dysfunctions of blood coagulation(increased risk of bleeding)

Causes of Sepsis
The most common primary sources of infection resulting in sepsis are the lungs, the abdomen(I.e. Abdominal Trauma), and the urinary tract. Sepsis can also occur after Multi Trauma (Polytrauma).
No source of Sepsis is found in one third of cases. The infectious agents are usually bacteria but can also be fungi and viruses. While gram-negative bacteria were previously the most common cause of sepsis, in the last decade, gram-positive bacteria, most commonly staphylococci, are thought to cause more than 50% of cases of sepsis.
Diagnosis
Prompt diagnosis is crucial to the management of sepsis, as initiation of early-goal-directed therapy is key to reducing Patients in Intensive Care dying from Sepsis.
Within the first three hours of suspected sepsis, diagnostic studies should include measurement of serum lactate, obtaining appropriate blood cultures before initiation of antimicrobial treatment, so long as this does not delay antimicrobial treatment by more than 45 minutes. To identify the organism(s) that may cause the Sepsis, at least two sets of blood cultures (aerobic and anaerobic bottles) should be obtained, with at least one drawn percutaneously and one drawn through each vascular access device (such as an IV catheter) in place more than 48 hours. If other sources are suspected, cultures of these sources, such as urine, cerebrospinal fluid, wounds, respiratory(lung) secretions, should be obtained as well, so long as this does not delay antimicrobial treatment.
Within six hours, if there is persistent low blood pressure(hypotension) despite initial fluid resuscitation of 30ml/kg, or if initial lactate is ? 4 mmol/L (36 mg/dL), central venous pressure and central venous oxygen saturation should be measured. Lactate should be re-measured if the initial lactate was elevated.
Within twelve hours, it is essential to diagnose or exclude any source of infection that would require emergent source control, such as necrotizing soft tissue infection, peritonitis, cholangitis, intestinal infarction.

How is Sepsis treated?
The therapy of sepsis rests on intravenous fluids, antibiotics, surgical drainage of infected fluid collections, and appropriate support for organ dysfunction. This may include hemodialysis in kidney failure, mechanical ventilation if lung dysfunction is present, transfusion of blood products, and drug and fluid therapy for heart failure. Ensuring adequate nutrition—preferably by enteral feeding(via nasogastric tube), but if necessary by parenteral nutrition—is important during prolonged critical illness.
In those with high blood sugar levels, insulin to bring it down to 7.8-10 mmol/L (140–180 mg/dL) is recommended with lower levels potentially worsening outcomes. Medication to prevent deep vein thrombosis and gastric ulcers may also be used.

Antibiotic Therapy
In severe sepsis, broad spectrum antibiotics are recommended within 1 hour of making the diagnosis. For every hour delay in the administration there is an associated 6% rise in mortality. Antibiotic regimens should be reassessed daily and narrowed if appropriate. Duration of treatment is typically 7–10 days with the type of antibiotic used directed by the results of the blood cultures.

One of the other goals during Sepsis is to manage and optimize heart function by optimizing preload, afterload and contractility. This is usually done with the use of Inotropes. It has been found that this is correlating with a reduced number of Patients dying from Sepsis.

Intravenous fluids
Fluids are titrated in response to heart rate, blood pressure, and urine output; restoring large fluid deficits can require 6 to 10L of crystalloids. In cases where a central venous catheter is used to measure blood pressures dynamically, fluids should be administered until the central venous pressure (CVP) reaches 8–12 cm of water (or 10–15 cm of water in mechanically ventilated patients). Once these goals are met, the mixed venous oxygen saturation (SvO2), i.e., the oxygen saturation of venous blood as it returns to the heart as measured at the vena cava, is optimized. If the SvO2 is less than 70%, blood is given to reach a hemoglobin of 10 g/dl and then inotropes are added until the SvO2 is optimized.
Once the person has been sufficiently fluid resuscitated but the mean blood pressure is not greater than 65 mmHg Inotropes are recommended

Ventilation
Elective tracheal intubation and mechanical ventilation may be performed to reduce oxygen demand if the SvO2 remains low despite optimization of haemodynamics.

Prognosis
Approximately 20–35% of people with severe sepsis and 30–70% of people with septic shock die. Lactate is a useful method of determining prognosis with those who have a level greater than 4 mmol/L having a mortality of 40% and those with a level of less than 2 mmol/L have a mortality of less than 15%.

What happens in Intensive Care?
Treatment for your loved one who is suffering from Sepsis may be straightforward or quite complex depending on the individual Patient and their immediate condition after they have been diagnosed with Sepsis.

Investigations such as blood tests(Blood& Pathology tests in Intensive Care), Chest X-ray, CT, ultrasound of the heart(Echoecardiography), Abdomen etc… are performed to identify the cause of the Sepsis and treatment will be commenced accordingly. Further investigations will be required if your loved one loses consciousness in a short time.

1. Crystalloids – salt, water and electrolyte solutions
2. Colloids – ‘plasma’ like solutions
3. Blood and blood products(Red blood cells, FFP’s= Fresh Frozen Plasma, Platelets etc…)
2. Drugs – to restore abnormal body functions:
1. Inotropes(Dobutamine/Dobutrex, Milrinone) – to assist the heart to pump with more force at the right rate
2. Vasodilators(GTN, Sodium Nitroprusside(SNP)) – to open up blood vessels
3. Vasoconstrictors(Noradrenaline, Adrenaline) – to narrow blood vessels
4. Antibiotics – to fight infection caused by bacteria
5. Steroids like Hydrocortisone may be given

The information contained in this sheet is general in nature and therefore cannot reflect individual Patient variation. It is provided as a back up to specific information which will be discussed with you by the Doctors and Nurses caring for your loved one.

How long will your loved one remain in ICU?
Your loved one will remain in intensive care while they have investigations and treatment. Each Patient’s condition is very unique and especially with varying types of shock, the length of stay can vary from a few days up to weeks or sometimes even longer. It is important to speak with the medical and nursing team caring for your loved one to discuss the potential outcome and prognosis.

Any Questions?
Of course, if you have any questions or concerns, please discuss them with the ICU nurses and doctors.
All Intensive Care interventions and procedures carry a degree of potential risk even when performed by skilled and experienced staff. Please discuss these issues with the medical and nursing staff who are caring for your loved one.
The information contained on this page is general in nature and therefore cannot reflect individual patient variation. It is meant as a back up to specific information which will be discussed with you by the Doctors and Nurses caring for your loved one. INTENSIVE CARE HOTLINE attests to the accuracy of the information contained here BUT takes no responsibility for how it may apply to an individual Patient. Please refer to the full disclaimer.

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