Target Health Blog

Sepsis

June 3, 2019

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Quiz
Source:

Sepsis Steps. Training tool for teaching the progression of sepsis stages
Graphic credit: by Hadroncastle - Own work, CC BY-SA 4.0,
https://commons.wikimedia.org/w/index.php?curid=44761944

Sepsis has been described since the time of Hippocrates.

Sepsis is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. Common signs and symptoms include fever, increased 1) ___ rate, increased breathing rate, and confusion. There may also be symptoms related to a specific infection, such as a cough with pneumonia, or painful urination with a kidney infection. In the very young, old, and people with a weakened immune system, there may be no symptoms of a specific infection and the body temperature may be low or normal, rather than high. Severe sepsis is sepsis causing poor organ function or insufficient blood flow. Insufficient blood flow may be evident by low blood pressure, high blood lactate, or low urine output. Septic shock is low 2) ___ pressure due to sepsis that does not improve after fluid replacement. Sepsis is caused by an inflammatory immune response triggered by an infection. Most commonly, the infection is bacterial, but it may also be fungal, viral, or protozoan. Common locations for the primary infection include the lungs, brain, urinary tract, skin, and abdominal organs. Risk factors include very young age, older age, a weakened immune system from conditions such as cancer or diabetes, major trauma, or burns.

An older method of diagnosis was based on meeting at least two systemic inflammatory response syndrome (SIRS) criteria due to a presumed infection. In 2016, SIRS was replaced with a shortened sequential organ failure assessment score (SOFA score) known as the quick SOFA score (qSOFA) which is two of the following three: increased breathing rate, change in level of consciousness, and low blood 3) ___. Blood cultures are recommended preferably before antibiotics are started; however, infection of the blood is not required for the diagnosis. Medical imaging should be used to look for the possible location of infection. Other potential causes of similar signs and symptoms include anaphylaxis, adrenal insufficiency, low blood volume, heart failure, and pulmonary embolism. Sepsis is usually treated with intravenous fluids and antibiotics. Typically, antibiotics are given as soon as possible. Often, ongoing care is performed in an intensive care unit. If fluid replacement is not enough to maintain blood pressure, medications that raise blood pressure may be used. Mechanical ventilation and dialysis may be needed to support the function of the lungs and kidneys, respectively. To guide treatment, a central venous catheter and an arterial catheter may be placed for access to the bloodstream. Other measurements such as cardiac output and superior vena cava oxygen saturation may be used. People with sepsis need preventive measures for DVT, (which stands for 4) ___ ___ ____), stress ulcers and pressure ulcers, unless other conditions prevent such interventions. Some might benefit from tight control of blood sugar levels with insulin. The use of corticosteroids is controversial, with some reviews finding benefit, and others not.

Disease severity partly determines the outcome. The risk of death from sepsis is as high as 30%, from severe sepsis as high as 50%, and from septic shock as high as 80%. The number of cases worldwide is unknown as there is little data from the developing world. Estimates suggest sepsis affects millions of people a year. In the developed world approximately 0.2 to 3 people per 1000 are affected by sepsis yearly, resulting in about a million cases per year in the United States. Rates of disease have been increasing. Sepsis is more common among 5) ___ than females. The terms “septicemia“ and “blood poisoning“ have been used in various ways and are no longer recommended. In addition to symptoms related to the actual cause, sepsis is frequently associated with the following - fever, low body temperature, rapid breathing, a fast heart rate, confusion, and edema. Early signs include a rapid heart rate, decreased urination, and high blood 6) ___. Signs of established sepsis include confusion, metabolic acidosis (which may be accompanied by a faster breathing rate that leads to respiratory alkalosis), low blood pressure due to decreased systemic vascular resistance, higher cardiac output, and disorders in blood-clotting that may lead to organ failure. The drop in blood pressure seen in sepsis can cause lightheadedness and is part of the criteria for septic shock.

Infections leading to sepsis are usually 7) ___, but may be fungal or viral. Gram-positive bacteria was the predominant cause of sepsis before the introduction of antibiotics in the 1950s. After the introduction of antibiotics, gram-negative bacteria became the predominant cause of sepsis from the 1960s to the 1980s. After the 1980s, gram-positive bacteria, most commonly staphylococci, are thought to cause more than 50% of cases of sepsis. Other commonly implicated bacteria include Streptococcus pyogenes, Escherichia coli, Pseudomonas aeruginosa, and Klebsiella species. Fungal sepsis accounts for approximately 5% of severe sepsis and septic shock cases; the most common cause of fungal sepsis is infection by Candida species of yeast, a frequent hospital-acquired infection. The most common sites of infection resulting in severe sepsis are the lungs, the abdomen, and the urinary tract. Typically, 50% of all sepsis cases start as an infection in the lungs. No definitive source is found in one third to one half of cases. Early diagnosis is necessary to properly manage sepsis, as initiation of rapid therapy is key to reducing deaths from severe sepsis. Some hospitals use alerts generated from electronic 8) ___ records to bring attention to potential cases as early as possible. Within the first three hours of suspected sepsis, diagnostic studies should include white blood 9) ___ counts, measuring serum lactate, and obtaining appropriate cultures before starting antibiotics, so long as this does not delay their use by more than 45 minutes.

To identify the causative organism(s), at least two sets of blood cultures using bottles with media for aerobic and anaerobic organisms should be obtained, with at least one drawn through the skin and one drawn through each vascular access device (such as an IV catheter) in place more than 48 hours. Bacteria are present in the blood in only about 30% of cases. Another possible method of detection is by polymerase chain reaction. If other sources of infection are suspected, cultures of these sources, such as urine, cerebrospinal fluid, wounds, or respiratory secretions, also should be obtained, as long as this does not delay the use of antibiotics. Within six hours, if blood pressure remains low despite initial fluid resuscitation of 30 ml/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. Evidence for point of care lactate measurement over usual methods of measurement, however, is poor. 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, infection causing inflammation of the abdominal cavity lining, infection of the bile duct, or intestinal infarction. A pierced internal organ (free air on abdominal x-ray or CT scan), an abnormal chest x-ray consistent with pneumonia (with focal opacification), or petechiae, purpura, or purpura fulminans may be evident of infection.

Early diagnosis of sepsis is one of the most important points to keep expectations high. The role of early recognition of organ system dysfunction should be studied in detail. For instance, dysfunction of the coagulation system is an early manifestation of 10) ___ and is seen commonly with this disease. The hematologic organ system is a major element in the response to a septic insult, and in the majority of patients, systemic activation of coagulation is present. Increasing evidence suggests that molecular mechanisms which cause inflammation-induced coagulation play an important role in the pathogenesis of sepsis. Prolongation of the PT and/or activated partial thromboplastin time is prevalent and detectable in 15-30% of septic patients.

ANSWERS: 1) heart; 2) blood; 3) pressure; 4) deep vein thrombosis; 5) males; 6) sugar; 7) bacterial; 8) health; 9) cell; 10) sepsis

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