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Sepsis

Sepsis

Sepsis is a condition in which the body is fighting a severe infection that has spread via the bloodstream. If a patient becomes "septic", they will likely have low blood pressureleading to poor circulation and lack of perfusion of vital tissues and organs. This condition is termed "shock". This condition can develop either as a result of the body's own defense system or from toxic substances made by the infecting agent (such as a bacteria, virus, orfungus).

 

People at Risk for Sepsis

 

  • People whose immune systems (the body's defense against microbes) are not functioning well because of an illness (such as diabetes or AIDS) or because of medical treatments (such as chemotherapy for cancer or steroids for a number of medical conditions) that weaken the immune system are more prone to develop sepsis. It is important to remember that even healthy people can become septic.
  • Because their immune systems are not completely developed, very young babies may get sepsis if they become infected and are not treated in a timely manner. Often, if they develop signs of an infection such as fever, infants have to receive antibiotics and be admitted to the hospital. Sepsis in the very young is often more difficult to diagnose because the typical signs of sepsis (fever, change in behavior) may not be present or may be more difficult to ascertain.
  • The elderly population, especially those with other medical illnesses such as diabetes, may be at increased risk as well. The number of people dying from sepsis has almost doubled in the past 20 years. This is most likely due to the increased number of patients who suffer from sepsis. The number of patients who develop sepsis has increased for many reasons.
  • There has been a large increase in sepsis because doctors have started treating cancer patients and organ-transplant patients, among others, with strong medications that weaken the immune system. In the past, these patients would have died due to complications of their disease. As we get better at treating the underlying illness, patients survive longer but then sometimes die due to the complications of the therapy.
  • Because of our aging population, the number of elderly people with weak immune systems has grown.
  • Because antibiotic use has increased, many strains of bacteria have become resistant to antibiotics, making the treatment of sepsis more difficult in some cases.

Symptoms

The adult patient should have a proven or suspected source of an infection (usually bacterial) and have at least two of the following problems: an elevated heart rate (tachycardia), either a high (fever) or low temperature (hypothermia), rapid breathing (>20 breaths per minute or a reduced PaCO2 level), or a white blood cell count that is either high, low, or composed of >10% band cells.
 
In most cases, it is fairly easy to ascertain heart rate (count pulse per minute), fever or hypothermia with a thermometer, and to count breaths per minute even at home.
 
It may be more difficult to prove a source of infection, but if the person has symptoms of infection such as productivecough, or dysuria, or fevers, or a wound with pus, it is fairly easy to suspect that a person with an infection may have sepsis. However, determination of the white blood cell count and PaCO2 is usually done by a lab. In most cases, the definitive diagnosis of sepsis is made by a physician in conjunction with laboratory tests.
 
Elderly patients have similar symptoms to those stated for adults, but the first apparent symptoms are often confusion along with chills, weakness, possibly faster breathing, and a dusky skin appearance. Pediatric patients (infants, toddlers, and children) also may develop similar symptoms to those in adults, but the most common symptoms are fever and reduced urine output. Children may show signs of lethargy and decreased age-appropriate mental status.
 
Neonatal sepsis (sepsis neonatorum) is suspected in neonates up to 28 days old if the rectal temperature is 100.4F or higher. Other signs and symptoms for neonatal sepsis include fever in the mother at time of delivery, cloudy or smelly amniotic fluid, abnormal vital signs, seizures, and projectile vomiting.
 
Some authors consider red lines or red streaks on the skin to be signs of sepsis. However, these streaks are due to local inflammatory changes in either local blood vessels or lymphatic vessels (lymphangitis). The red streaks or lines are worrisome as they usually indicate a spreading infection that can result in sepsis.

Causes

The majority of cases of sepsis are due to bacterial infections, some are due to fungal infections, and very few are due to other causes of infection or agents that may cause SIRS. The infectious agents, usually bacteria, begin infecting almost any organ location or implanted device (for example, skin, lung, gastrointestinal tract, surgical site, intravenous catheter, etc.).

 

The infecting agents or their toxins (or both) then spread directly or indirectly into the bloodstream. This allows them to spread to almost any other organ system. SIRS criteria result as the body tries to counteract the damage done by these blood-borne agents.

 

Common bacterial causes of sepsis are gram-negative bacilli (for example, E. coli, P. aeruginosa, E. corrodens and Haemophilus influenzae in neonates), S. aureus,Streptococcus species and Enterococcusspecies; however, there are a large number of bacterial genera that have been known to cause sepsis.

 

Candida species are some of the most frequent fungi that cause sepsis. In general, a person with sepsis can be contagious, so precautions such as hand washing, sterile gloves, masks, and clothing coverage should be considered depending on the patient's infection source.

 

How is sepsis diagnosed?

 

Clinically, the patient needs to fit at least two of the SIRS criteria listed above and have a suspected or proven infection. Definitive diagnosis depends on a positive blood culture for an infectious agent and at least two of the SIRS criteria. However, two subsets of the four criteria depend on lab analysis; white blood cell examinations and PaCO2. These subset criteria, like blood cultures, are measured in clinical laboratories.

 

There are other diagnoses that indicate the severity of the patient's sepsis. Severe sepsis is diagnosed when the septic patient has organ dysfunction (for example, low or no urine flow, altered mental status). Severe sepsis can also include sepsis-induced hypotension (also termed septic shock) when the patient's blood pressure falls.

Treatment

In almost every case of sepsis, patients need to be hospitalized, treated with appropriate intravenous antibiotics, and given therapy to support any organ dysfunction. Sepsis can quickly cause organ damage and death; therapy should not be delayed as statistics suggest as high as a 7% mortality increase per hour if antibiotics are delayed in severe sepsis. Most cases of sepsis are treated in an intensive care unit (ICU) of the hospital.

 

Appropriate antibiotics to treat sepsis are combinations of two or three antibiotics given at the same time; most combinations usually include vancomycin to treat many MRSA infections. However, once the infecting organism is isolated, labs can determine which antibiotics are most effective against the organisms, and those antibiotics should be used to treat the patient. In addition to antibiotics, two other major therapeutic interventions, organ-system support and surgery, may be needed.

 

First, if an organ system needs support, the intensive care unit can often provide it (for example, intubation to support lung function or dialysis to support kidney function). Secondly, surgery may be needed to drain or remove the source of infection. Amputation of extremities has been done to save some patients' lives.

 

A recent research report may alter a common treatment for septic shock. Because of the low blood pressure seen with septic shock, IV fluid boluses have been used to support the patient's blood pressure. However, a 2011 study in over 3,000 children in Africa with impaired perfusion (shock) the fluid bolus treatments actually increased mortality in the children.

 

This surprising result has raised questions about how clinicians can best manage septic shock in the future. For example, in 2004, guidelines were published that "bundled" therapeutic methods (for example, blood cultures, antibiotic therapy, and fluid therapy) to treat sepsis in an initial six-hour period that included fluid boluses. This septic treatment bundle of techniques may need revision or reexamination.

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