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== Introduction ==
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[[File:Sepsis treatment.jpg|alt=|thumb|Sepsis Treatment]]
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Sepsis is a syndrome, with a poorly understood pathogenesis, causing life-threatening [[Vital Organs|organ]] dysfunction. Sepsis occurs when the body's response to this infection is overwhelming, potentially leading to organ failure and septic [[shock]]. It is associated with high morbidity and mortality rates, being a final common pathway to death from many infectious diseases worldwide.<ref name=":4">Life in the fast lane [https://litfl.com/sepsis-definitions-and-diagnosis/ Sepsis Definitions and Diagnosis] Available:https://litfl.com/sepsis-definitions-and-diagnosis/ (accessed 31.12.2022)</ref><ref>Zhang W, Zheng Y, Feng X, Chen M, Kang Y. [https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-019-3790-0#Sec22 Systemic inflammatory response syndrome in Sepsis-3: a retrospective study.] BMC infectious diseases. 2019 Dec;19(1):1-0.Available:https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-019-3790-0#Sec22 (accessed 31.12.2022)</ref><ref name=":6">World health organisation [https://www.who.int/news-room/fact-sheets/detail/sepsis Sepsis] Available:https://www.who.int/news-room/fact-sheets/detail/sepsis (accessed 31.12.2022)</ref> Sepsis needs urgent treatment as it can quickly worsen.<ref name=":0">NICE [https://www.nice.org.uk/guidance/ng51/ifp/chapter/What-is-sepsis Sepsis: recognition, diagnosis and early management] Available:https://www.nice.org.uk/guidance/ng51/ifp/chapter/What-is-sepsis (accessed 31.12.2022)</ref>


== Description ==
== Epidemiology ==
The potentially life-threatening term of sepsis is defined as a systematic response to fight off the cause of an infection. It can be complicated by systemic inflammatory response syndrome (SIRS), resulting in a generalised inflammatory response, or in severe cases, septic shock. During septic shock, the reserve tissue capacity of tissue respiration is exhausted, resulting in the failure of the supply to meet the demand in terms of oxygenation. This results in hypotension not responding to fluid resuscitation. This can potentially lead to multiorgan failure where the body is unable to maintain haemostasis without medical intervention, a common cause of death in the ICU setting.<ref name=":0">Hough A. [https://books.google.co.za/books?hl=en&lr=&id=Uk1NfFGMrJoC&oi=fnd&pg=PA1&dq=physiotherapy+in+respiratory+care&ots=-OGsYM9A8r&sig=9rLChntH7new4xMcNA9V_orlCGA&redir_esc=y#v=onepage&q=physiotherapy%20in%20respiratory%20care&f=false Physiotherapy in respiratory care: a problem-solving approach to respiratory and cardiac management.] Springer; 2013.</ref>
The worldwide burden of sepsis is hard to establish.


== Clinically Relevant Anatomy  ==
* A 2017 study estimated sepsis  accounted for almost 20% of all global deaths, with 48.9 million cases and 11 million sepsis-related deaths worldwide (twice that thought previously).<ref name=":5">Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, Colombara DV, Ikuta KS, Kissoon N, Finfer S, Fleischmann-Struzek C. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6970225/ Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study]. The Lancet. 2020 Jan 18;395(10219):200-11.Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6970225/ (accessed 31.12.2022)</ref>
* Almost half of all global sepsis cases occurred among children in 2017.<ref name=":5" />
* Roughly 85% of sepsis cases and sepsis-related deaths worldwide occur in low- and middle-income countries.<ref name=":5" />
* In the United States approximately 270,000 deaths annually.<ref name=":7">Gauer R, Forbes D, Boyer N. [https://www.aafp.org/pubs/afp/issues/2020/0401/p409.html Sepsis: diagnosis and management]. American family physician. 2020 Apr 1;101(7):409-18.Available:https://www.aafp.org/pubs/afp/issues/2020/0401/p409.html (accessed 31.12.2022)</ref><ref name=":6" />
== Etiology ==
Sepsis occurs when the body's response to this infection turns on the body, potentially leading to organ failure and septic [[shock]].<ref name=":8" />  The 2009 European Prevalence of Infection in Intensive Care (EPIC II study) determined that gram-negative [[Bacterial Infections|bacterial]] infections far exceed other etiologies as the most common cause of sepsis syndromes with a frequency of 62%, followed by gram-positive infections at 47%.<ref name=":3">Mahapatra S, Heffner AC. [https://www.ncbi.nlm.nih.gov/books/NBK430939/ Septic Shock (Sepsis)]. InStatPearls [Internet] 2019 Jun 4. StatPearls Publishing.Available from:https://www.ncbi.nlm.nih.gov/books/NBK430939/ (last accessed 22.9.2020)</ref>


add text here relating to '''''clinically relevant''''' anatomy of the condition<br>  
'''View this 3 minute video titled "Sepsis and Septic Shock, Animation."'''{{#ev:youtube|v=-MXi4mOMmI4|300}}<ref>Alila medical media. Sepsis and Septic Shock, Animation.. Available from: https://www.youtube.com/watch?v=-MXi4mOMmI4 [last accessed 31.12.2022]</ref>  


== Epidemiology and Etiology  ==
== Risk Populations ==
* Babies younger than 1 year
* [[Older People Introduction|Older People]]
* [[Introduction to Frailty|Frail]] people
* [[Diabetes|Diabetics]]
* [[Immunocompromised Client|Immunocompromised]]
* Perinatal women
* People who have recently had [[Surgery and General Anaesthetic|surgery]]
* People who have recently had a serious illness.<ref name=":0" />


=== Epidemiology ===
* 80% of sepsis cases are the result of the following infections:<ref name=":1">Annane D, Bellissant E, Cavaillon JM. [http://gim.org.uk/sdarticle.pdf Septic shock.] The Lancet 2005;365(9453):63-78.</ref>
The incidence of sepsis is set at 50-95 per 100 000 with an suspected increase of 9% per year. This is further made up by:<ref name=":1">Annane D, Bellissant E, Cavaillon JM. [http://gim.org.uk/sdarticle.pdf Septic shock.] The Lancet 2005;365(9453):63-78.</ref>
* 2% of hospital admissions
* 9% of sepsis results in severe sepsis
* 3% septic shock
* 10% of ICU admissions per year
* Peak age around 60's
 
Risk factors:<ref name=":1" />
* Cancer
* Immunodeficiency
* Chronic organ failure
* Male > female
* More common in non-white ethnic origin in North Americans
* Polymorphisms in genes that regulate immunity
 
=== Etiology ===
Sepsis is the result of gram-negative, gram-positive, polymicrobial bacteria, multidrug-resistant bacteria and fungi. 80% of sepsis cases is the result of the following infections.<ref name=":1" />
* Chest (e.g. [[pneumonia]])
* Chest (e.g. [[pneumonia]])
* Abdomen
* Abdomen
* Genitourinary system
* Genitourinary system
* Primary bloodstream  
* Primary bloodstream  
Gram-positive bacteria 30–50% Meticillin-susceptible S aureus 14–24% Meticillin-resistant S aureus 5–11% Other Staphylococcus spp 1–3% Streptococcus pneumoniae 9–12% Other Streptococcus spp 6–11% Enterococcus spp 3–13% Anaerobes 1–2% Other gram-positive bacteria 1–5% Gram-negative bacteria 25–30% E coli 9–27% Pseudomonas aeruginosa 8–15% Klebsiella pneumoniae 2–7% Other Enterobacter spp 6–16% Haemophilus influenzae 2–10% Anaerobes 3–7% Other gram-negative bacteria 3–12% Fungus Candida albicans 1–3% Other Candida spp 1–2% Yeast 1% Parasites 1–3% Viruses 2–4% *From published clinical trials145,150 and epidemiological studies.5,6 Table 1: Main pathogens in septic shock


== Mechanism of Injury / Pathological Process ==
== Pathological Process ==
Sepsis results when an infectious insult precipitates a localized inflammatory reaction that goes on to cause systemic symptoms of fever or hypothermia, [[tachycardia]], tachypnea, and leukocytosis or leukopenia (a clinical symptom called systemic inflammatory response syndrome). The inflammatory reaction is mediated by the release of [[cytokines]] which activate the extrinsic [[Compliment System|coagulation cascade]] and inhibit fibrinolysis. This upshot is microvascular [[thrombosis]], a potential factor producing organ dysfunction. Sepsis is a complex syndrome involving activation of a variety of systems.<ref>Jacobi J. [https://pubmed.ncbi.nlm.nih.gov/11885412/ Pathophysiology of sepsis]. Am J Health Syst Pharm. 2002 Feb 15;59 Suppl 1:S3-8. doi: 10.1093/ajhp/59.suppl_1.S3. PMID: 11885412. Available:https://pubmed.ncbi.nlm.nih.gov/11885412/ (accessed 31.12.2022)</ref>


Pathogens have the ability to trigger intercellular events in a variety of cells, including the neuroendocrine system, immune cells, epithelium and endothelium. Proinflammatory mediators attempt to eradicate the pathogens, a process that is controlled by anti-inflammatory mediators. This inflammatory process leads to tissue damage, changes in the leukocytes resulting in immune changes. When this natural control process fails, it leads to systemic inflammation and the infection is converted to sepsis or septic shock.<ref name=":1" />
== Clinical Presentation  ==
Symptoms of sepsis: non-specific and may include:


The hypothalamic thermostat is reset by the fever caused by sepsis. In an attempt to cool down, it results in peripheral vasodilatoation and subsequent depletion of the visceral perfusion. Excess nitric oxide production is stimulated by endotoxins and this leads to uncontrolled vasodilatation and a “functional haemorrhage”. Increased cardiac output is thus unsuccessful at maintaining an adequate blood pressure. This can lead to hypoxic tissue damage.
* Localising symptoms of infection (e.g. productive cough, vomiting, diarrhoea, dysuria)
* Drowsiness
* Confusion
* Dizziness
* Malaise


Shock in general normally runs the following course:
Clinical signs of sepsis may include:


Insufficient tissue perfusion → anaerobic metabolism → lactic acidosis → metabolic acidosis → cellular damage → organ failure.
* Tachycardia
 
* Hypotension
The definition of sepsis is often over-simplified as being the result of exacerbated inflammatory responses. However, pathogenesis involves several factors that interact in a long chain of events from pathogen recognition to overwhelming of host responses. Lancet 2005; 365: 63–78 Service de Réanimation, Hôpital Raymond Poincaré, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Paris Ile de France Ouest, Université de Versailles Saint Quentin en Yvelines, Garches, France (Prof Djillali Annane MD); Centre d’Investigation Clinique INSERM 0203, Unité de Pharmacologie Clinique, Hôpital de Pontchaillou, CHU de Rennes, Faculté de Médecine, Université de Rennes 1, Rennes, France (Prof E Bellissant MD); UP Cytokines & Inflammation, Institut Pasteur, Paris, France (J-M Cavaillon PhD) Correspondence to: Professor Djillali Annane, Service de Réanimation Médicale, Hôpital Raymond Poincaré, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Paris Ile de France Ouest, Université de Versailles Saint-Quentin en Yvelines, 104 Boulevard Raymond Poincaré, 92380 Garches, France [email protected] www.thelancet.com Vol 365 January 1, 2005 63 Septic shock Djillali Annane, Eric Bellissant, Jean-Marc Cavaillon Septic shock, the most severe complication of sepsis, is a deadly disease. In recent years, exciting advances have been made in the understanding of its pathophysiology and treatment. Pathogens, via their microbial-associated molecular patterns, trigger sequential intracellular events in immune cells, epithelium, endothelium, and the neuroendocrine system. Proinflammatory mediators that contribute to eradication of invading microorganisms are produced, and anti-inflammatory mediators control this response. The inflammatory response leads to damage to host tissue, and the anti-inflammatory response causes leucocyte reprogramming and changes in immune status. The time-window for interventions is short, and treatment must promptly control the source of infection and restore haemodynamic homoeostasis. Further research is needed to establish which fluids and vasopressors are best. Some patients with septic shock might benefit from drugs such as corticosteroids or activated protein C. Other therapeutic strategies are under investigation, including those that target late proinflammatory mediators, endothelium, or the neuroendocrine system. Search strategy and selection criteria We attempted to identify all relevant studies irrespective of language or publication status (published, unpublished, in press, and in progress). We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004) using the terms “sepsis” and “septic shock”, and MEDLINE (1966 to June 2004), EMBASE (1974 to June 2004), and LILACS (www.bireme.br; accessed Aug 1, 2003) databases using the terms “septic shock”, “sepsis”, “septicaemia”, “endotoxin”, “lipopolysaccharide” variably combined with “incidence”, “prevalence”, “cause”, “origin”, “diagnosis”, “management”, “treatment”, “therapy”, “prognosis”, “morbidity”, and “mortality”. Studies were selected on the basis of relevance to septic shock. Seminar Patterns and receptors Matzinger10 redefined immunity by postulating that immune system activity stemmed from recognition of and reaction to internal danger signals, rather than from discrimination between self and non-self molecules. Danger signals also include recognition of exogenous molecules, pathogen-associated molecular patterns, which are surface molecules such as endotoxin (lipopolysaccharide), lipoproteins, outermembrane proteins, flagellin, fimbriae, peptidoglycan, peptidoglycan-associated lipoprotein, and lipoteichoic acid; and internal motifs released during bacterial lysis, such as heat-shock proteins and DNA fragments. These molecules are common to pathogenic, non-pathogenic, and commensal bacteria, making “microbial-associated molecular patterns” a better term. These patterns are recognised by specific pattern recognition receptors, which induce cytokine expression. These microbial patterns act synergistically with one another, with host mediators, and with hypoxia. Of pattern recognition receptors, the toll-like receptors are characterised by an extracellular leucinerich repeat domain and a cytoplasmic toll-interleukin-1 receptor (TIR) domain that shares considerable homology with the interleukin-1 receptor cytoplasmic domain. Currently, ten toll-like receptors have been described in humans, and the list of their specific microbial ligands is growing.11 Signal transduction after interaction between microbial-associated molecular patterns and these receptors results in activation of numerous adaptors, some with the TIR domain (myeloid differentiation protein [MyD] 88, TIR domaincontaining adaptor protein, TIR receptor domaincontaining adaptor protein inducing interferon � [TRIF], and TRIF-related adaptor molecule), and of kinase proteins. MyD88 interacts directly with most toll-like receptors and appears upstream from activation of the transcription nuclear factor-B. TRIF results in activation of nuclear factor interferon regulatory factor 3, promoting production of interferon � (figure 2).11 Additionally, molecules in the cytoplasm (MyD88s, interleukin-1 receptor-associated kinase-M, Tollip, suppressor of cytokine signalling 1) or at the cell surface (single immunoglobulin interleukin-1R-related molecule, ST2) negatively control the signalling cascade. Nod1 and Nod2 proteins are intracellular pattern recognition receptors.12 Nod1’s ligand is a peptidoglycan fragment that is almost exclusive to gram-negative bacteria. Nod2 detects a different such fragment and also recognises muramyl dipeptide, the smallest bioactive fragment common to all peptidoglycans. Four peptidoglycan recognition proteins (PGRPs), a third family of pattern recognition receptors, have been characterised in people.13 Three are membrane-bound proteins, PGRP-I, PGRP-I�, and PGRP-L. The fourth is the soluble molecule PGRP-S.
* Tachypnoea
 
* Cyanosis
== Clinical Presentation  ==
* Fever/hypothermia
* Oliguria
* Non-blanching rash
* Mottled/ashen appearance<ref>Geeky medics [https://geekymedics.com/acute-management-of-sepsis/ Sepsis] Available:https://geekymedics.com/acute-management-of-sepsis/ (accessed 31.12.2022)</ref>
'''Watch this 2 minute video "How to recognize sepsis symptoms"'''{{#ev:youtube|dbgWpeEEtaM|300}}


'''Criteria'''<ref name=":0" />
== Prognosis ==
 
Septic shock is a serious illness and despite all the advances in medicine, it still carries high mortality which can exceed 40%.
Two or more of the following:
* Mortality does depend on many factors including the type of organism, antibiotic sensitivity, number of organs affected, and patient age.
* High grade (> 38˚C) or low grade (< 36˚C ) fevers
* The more factors that match SIRS, the higher the mortality.
* Heart rate > 90/minute
* Data suggest that tachypnea and altered mental status are excellent predictors of poor outcomes.
* RR > 20/minute OR PaCO2 < 4.3kPa
* Prolonged use of inotropes to maintain blood pressure is also associated with adverse outcomes.
* WCC > 12
* Those who survive are left with significant functional and cognitive deficits<ref name=":3" />.
'''Signs and symptoms'''
* Pyrexia
* Flushed presentation
* Tachypnea
* Hypotension
* Bounding pulse
* Restricted regional blood flow as the result of vasopressors<br>


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==
Prompt recognition and escalation to a senior medical officer improves sepsis outcomes.<ref>Queensland Government [https://clinicalexcellence.qld.gov.au/priority-areas/safety-and-quality/sepsis/recognition-and-treatment Sepsis] Available:https://clinicalexcellence.qld.gov.au/priority-areas/safety-and-quality/sepsis/recognition-and-treatment (accessed 31.12.2022)</ref>  The guidelines recommend the [[Sequential Organ Failure Assessment Score|Sequential Organ Failure Assessment]] (original and quick versions) as an important tool for early diagnosis.<ref name=":7" />


add text here relating to diagnostic tests for the condition<br>  
* [[Blood Tests|Blood tests]] : test for proof of infection; clotting issues; abnormal liver or kidney function; impaired oxygen availability; [[Electrolytes|electrolyte]] imbalances
 
* Other lab tests may be used to help identify the source of the infection: [[Urine]]; wound secretion; respiratory secretions
== Outcome Measures  ==
* If the site of infection is not readily found other imaging tests including [[X-Rays|X-ray]]. [[CT Scans|CT]], [[MRI Scans|MRI]] and [[Ultrasound Scans|ultrasounds]] may be ordered.<ref name=":8">MAYO clinic Sepsis Available:https://www.mayoclinic.org/diseases-conditions/sepsis/diagnosis-treatment/drc-20351219 (accessed 31.12.2022)</ref>


add links to outcome measures here (see [[Outcome Measures|Outcome Measures Database]])  
== Medical Management ==
[[File:Intensive Care Unit.jpg|right|frameless]]Identifying and recognising the signs and symptoms of sepsis, along with the awareness of some biomarkers (eg C reactive protein), are critical elements for diagnosing sepsis and instituting appropriate management. After early recognition and diagnostics, identifying a causal pathogen of infection targeted antimicrobial treatment can commence. Prompt fluid resuscitation will improve volume status. Vasopressors may be needed to help maintain tissue perfusion. Repeated exams and assessments, including monitoring vital signs, guide the appropriate management of sepsis over time.<ref name=":6" />{{#ev:youtube|watch?v=QzIiClJtwN8}}


== Medical Management ==
== Physiotherapy Management ==
 
See the page for the [[Physiotherapists Role in ICU|role of physiotherapy in the ICU]].
Medical management is vital to prevent further inflammatory response by the cause of the sepsis.<ref name=":0" /> This is normally done by means of ventilatory and haemodynamic support. Treatment is aimed at controlling the cause of infection and restoring haemodynamic homeostasis. 
* Physiotherapy interventions in the ICU setting normally consist of respiratory physiotherapy focusing on airway clearance techniques and early mobilization. During acute sepsis or septic shock, patients are often too unstable for physiotherapy intervention, which only starts when the patient is haemodynamically stable.  
 
* Positioning plays a big role in the management of patients with sepsis. A heads-up position of 30-45 degrees is recommended to decrease the risk of aspiration pneumonia and ventilator-associated pneumonia, where prone positioning is recommended in sepsis induced [[Acute Respiratory Distress Syndrome (ARDS)|ARDS]] with a PF ratio of less than 150.<ref name=":2">Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME, Rochwerg B. [https://link.springer.com/content/pdf/10.1007%252Fs00134-017-4683-6.pdf Surviving sepsis campaign: international guidelines for the management of sepsis and septic shock: 2016.] Intensive care medicine 2017;43(3):304-77.</ref>
Aims:
* A common result of these is [[Critical Illness Polyneuropathy (CIP)|critical illness neuropathy]], and extensive rehabilitation should then be incorporated in the ICU, after discharge to the ward, as well as in the out-patient setting with the aim of getting the patient back to his baseline level of function and participation as per the [[International Classification of Functioning, Disability and Health (ICF)|ICF]] model.
* Restoration of normal haemostasis
* Sustain tissue perfusion
* Avoid focussing on a single system
* Maintain oxygen delivery
* Keeping pH > 7.35
Strategies to improve oxygen delivery include:
* Respiratory support
* Inotropic support
* Vasodilators
Control of oxygen consumption is done by the following means:
* Respiratory support
* Sedation
* Paralysis
* Avoidance of pyrexia and stressors
* Supportive:
** Blood transfusion (packed red blood cells)
** Haemofiltration
Correction of metabolic acidosis (lactate-induced):
* Haemofiltration if pH < 7.2
* Changes to IPPV to improve PaCO2
Fluid management:
* Needs to be carefully administrated to avoid complications such as pulmonary oedema as a result of overload, as this will negatively affect oxygen delivery due to circulating volume problems.
* For optimal cardiac output:  PAWP = 18cmH2O and CVP = 10-12cmHO
Additional:
* Nutritional support is an important factor in the management of septic shock, as it can increase energy consumption up to 50%. It however negatively affects the utilization of nutrition, resulting in katabolism and subsequent muscle wasting.
* Antibiotics: Potential to exacerbate symptoms due to physiology described earlier
* Early initiated steroids, especially in cases with Gram-negativ septicaemia<br>
 
== Differential Diagnosis  ==
 
add text here relating to the differential diagnosis of this condition<br>
 
== Physiotherapy management  ==
 
Physiotherapy in the ICU
 
Physiotherapy interventions in the ICU setting normally consists of respiratory physiotherapy focussing on airway clearance technique and early mobilization. During acute sepsis or septic shock, patients are often too unstable for physiotherapy intervention, which only starts when the patient is haemodynamically stable.
 
A common result of these are critical illness neuropathy, and extensive rehabiltaiton should then be incorporated in the ICU, after discharge to the ward, as well as in the out-patient setting with the aim of getting the patient back to his baseline level of function and participation as per the ICF model.<br>


== Resources    ==
== Resources    ==
 
* [https://www.sccm.org/SurvivingSepsisCampaign/Guidelines Surviving Sepsis Guidelines and Bundles]
add appropriate resources here
* [https://www.cdc.gov/sepsis/pdfs/Sepsis-Surveillance-Toolkit-Aug-2018_508.pdf Hospital Toolkit for Adult Sepsis Surveillance]<br>  
 
== Case Studies / Key evidence  ==
 
add links to case studies here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>  


== References  ==
== References  ==
References will automatically be added here, see [[Adding References|adding references tutorial]].
<references />
<references />
[[Category:Acute Care]]
[[Category:Interventions]]
[[Category:Older People/Geriatrics]]
[[Category:Critical Care]]

Latest revision as of 17:13, 27 June 2023

Original Editors - Leana Louw

Top Contributors - Lucinda hampton, Leana Louw, Rachael Lowe, Kim Jackson, Admin, Aminat Abolade, Uchechukwu Chukwuemeka and Carina Therese Magtibay

Introduction[edit | edit source]

Sepsis Treatment

Sepsis is a syndrome, with a poorly understood pathogenesis, causing life-threatening organ dysfunction. Sepsis occurs when the body's response to this infection is overwhelming, potentially leading to organ failure and septic shock. It is associated with high morbidity and mortality rates, being a final common pathway to death from many infectious diseases worldwide.[1][2][3] Sepsis needs urgent treatment as it can quickly worsen.[4]

Epidemiology[edit | edit source]

The worldwide burden of sepsis is hard to establish.

  • A 2017 study estimated sepsis accounted for almost 20% of all global deaths, with 48.9 million cases and 11 million sepsis-related deaths worldwide (twice that thought previously).[5]
  • Almost half of all global sepsis cases occurred among children in 2017.[5]
  • Roughly 85% of sepsis cases and sepsis-related deaths worldwide occur in low- and middle-income countries.[5]
  • In the United States approximately 270,000 deaths annually.[6][3]

Etiology[edit | edit source]

Sepsis occurs when the body's response to this infection turns on the body, potentially leading to organ failure and septic shock.[7] The 2009 European Prevalence of Infection in Intensive Care (EPIC II study) determined that gram-negative bacterial infections far exceed other etiologies as the most common cause of sepsis syndromes with a frequency of 62%, followed by gram-positive infections at 47%.[8]

View this 3 minute video titled "Sepsis and Septic Shock, Animation."

[9]

Risk Populations[edit | edit source]

  • 80% of sepsis cases are the result of the following infections:[10]
  • Chest (e.g. pneumonia)
  • Abdomen
  • Genitourinary system
  • Primary bloodstream

Pathological Process[edit | edit source]

Sepsis results when an infectious insult precipitates a localized inflammatory reaction that goes on to cause systemic symptoms of fever or hypothermia, tachycardia, tachypnea, and leukocytosis or leukopenia (a clinical symptom called systemic inflammatory response syndrome). The inflammatory reaction is mediated by the release of cytokines which activate the extrinsic coagulation cascade and inhibit fibrinolysis. This upshot is microvascular thrombosis, a potential factor producing organ dysfunction. Sepsis is a complex syndrome involving activation of a variety of systems.[11]

Clinical Presentation[edit | edit source]

Symptoms of sepsis: non-specific and may include:

  • Localising symptoms of infection (e.g. productive cough, vomiting, diarrhoea, dysuria)
  • Drowsiness
  • Confusion
  • Dizziness
  • Malaise

Clinical signs of sepsis may include:

  • Tachycardia
  • Hypotension
  • Tachypnoea
  • Cyanosis
  • Fever/hypothermia
  • Oliguria
  • Non-blanching rash
  • Mottled/ashen appearance[12]

Watch this 2 minute video "How to recognize sepsis symptoms"

Prognosis[edit | edit source]

Septic shock is a serious illness and despite all the advances in medicine, it still carries high mortality which can exceed 40%.

  • Mortality does depend on many factors including the type of organism, antibiotic sensitivity, number of organs affected, and patient age.
  • The more factors that match SIRS, the higher the mortality.
  • Data suggest that tachypnea and altered mental status are excellent predictors of poor outcomes.
  • Prolonged use of inotropes to maintain blood pressure is also associated with adverse outcomes.
  • Those who survive are left with significant functional and cognitive deficits[8].

Diagnostic Procedures[edit | edit source]

Prompt recognition and escalation to a senior medical officer improves sepsis outcomes.[13] The guidelines recommend the Sequential Organ Failure Assessment (original and quick versions) as an important tool for early diagnosis.[6]

  • Blood tests : test for proof of infection; clotting issues; abnormal liver or kidney function; impaired oxygen availability; electrolyte imbalances
  • Other lab tests may be used to help identify the source of the infection: Urine; wound secretion; respiratory secretions
  • If the site of infection is not readily found other imaging tests including X-ray. CT, MRI and ultrasounds may be ordered.[7]

Medical Management[edit | edit source]

Intensive Care Unit.jpg

Identifying and recognising the signs and symptoms of sepsis, along with the awareness of some biomarkers (eg C reactive protein), are critical elements for diagnosing sepsis and instituting appropriate management. After early recognition and diagnostics, identifying a causal pathogen of infection targeted antimicrobial treatment can commence. Prompt fluid resuscitation will improve volume status. Vasopressors may be needed to help maintain tissue perfusion. Repeated exams and assessments, including monitoring vital signs, guide the appropriate management of sepsis over time.[3]

Physiotherapy Management[edit | edit source]

See the page for the role of physiotherapy in the ICU.

  • Physiotherapy interventions in the ICU setting normally consist of respiratory physiotherapy focusing on airway clearance techniques and early mobilization. During acute sepsis or septic shock, patients are often too unstable for physiotherapy intervention, which only starts when the patient is haemodynamically stable.
  • Positioning plays a big role in the management of patients with sepsis. A heads-up position of 30-45 degrees is recommended to decrease the risk of aspiration pneumonia and ventilator-associated pneumonia, where prone positioning is recommended in sepsis induced ARDS with a PF ratio of less than 150.[14]
  • A common result of these is critical illness neuropathy, and extensive rehabilitation should then be incorporated in the ICU, after discharge to the ward, as well as in the out-patient setting with the aim of getting the patient back to his baseline level of function and participation as per the ICF model.

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ Life in the fast lane Sepsis Definitions and Diagnosis Available:https://litfl.com/sepsis-definitions-and-diagnosis/ (accessed 31.12.2022)
  2. ↑ Zhang W, Zheng Y, Feng X, Chen M, Kang Y. Systemic inflammatory response syndrome in Sepsis-3: a retrospective study. BMC infectious diseases. 2019 Dec;19(1):1-0.Available:https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-019-3790-0#Sec22 (accessed 31.12.2022)
  3. ↑ 3.0 3.1 3.2 World health organisation Sepsis Available:https://www.who.int/news-room/fact-sheets/detail/sepsis (accessed 31.12.2022)
  4. ↑ 4.0 4.1 NICE Sepsis: recognition, diagnosis and early management Available:https://www.nice.org.uk/guidance/ng51/ifp/chapter/What-is-sepsis (accessed 31.12.2022)
  5. ↑ 5.0 5.1 5.2 Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, Colombara DV, Ikuta KS, Kissoon N, Finfer S, Fleischmann-Struzek C. Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study. The Lancet. 2020 Jan 18;395(10219):200-11.Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6970225/ (accessed 31.12.2022)
  6. ↑ 6.0 6.1 Gauer R, Forbes D, Boyer N. Sepsis: diagnosis and management. American family physician. 2020 Apr 1;101(7):409-18.Available:https://www.aafp.org/pubs/afp/issues/2020/0401/p409.html (accessed 31.12.2022)
  7. ↑ 7.0 7.1 MAYO clinic Sepsis Available:https://www.mayoclinic.org/diseases-conditions/sepsis/diagnosis-treatment/drc-20351219 (accessed 31.12.2022)
  8. ↑ 8.0 8.1 Mahapatra S, Heffner AC. Septic Shock (Sepsis). InStatPearls [Internet] 2019 Jun 4. StatPearls Publishing.Available from:https://www.ncbi.nlm.nih.gov/books/NBK430939/ (last accessed 22.9.2020)
  9. ↑ Alila medical media. Sepsis and Septic Shock, Animation.. Available from: https://www.youtube.com/watch?v=-MXi4mOMmI4 [last accessed 31.12.2022]
  10. ↑ Annane D, Bellissant E, Cavaillon JM. Septic shock. The Lancet 2005;365(9453):63-78.
  11. ↑ Jacobi J. Pathophysiology of sepsis. Am J Health Syst Pharm. 2002 Feb 15;59 Suppl 1:S3-8. doi: 10.1093/ajhp/59.suppl_1.S3. PMID: 11885412. Available:https://pubmed.ncbi.nlm.nih.gov/11885412/ (accessed 31.12.2022)
  12. ↑ Geeky medics Sepsis Available:https://geekymedics.com/acute-management-of-sepsis/ (accessed 31.12.2022)
  13. ↑ Queensland Government Sepsis Available:https://clinicalexcellence.qld.gov.au/priority-areas/safety-and-quality/sepsis/recognition-and-treatment (accessed 31.12.2022)
  14. ↑ Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME, Rochwerg B. Surviving sepsis campaign: international guidelines for the management of sepsis and septic shock: 2016. Intensive care medicine 2017;43(3):304-77.
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