Sepsis: Difference between revisions

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== Description ==
== Introduction ==
The potentially life-threatening term of sepsis is defined as a systematic response to fight off the cause of an infection, or in other words, an exacerbated immune response. 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>
[[File:Sepsis treatment.jpg|alt=|thumb|Sepsis Treatment]]
{{#ev:youtube|watch?v=L5xKW--drRg}}
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>
== Epidemiology and Etiology  ==


=== Epidemiology ===
== Epidemiology ==
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>
The worldwide burden of sepsis is hard to establish.
* 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" />
* 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>
* Cancer
* Almost half of all global sepsis cases occurred among children in 2017.<ref name=":5" />
* Immunodeficiency
* Roughly 85% of sepsis cases and sepsis-related deaths worldwide occur in low- and middle-income countries.<ref name=":5" />
* Chronic organ failure
* 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" />
* Male > female
== Etiology ==
* More common in non-white ethnic origin in North Americans
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>
* Polymorphisms in genes that regulate immunity


=== Etiology ===
'''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>
Sepsis is the result of a variety of pathogens, mostly gram-positive. Common pathogens include the following:
* 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%)


80% of sepsis cases is the result of the following infections:<ref name=":1" />
== 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" />
 
* 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>
* Chest (e.g. [[pneumonia]])
* Chest (e.g. [[pneumonia]])
* Abdomen
* Abdomen
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* Primary bloodstream  
* Primary bloodstream  


== Mechanism of Injury / Pathological Process ==
== Pathological Process ==
{{#ev:youtube|watch?v=MQHWtvjHXT4}}
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" />


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.<ref name=":1" />
== Clinical Presentation  ==
Symptoms of sepsis: non-specific and may include:


Shock in general normally runs the following course:<ref name=":1" />
* Localising symptoms of infection (e.g. productive cough, vomiting, diarrhoea, dysuria)
* Drowsiness
* Confusion
* Dizziness
* Malaise


Insufficient tissue perfusion → anaerobic metabolism → lactic acidosis → metabolic acidosis → cellular damage → organ failure.
Clinical signs of sepsis may include:


== Clinical Presentation  ==
* Tachycardia
{{#ev:youtube|dbgWpeEEtaM|300}}
* Hypotension
'''Criteria'''<ref name=":0" />
* Tachypnoea
* Cyanosis
* 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}}


Two or more of the following:
== Prognosis ==
* High grade (> 38˚C) or low grade (< 36˚C ) fevers
Septic shock is a serious illness and despite all the advances in medicine, it still carries high mortality which can exceed 40%.
* Heart rate > 90/minute
* Mortality does depend on many factors including the type of organism, antibiotic sensitivity, number of organs affected, and patient age.
* RR > 20/minute OR PaCO2 < 4.3kPa
* The more factors that match SIRS, the higher the mortality.
* WCC > 12
* Data suggest that tachypnea and altered mental status are excellent predictors of poor outcomes.
'''Signs and symptoms'''<ref name=":1" />  
* Prolonged use of inotropes to maintain blood pressure is also associated with adverse outcomes.
* Pyrexia
* Those who survive are left with significant functional and cognitive deficits<ref name=":3" />.
* Flushed presentation
* Tachypnea
* Hypotension
* Bounding pulse
* Restricted regional blood flow as the result of vasopressors
* Signs of tissue hypoperfusion:
** Areas of mottled skin
** Oliguria
** Mental confusion
** Delayed capillary refill
** Hyperlactacidaemia


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==
Septic shock can only be diagnosed when it fits to the clinical criteria and a infection (and the pathogen if possible) is verified.<ref name=":1" />  
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" />  
* Identification of infection:
** Look for obvious signs - e.g. community-aquired pneumonia, prupura fulminans, cellulitis, wound discharge.
** Blood tests / tissue biopsy or sample to determine pathogen
* Bloods:
** PCR
** Microarray based rapid
* Assess for issue hypoperfusion
** [[Glasgow Coma Scale|Glasgow coma scale]] to determine mental confusion (unable to do in sedated patients)
** Input and output measures to determine oliguria
* Multi-organ failure
== Outcome Measures  ==
* SOFA (sepsis-related organ failure assessment) score 
* [https://qsofa.org/ qSOFA] (quick sepsis-related organ failure assessment)
 
== Medical Management  ==
{{#ev:youtube|watch?v=OgQ6avlpBRY}}
Medical management is vital to prevent further inflammatory response.<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.<ref name=":1" /> The key to improved outcomes is in early identification and appropriate management thereof in the initial hours after onset.<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 management of sepsis and septic shock: 2016.] Intensive care medicine 2017;43(3):304-77.</ref> 
 
'''Aims'''<ref name=":0" />
* Restoration of normal haemostasis
* Sustain tissue perfusion
* Avoid focusing on a single system
* Maintain oxygen delivery
** Respiratory support
** Inotropic support
** Vasodilators
* Keeping pH > 7.35
 
'''Control infection source'''<ref name=":1" /> 
* Antibiotics 
* Removal of infected/necrotic tissue (where applicable) 
 
'''Shock management'''<ref name=":1" /> 
* Aim for restoration to the following values (if possible within 6 hours): 
** CVP:  8-12mmHg 
** MAP:  65-90 
** Sats > 70% 
* Management strategies: 
** Fluids<ref name=":0" />
*** 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
*** Repeat until cardiac output increase with > 10% with central venous pressure increase of < 3 mmHg
** Vasopressors (if hypotension still present after management with fluids)
*** Dopamine or norepinephrine 
*** Aim to restore MAP to 60-90 
** Inotropes 
** Blood transfusions 
** Mechanical ventilation 
 
'''Organ dysfunction management'''<ref name=":1" /> 
* In cases of renal failure:  Renal replacement treatment 
* In ARDS/acute lung injury:  Mechanical ventilation with tidal volumes of 6-7ml/kg ideal body weight 
 
'''Enhancing or replacing host responses'''<ref name=":1" />   
* Endocrine response: 
** Low-dose corticosteroids 
** Low-dose vasopresssin (if corticosteroids are not able to be administrated or not working) 
* Haemostasis response:  Drotrecogin alfa 
 
'''Control of oxygen consumption'''<ref name=":0" />
* Respiratory support:
** Oxygen in cases of ARDS or acute lung injury
** Mechanical ventilation with tidal volume aims of 6-7ml/kg ideal body weight
* Sedation
* Paralysis
* Avoidance of pyrexia and stressors
* Supportive:
** Blood transfusion (packed red blood cells) - also aids in optimisation of haemodynamic status
** Haemofiltration
 
'''Correction of metabolic acidosis (lactate-induced)'''<ref name=":0" />
* Haemofiltration if pH < 7.2
* Changes to IPPV to improve PaCO2


'''Other'''<ref name=":0" /><ref name=":1" />
* [[Blood Tests|Blood tests]] : test for proof of infection; clotting issues; abnormal liver or kidney function; impaired oxygen availability; [[Electrolytes|electrolyte]] imbalances
* 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 catabolism and subsequent muscle wasting.
* Other lab tests may be used to help identify the source of the infection: [[Urine]]; wound secretion; respiratory secretions
** Consider enteral supplementation
* 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>
* Steroids (gram-negative septicaemia)
* Activated protein C
* Maintain HGT:  4-6 mmol/L
* Prevent hospital-acquired infections
* Administration of vaccines (where applicable)
* IVIG's
{{#ev:youtube|watch?v=QzIiClJtwN8}}


== Physiotherapy management ==
== 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}}


== Physiotherapy Management ==
See the page for the [[Physiotherapists Role in ICU|role of physiotherapy in the ICU]].
See the page for the [[Physiotherapists Role in ICU|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.  
Physiotherapy interventions in the ICU setting normally consists 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>
 
* 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.
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.<ref name=":2" />
 
A common result of these are [[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.


== Resources    ==
== Resources    ==
Line 193: Line 91:
== References  ==
== References  ==
<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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