Sepsis
Sepsis is a complex condition characterized by the simultaneous activation of inflammation and coagulation in response to a microbial insult. Clinical features of sepsis include varying degrees of alterations in temperature, mental fog/AMS, hypotension, decreased urine output, and unexplained thrombocytopenia and initial assessment should include careful evaluation of these systems. There are three stages to sepsis that exist along a continuum. The first stage is sepsis as defined by the SIRS criteria including a temperature > 38o C or <36o C, tachycardia with a heartrate of > 90/min, tachypnea with a respiratory rate >20/min or requiring mechanical ventilation, and WBC > 12 x109/L or < 4 x109/L. The presence of two or more of these criteria suggests sepsis. The second stage is severe sepsis, which includes organ dysfunction and hypotension in addition to the criteria from sepsis. The third stage is septic shock which includes the elements of severe sepsis with the addition of persistent arterial hypotension (systolic arterial pressure < 90 mmHg or mean arterial pressure (MAP) of < 65 mmHg usually requiring vasopressors and >2 organs effected (Polat et al, 2017). Additionally, in the inpatient hospital setting, an increase of a SOFA score of > 2 points including AMS or GCS <15, SBP < 100 mmHg, and respiratory rate > 22/min, should prompt consideration of a possible infection (Gyawali, Ramakrishna, & Dhamon, 2019). Using the criteria above, the patient in the scenario is experiencing severe sepsis as evidenced by fever, leukocytosis, hypotension, AMS, and the presence of end organ dysfunction in only one organ.
Not all the elements listed above are always present in sepsis due to immunocompromised states, physiology changes associated with older age, and other critical illnesses that may result in alterations in temperature, heart rate, and respiratory rate. As such, the differential diagnoses are broad and may include pancreatitis, DKA, dehydration, and pulmonary embolism. There is no specific treatment for sepsis and management relies on protocols, infection control, and support of organ function (Vincent, 2016). The initial stages of sepsis treatment are driven by goal directed therapy to prevent transition to a more severe illness and includes serum lactate measurement, procalcitonin level, appropriate cultures, administration of broad-spectrum antibiotics, the administration of isotonic fluids during the first 3 hours. For severe sepsis and hypotension unresponsive to initial fluid resuscitation, a vasopressor, preferable norepinephrine, may be added and fluids changed to crystalloids at 30 ml/kg for lactate levels > 4 mmol to be guided by ongoing hemodynamic status monitoring and within 6 hours. The treatment for septic shock may include the above with the addition of mechanical ventilation and CVP and SCVO2 monitoring and potentially dialysis/CRRT. At any stage, source control is vital and may include physical or surgical measures including drainage of infected fluid collections, removal of potentially infected invasive devices and resection of perforated intestines (Gyawali, Ramakrishna, & Dhamon, 2019).
References
Gyawali, B., Ramakrishna, K., & Dhamon, A.S. (2019). Sepsis: The evolution in definition, pathophysiology, and management. SAGE
Open Medicine, 7:2050312119835043. https://doi:10.1177/2050312119835043
Polat, G., Ugan, R.A., Cadirci, E., & Halici, Z. (2017). Sepsis and septic shock: Current treatment strategies and new approaches. The
Eurasian Journal of Medicine, 49(1), 53-58. https://doi:10.5152/erasianjmed.2017.17062
Vincent, J.L. (2016). The clinical challenge of sepsis identification and monitoring. PLOS Medicine, 13(5): e1002022.
https://doi:10,1371/journl.pmed.1002022
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