Sepsis is a life-threatening condition that can rapidly lead to multiple organ failure and shock, often resulting in fatality. Patient survival hinges on a strong suspicion of sepsis, prompt identification, and immediate medical intervention.
Initial findings associated with sepsis are typically non-specific and often stem from the primary infection. These may include elevated white blood cell count (leukocytosis), rapid breathing (tachypnea), increased heart rate (tachycardia), and changes in mental state.
Patients exhibiting signs of sepsis, particularly those indicating organ dysfunction, require immediate evaluation in a hospital setting.
Broad-spectrum antibiotics should be administered empirically without delay, ideally within the first hour for patients progressing towards septic shock. The choice of antibiotics should be guided by the most probable pathogens and the site of infection.
Blood cultures, along with cultures from other potentially infected bodily fluids as indicated by symptoms and patient risk factors, are crucial. Ideally, these should be obtained before starting antibiotic treatment.
Identifying and controlling the source of infection is a critical and urgent step, aimed to be completed within 6-12 hours of sepsis recognition.
Evidence of shock necessitates immediate attention and treatment with intravenous fluid resuscitation. Persistent shock despite fluid administration requires consideration of vasopressors and/or inotropic agents, along with urgent admission to critical care.
Defining Sepsis: A Shift in Diagnostic Criteria
Sepsis is currently defined as life-threatening organ dysfunction resulting from a dysregulated host response to infection.[1] This definition was updated in 2016 by the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), marking a significant shift in how sepsis is understood and diagnosed.[1]
The Sepsis-3 guidelines recommended the use of the Sequential Organ Failure Assessment (SOFA) score or the quick SOFA (qSOFA) score to define organ dysfunction. However, it’s important to note that these scores are often indicators of later stages of deterioration and are not recommended as standalone screening tools for early sepsis detection.[2, 3, 4] In clinical practice, early diagnosis of suspected sepsis is crucial for any patient with a presumed infection who is deemed at risk of worsening condition based on clinical assessment, early warning scores, or risk stratification tools.[3, 5, 6]
The 2016 consensus definitions represented a move away from the previous Systemic Inflammatory Response Syndrome (SIRS) criteria and the 1991 definition. Previously, severe sepsis was described as sepsis accompanied by organ dysfunction, hypoperfusion, or hypotension, while septic shock was defined as sepsis with hypotension despite adequate fluid replacement.[7]
The Sepsis-3 definitions rendered the term “severe sepsis” redundant, reflecting the revised understanding of sepsis as a spectrum of illness.[1] Septic shock is now defined as a subset of sepsis characterized by:
- Persistent hypotension requiring vasopressors to maintain a mean arterial pressure (MAP) of 65 mmHg or greater.
- Serum lactate levels greater than 2 mmol/L (>18 mg/dL).[1]
Septic shock signifies profound circulatory, cellular, and metabolic abnormalities and carries a higher mortality risk compared to sepsis alone.[1] Early recognition of the criteria for both sepsis and septic shock is paramount for effective and timely intervention, ultimately improving patient outcomes.
References
[1] Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. https://jamanetwork.com/journals/jama/fullarticle/2492881 http://www.ncbi.nlm.nih.gov/pubmed/26903338?tool=bestpractice.com
[2] Nieves Ortega R, Rosin C, Bingisser R, et al. Clinical scores and formal triage for screening of sepsis and adverse outcomes on arrival in an emergency department all-comer cohort. J Emerg Med. 2019 Oct;57(4):453-60.e2. http://www.ncbi.nlm.nih.gov/pubmed/31500993?tool=bestpractice.com
[3] Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143. https://journals.lww.com/ccmjournal/fulltext/2021/11000/surviving_sepsis_campaign__international.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com
[4] Haydar S, Spanier M, Weems P, et al. Comparison of QSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis. Am J Emerg Med. 2017 Nov;35(11):1730-3. http://www.ncbi.nlm.nih.gov/pubmed/28712645?tool=bestpractice.com
[5] Churpek MM, Snyder A, Han X, et al. Quick Sepsis-related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores for detecting clinical deterioration in infected patients outside the intensive care unit. Am J Respir Crit Care Med. 2017 Apr 1;195(7):906-11. https://www.atsjournals.org/doi/10.1164/rccm.201604-0854OC http://www.ncbi.nlm.nih.gov/pubmed/27649072?tool=bestpractice.com
[6] Fernando SM, Tran A, Taljaard M, et al. Prognostic accuracy of the Quick Sequential Organ Failure Assessment for mortality in patients with suspected infection: a systematic review and meta-analysis. Ann Intern Med. 2018 Feb 20;168(4):266-75. http://www.ncbi.nlm.nih.gov/pubmed/29404582?tool=bestpractice.com
[7] Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003 Apr;31(4):1250-6. http://www.ncbi.nlm.nih.gov/pubmed/12682500?tool=bestpractice.com
