Dr SK Todi, Head of the Deptt, Crtical Care, AMRI Hospitals, Kolkata gives an outlook about sepsis and its major clinical challenge in the intensive care unit
Sepsis is a serious multi-system potentially life-threatening complication that can occur with any infection. Once sepsis develops, it causes a series of chemicals reactions in response to, usually, a bacterial infection spreading throughout the bloodstream. This triggers a series of inflammatory reactions, which can increase both blood clotting and bleeding, then in turn damage organs and blood vessels causing multi-organ failure — eventually leading to septic shock as blood pressure drops. Once this cascade of reactions is initiated, the problem goes beyond just treating the infection. Despite antibiotics, which may kill the offending bacteria, once a person becomes severely septic, it is often too late and the end result is death.
Sepsis is a major clinical challenge in the intensive care unit. Hence a greater understanding of sepsis in the critical care setting and improvement in diagnosis and management have the capacity to significantly impact on the overall population mortality as well as mortality in the ICU.
Systemic Inflammatory Response Syndrome (SIRS) is a condition observed among critically ill patients, which is sustained by proinflammatory cytokines and factors that mediate endothelial activation and adhesion resulting in capillary leakage. SIRS must have at least two of the following abnormal vital signs or symptoms:
- < Fever over 101.3°F (38.5°C) or below 95°F
- < Heart rate over 90 beats/minute
- < Respiratory rate over 20 breaths/minute
- < White blood cell count less than 4000 cells/mm3 or more than 12,000 cells/mm3
Sepsis is defined as SIRS with a documented site of infection and severe sepsis defined as sepsis associated with organ dysfunction and Septic shock is defined as sepsis with associated hypotension despite adequate antibiotic and aggressive fluid resuscitation. Signs of organ hypo perfusion may be present including decreased urine output and altered mental status.
During the initial survey, an infectious etiology is sought. All cultures (blood, urine and other body fluids suspected for infection) should be sent and early antibiotic instituted in a rational manner and if source cannot be immediately defined it is prudent to start with broad spectrum antibiotics and then narrow down the coverage as culture results become available.
Golden hour of sepsis management
For patients with severe sepsis or septic shock, therapy in the first few hours is devoted to appropriate antibiotic along with restoring an adequate circulation, primarily with fluids (as per Early Goal Directed Therapy – EGDT) and secondarily with vasoactive medicines to prevent further deterioration of organ function. Oxygen demand can be reduced by institution of mechanical ventilation.
Therapies to be considered in the appropriate patients include activated protein C, moderate dose corticosteroids, intensive insulin therapy and protective lung ventilation.
Failure to intervene in a timely manner with appropriate treatments, increases the livelihood of developing organ system failure, a dreaded complication of sepsis.
It is incumbent on the physician to quickly identify patients at risk of progressing to severe sepsis and septic shock and rapidly institute therapies to slow or halt the progression of disease.
Hospital-acquired infections have profound social, economic, and personal costs to patients in the intensive care unit (ICU). Numerous risk factors, such as poor nutrition and hyperglycemia directly involve patients. Meanwhile, hand hygiene, environmental cleaning and appropriate hospital staffing can impact ICU infection rates.
A multi-directional approach-including continuing staff education, minimising risk factors and implementing guidelines established by national committees is necessary to decrease infections such as catheter-related bloodstream infections, urinary tract infections, ventilator-associated pneumonia and clostridium difficile. Infection-control committees can assist in implementing policies. This is an active area of research and we anticipate continued advancements to improve patient care.