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Sepsis

Sepsis (in Greek Σήψις, putrefaction) is a serious medical condition caused by a severe infection. The more critical subsets of sepsis include severe sepsis (sepsis with acute organ dysfunction) and septic shock (sepsis with refractory arterial hypotension). If a proven source of infection is lacking but the other criteria of sepsis are met the condition is known as systemic inflammatory response syndrome. more...

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Septicemia is sepsis of the bloodstream caused by bacteremia, which is the presence of bacteria in the bloodstream. The term septicemia is also used to refer to sepsis in general.

Symptoms

The systemic inflammatory response leads to widespread activation of inflammation and coagulation pathways. This may progress to dysfunction of the circulatory system and, even under optimal treatment, multiple organ dysfunction syndrome and eventually death.

Sepsis is common and also more dangerous in elderly, immunocompromised, and critically ill patients. It occurs in 2% of all hospitalizations and accounts for as much as 25% of intensive care unit (ICU) bed utilization. It is a major cause of death in intensive care units worldwide, with mortality rates that range from 20% for sepsis to 40% for severe sepsis to >60% for septic shock. In the United States, sepsis is the leading cause of death in non-coronary ICU patients, and the tenth most common cause of death overall according to 2000 data from the Centers for Disease Control and Prevention.

A problem in the adequate management of septic patients has been the delay in administering the right treatment after sepsis has been recognized. A large international collaboration was established to educate people about sepsis and to improve patient outcomes with sepsis, entitled the "Surviving Sepsis Campaign." The Campaign has published an evidence-based review of management strategies for severe sepsis, with the aim to publish a complete set of guidelines within 3 years.

Definition of sepsis

Sepsis can be diagnosed if there is a proven source of infection, such as a positive blood culture and two or more of the following:

  • Heart rate > 90 beats per minute
  • Body temperature < 36 (96.8°F) or > 38°C (100.4°F)
  • Hyperventilation (high respiratory rate) > 20 breaths per minute or, on blood gas, a PaCO2 less than 32 mm Hg
  • White blood cell count < 4000 cells/mm³ or > 12000 cells/mm³ (< 4 x 109 or > 12 x 109 cells/L).

Treatment

The therapy of sepsis rests on antibiotics, surgical drainage of infected fluid collections, fluid replacement and appropriate support for organ dysfunction. This may include hemodialysis in kidney failure, mechanical ventilation in pulmonary dysfunction, transfusion of blood plasma, platelets and coagulation factors to stabilize blood coagulation, and drug and fluid therapy for circulatory failure. Ensuring adequate nutrition, if necessary by parenteral nutrition, is important during prolonged illness.

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S.E.P.S.I.S: Sepsis Education Plus Successful Implementation and Sustainability in the absence of a rapid response team
From CHEST, 10/1/05 by Avelino Verceles

PURPOSE: Although institutions worldwide are acknowledging the decrease in mortality from therapies presented within the Surviving Sepsis campaign, many have encountered major obstacles in implementation. At our tertiary care, University Hospital facility we devised a "hospital-centric" sepsis pathway using a multi-format educational approach. We believe an educational program emphasizing ways to identify patient signs and symptoms is a more efficient way to improve outcomes, rather than appropriating resources to a specialized team, such as a Rapid Response Team.

METHODS: As an institution-wide performance improvement project, we introduced a sepsis protocol in our institution's Medical, Cardiac, Cardiothoracic, Surgical, and Neurological Critical Care Units, to be implemented in the immediate resuscitation of patients in severe sepsis (SS). The S.E.P.S.I.S. program was entitled "The Need For Speed". A simple one page flow diagram was distributed as the sepsis pathway in every bedside nursing folder, together with a three page companion outlining current evidence-based-therapies in treating SS. After introducing the sepsis pathway to the house staff and nursing staff, we collected performance improvement data from May 2004-August 2004 focusing on protocol milestone goals and mortality. Our "bundle" was time to antibiotics, CVP [greater than or equal to] MAP [greater than or equal to] 65, and SvO2 [greater than or equal to] 70 (Chest 2004,126:863S). During that time we educated all workers involved in patient care, with regards to our Educational Program. This included weekly educational sessions, focused on the sepsis protocol and the reasoning behind milestone goals. Also, bedside teaching regarding therapy for SS was conducted during ICU rounds. During a second period, September 2004--October 2004, we again assessed milestone and mortality data. Our results were presented to our institution's Performance Improvement committee. This project was approved by our Institutional Review Board.

RESULTS: See Tables.

CONCLUSION: We achieved a significant reduction in mortality of patients using our multi-format educational approach without a Rapid Response Team.

CLINICAL IMPLICATIONS: Others may wish to incorporate all or part of our multi-format, "hospital-centric" educational approach. We believe that we will sustain our decreased mortality of patients with SS through this approach.

DISCLOSURE: Avelino Verceles, None.

Avelino Verceles MD * R. M. Schwarcz MD Paul Birnbaum MD Praveen Mannam MD Herbert Patrick MD Drexel University College of Medicine, Philadelphia, PA

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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