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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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Evaluation of the management of sepsis in the emergency department
From CHEST, 10/1/05 by Maria I. Rudis

PURPOSE: The 2004 Surviving Sepsis Campaign Guidelines (SSCG)emphasize the importance of early aggressive sepsis treatment to reduce mortality. We sought to determine compliance with the SSCG in patients(pts) with sepsis in the ED, specifically the timeliness and extent offluid administration and antimicrobial therapy, the use of earlygoal-directed therapy (EGDT), and the nature of vasopressor use.

METHODS: Retrospective cohort of consecutive pts with an ED diagnosis of sepsis' in ourlarge, urban, county, level I trauma center from 12/03-5/04. Pts were excluded if age <18 yrs, had a requirement for immediate surgery, DNR status or were incarcerated.

RESULTS: After excluding 23 pts who did not meet inclusion criteria fromall ptswith sepsis (n = 107), our cohort consisted of 84 pts with a mean age of 50.2 [+ or -] 19.6 yrs and 49% males. The ethnicity reflects that ofourgeneral ED population (62% latino, 18% caucasian, 11% Asian and9% African American). Mean volume of IV fluid administered in the first 6h in the ED was 1951 [+ or -] 1644 ml, with the majority of pts(60.7%) receiving 1-3.5 L. Mean time to antibiotic administration fromtime ofpresentation (4.7 [+ or -] 4.3 h) or from physician evaluation (2.3 [+ or -] 2.9 h) exceeds the recommended 1 h by the SSCG. Vasopressorswere given to 26 (30.9%) pts, with the majority receiving dopamine(25.0%) and norepinephine (6%) as first line agents. No pt was managed using EGDT. Mean LOS in the ED,ICU and hospital were 21.6 [+ or -] 18.6h, 8.9 [+ or -] 13.8d, and 13.6 [+ or -] 18.3 d, respectively.

CONCLUSION: ED management of pts with sepsis does not currently meet the parameters as set by SSCG. Assessment of 28-day mortality may determine impact of ED treatment of septic pts.

CLINICAL IMPLICATIONS: Interventions to optimize compliance with SSCG are needed in the ED.

DISCLOSURE: Maria Rudis, None.

Maria I. Rudis PharmD * Kathy L. Rowland PharmD Jill M. Hara PharmD Philip Bretsky PhD Mark Hollinger RN Kathryn Challoner MD Ed Newton MD USC School of Pharmacy, Los Angeles, CA

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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