Home Forums Other Specialities General Topics Sepsis (Previously termed Septicaemia)

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    Anonymous
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    The Health Service Ombudsman in U.K. has found significant failings in the treatment of sepsis by the doctors. It is reported that about 37,000 people die of sepsis each year. This is about a 3rd of all admissions to hospital for sepsis.

    The National Institute for Health and Care Excellence will soon be producing guidance for GPs and clinicians to help them recognise sepsis at an early stage.

    The importance of recognizing sepsis is especially underscored by the fact that, unlike many other diseases, sepsis can often be cured, leaving no residual symptoms. Sepsis previously termed Septicaemia is often not recognised in the early stages. It is diagnosed by a combination of clinical and laboratory findings. Symptoms and signs can easily baffle an inexperienced doctor. Patient’s temperature may be subnormal or very high depending on the stage of infection. White cell count may be abnormally high or abnormally low. An experienced clinician should be able to diagnose sepsis at an early stage.

    It is easier to recognise sepsis when the patient is already in hospital and is being treated for conditions like Pneumonia, Meningitis or Burns. Sepsis can also follow a routine operation or a major injury as in a road traffic accident.

    Apart from hospital acquired infection that can lead to sepsis the most common causes are pneumonia, bowel perforation, urinary infection, and severe skin infections with or without necrotising Fasciitis.

    The people at risk: Very young and very old are always at risk. Patients on long term steroids, immunosupressives , chemotherapy / radiation for cancer are all at risk. Patients who have had a splenectomy or being treated for diabetes, cirrhosis or AIDS are also at risk. Urinary tract infection and cellulitis can lead to sepsis.

    Symptoms and Signs: Symptoms in the early stages are no different to an ordinary flu. However it could progress to fever with rigour, disorientation, multiple joint pain and skin rashes. When the severity increases patients may become dizzy or complain of palpitation. The respiratory rate could increase, urinary output fall and the blood pressure drop. Patient may also present with what looks like an ordinary respiratory infection.

    Mayo Clinic indicates that to be diagnosed with Sepsis, you must exhibit at least two of the following symptoms:

    1. Fever above 101.3 F (38.5 C) or below 95 F (35 C)
    2. Heart rate higher than 90 beats a minute
    3. Respiratory rate higher than 20 per minute
    4. Probable or confirmed infection at some site

    Severe sepsis
    The diagnosis will be upgraded to severe sepsis if there is at least one of the following signs or symptoms, which indicate that an organ may be failing:

    1. Significantly decreased urine output
    2. Abrupt change in mental status
    3. Decrease in platelet count
    4. Dyspnoea
    5. Palpitation
    6. Abdominal pain

    Septic shock
    To be diagnosed with septic shock, along with signs and symptoms of severe sepsis, the blood pressure would have dropped to extremely low levels and does not respond to simple fluid replacement.

    Organisms causing Sepsis:

    Bacteria are the main organism causing sepsis. Any one from a number of gram positive or gram negative bacteria may be involved. Blood cultures repeated thrice will usually identify the bacteria. Virus causing sepsis is not usually identified but fortunately they are less serious and usually self-limiting. Fungus can also cause sepsis and they are usually a bit more serious. They will respond to medication. Parasites are the least common infecting agents.

    Improved diagnosis and prompt rapid treatment will save lives.

    Complications

    As sepsis worsens, blood flow to vital organs is impaired which might lead to organ failure. Sepsis can also cause disseminated intravascular coagulation leading to microvascular thrombosis which again would lead to varying degrees of (multiple) organ failure and gangrene.

    Respiratory System: Diffuse alveolar damage and adult respiratory distress syndrome (ARDS) is another serious complication in sepsis. The alveolar endothelial cells are damaged by cytokines produced by the immune system reacting to the infective organism’s toxins. The alveolar walls subsequently get covered by hyaline membranes which would cause hypoxia that does not respond to oxygen therapy.

    Heart: Heart muscles may be damaged similar to the lung by the circulating cytokines. This could lead to heart failure.

    Kidneys: Hypotension, DIC, and possibly the bacterial toxins and cytokines will lead to damage of the renal tubular epithelium. This will lead to oliguria and azotemia and ultimately causing acute renal failure

    Liver : Liver cell damage could present with a jaundiced patient.

    Most people recover from mild sepsis, but the mortality rate for septic shock is close to 50 percent.

    Treatment:
    Early, aggressive treatment increases the chances of survival. The basis of treatment for septic shock focuses on controlling and eliminating the infection and stabilising the function of the heart and lung. This in turn should prevent organ failure or aid in recovery of the failing organ.

    Medication:
    Antibiotics. Treatment with antibiotics should be started immediately. As the organism may not be known before starting treatment, a broad-spectrum antibiotic is administered intravenously. Once the organism is identified and sensitivity checked, treatment with the specific antibiotic is commenced.

    Vasopressors are used to maintain the blood pressure. Sometimes steroids may also be used.

    In spite of all this treatment if the blood oxygen tension remains low, it would be necessary to ventilate the patient. If the kidneys start to fail patient may require dialysis.

    Surgery
    Surgery may be needed to remove sources of infection producing pus or in treating peritonitis caused by bowel perforation , infected/perforated appendix, liver abscess etc.

    (I have posted this subject in General Topics as it can be of interest to all specialities.)

    Badri.

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