Management of Sepsis Patient

A sepsis patient presents with systemic infection, fever, low blood pressure, and organ dysfunction. Nurses monitor vitals, administer antibiotics, and support oxygenation and fluid balance—essential for preventing septic shock and improving outcomes

Sepsis is the body’s extreme reaction to an infection. Sepsis is defined as a clinical syndrome caused by an infection that may have a profound adverse physiological consequence. Sepsis happens when an infection initiates a chain reaction in the body and it can rapidly progress to tissue damage, organ failure, and death. The latest definition of sepsis by Surviving Sepsis Campaign (SSC) focuses on patient’s response to infection resulting in organ dysfunction and hypoperfusion.

Sepsis is one of the leading causes of mortality and morbidity worldwide and is the second leading cause of death in the United States. There are a few studies conducted in India among intensive care unit (ICU) patients that show that mortality caused by sepsis is high among the ICU patient population. The ICU, patient mortality rate among all admissions was 13.9% and that of severe sepsis patients was 54.1% (Todd, Bhattacharya and Chatterjee, 2007). These data indicate that sepsis is a growing concern in developing countries such as India.

Centers for Disease Control and Prevention (CDC) reports that at least 1.7 million adults in America develop sepsis annually. One in three patients who die in the hospital has sepsis. The true incidence of sepsis is not known because of the complexity of the condition.

Early recognition and intervention is key for the survival of patients with sepsis. The Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) launched the Surviving Sepsis Campaign in 2002 to reduce the overall morbidity and mortality of patients with sepsis. This campaign updates their guidelines every 4 years. The new guidelines have increased the focus on early identification of infection, septic shock and sepsis, and rapid administration of aggressive fluid resuscitation to restore tissue perfusion.

Managing a Sepsis Patient

Managing a patient with sepsis requires rapid recognition, prompt intervention, and continuous reassessment to halt the progression of organ dysfunction. Below is an overview of the key steps in the management of a sepsis patient:

1. Early Identification and Assessment

• Recognize Clinical Signs: Look for indicators of infection (fever, chills, altered mental status) along with signs of organ dysfunction such as hypotension, tachycardia, increased respiratory rate, and decreased urine output. Tools like qSOFA (Quick Sequential Organ Failure Assessment) can help quickly flag patients at risk.
• Initial Evaluation: Obtain a focused history and perform a rapid physical exam. Laboratory tests, including complete blood count, serum lactate, renal and liver function panels, and blood cultures, should be drawn promptly to confirm the diagnosis and evaluate severity.

2. Immediate Resuscitation (First Hour of Management)

• Airway and Breathing: Ensure the airway is protected. Provide supplemental oxygen to maintain adequate oxygen saturation, and be prepared to initiate advanced airway support if respiratory distress is pronounced.
• Circulation and Fluid Resuscitation: Establish intravenous access immediately. Begin fluid resuscitation with isotonic crystalloid solutions (e.g., 0.9% normal saline or lactated Ringer’s) at a dosing guideline of approximately 30 mL/kg, particularly in patients with septic shock. Early fluid administration helps restore perfusion and reduce lactate levels.
• Monitoring: Continuously monitor vital signs, urine output, and clinical indicators of perfusion. Reassess lactate levels periodically; a rising lactate suggests worsening tissue hypoperfusion.

3. Early Administration of Antibiotics

• Broad-Spectrum Coverage: Empiric broad-spectrum antibiotics should be started within the first hour of recognizing sepsis, ideally after obtaining blood cultures. The choice of antibiotics is guided by the suspected source of infection and local resistance patterns.
• Culture Confirmation: Although antibiotics are initiated empirically, appropriate cultures (blood, urine, sputum, etc.) must be obtained before starting antimicrobial therapy when possible, without causing undue delay in treatment.

4. Source Control

• Identifying the Infection Focus: Rapidly determine the likely source of infection—whether pneumonia, intra-abdominal, urinary tract, or another source.
• Interventions: Once identified, source control may require procedures such as drainage of an abscess, debridement of infected tissue, or removal of an infected device. Early surgical consultation can be critical in cases where operative intervention is indicated.

5. Hemodynamic Support and Further Management

• Vasopressor Therapy: If hypotension persists after adequate fluid resuscitation, initiate vasopressors (norepinephrine is typically the first-line agent) to maintain a mean arterial pressure (MAP) of 65 mmHg or higher.
• Advanced Monitoring: In the intensive care setting, consider invasive monitoring (e.g., arterial lines, central venous catheters) to more accurately guide resuscitation and titration of therapies.
• Organ Support: Address and support any organ system dysfunction with appropriate measures, including mechanical ventilation for respiratory failure or renal replacement therapy for acute kidney injury.

6. Ongoing Reassessment and Multidisciplinary Collaboration

• Frequent Re-evaluation: The patient’s clinical status should be continuously reassessed. Look for improvements in vital signs, resolution of hypotension, and lactate clearance. Adjust management based on the evolving clinical picture.
• Team-Based Approach: Engage a multidisciplinary team—including critical care, infectious diseases, and surgical specialists—to ensure comprehensive management. Effective communication among team members is essential for timely interventions.

Stages of progression of sepsis

Sepsis progresses rapidly through various stages till it reaches an irreversible stage resulting in multiorgan failure and death if not intervened at the right time and treated in the right way. The stages of sepsis are as follows:

• Systemic inflammatory response syndrome (SIRS): Clinical systemic response to an inflammation or an infection.
• Sepsis: Body’s response to infection.
• Severe sepsis: Sepsis-induced tissue hypoperfusion or organ dysfunction presumably caused by infection.
• Septic shock: Severe sepsis with refractory hypotension persisting after crystalloid fluid administration.

The latest update of the SSC attempts at removing the SIRS as the cause is not always an infection. Severe sepsis is also not included as that stage is hard to identify and does not affect management of the condition. Septic shock is considered as the stage of severe hypoperfusion resulting in multiple organ dysfunction syndrome (MODS).

Clinical manifestation of various phases of sepsis

Management of sepsis

Sepsis claims more lives than is documented. Sepsis is a complex set of syndromes that is sometimes very difficult to recognize. The surviving Sepsis Campaign brought about its latest protocol in 2018. The factor paramount to sepsis management has been early identification.

• Early identification of SIRS and sepsis and preventing the patient from going into irreversible septic shock.
• Rapid antibiotic administration, aggressive fluid resuscitation to restore tissue perfusion.

Time is of paramount importance when managing sepsis. Sepsis must be considered a medical emergency like myocardial infarction or stroke. The latest protocol as per SSC is as follows:

• Identifying Time Zero or the time of presentation, which is the time the sepsis symptoms are identified by the health care professional.
• Obtain laboratory results such as blood cultures, lactic acid, bilirubin, blood count, creatinine, coagulation studies, etc.
• Obtain blood cultures before the antibiotic dose is given. Broad spectrum antibiotics are preferred as the first line of management.
• Rapid administration of crystalloid fluids (30 mL/kg) is recommended if systolic blood pressure is less than 90 mm Hg or lactic acid is more than 4 mmol/L. Fluid resuscitation is important even for renal or cardiac patients. Follow the physician’s order for holding fluids.
• Repeat lactic acid if the first level was >2 mmol/L.
• Administer vasopressors such as norepinephrine or neosynephrine to maintain systolic blood pressure of >100 mm Hg and a mean arterial pressure (MAP) of >65 mm Hg, if the patient is hypotensive even after adequate fluid resuscitation.

REFERENCES

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