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34: Sepsis

Rakesh S. Engineer, MD

Key Points

  • Identification of the septic patient is the important first step. All other critical actions are missed if this does not occur.

  • Lactate measurement is critical to determining sepsis severity, response to therapy, and prognosis.

  • Early administration of appropriate antimicrobials and early goal-directed therapy are the mainstays of treatment.

  • Resuscitation of the critically ill septic patient should occur concurrent or before diagnostic evaluation.

Introduction

Sepsis is now defined as “infection plus systemic manifestations of infection” (Table 34-1). Systemic inflammatory response syndrome is no longer a strict criteria. There are 3 sepsis syndromes (stages): uncomplicated sepsis, severe sepsis, and septic shock. Sepsis becomes severe sepsis when there is tissue hypoperfusion or organ dysfunction (Table 34-2). Septic shock is defined as a systolic blood pressure (SBP) <90 mmHg or 40 mmHg below one's baseline blood pressure, despite two 20- to 30-mL/kg boluses.

Table 34-1.

Diagnostic criteria for sepsis.

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Table 34-1.

Diagnostic criteria for sepsis.
Infection, documented or suspected, and some of the following:
General variables

  • Fever (>38.3 °C)

  • Hypothermia (<36 °C)

  • Heart rate >90 beats/min

  • Tachypnea

  • Altered mental status (delirium)

  • Significant edema or positive fluid balance (>20 mL/kg over 24 hrs)

  • Hyperglycemia (>140 mg/dL) in the absence of diabetes
Inflammatory variables

  • Leukocytosis (WBC count >12,000/μL)

  • Leukopenia (WBC count <4000/μL)

  • Normal WBC count with >10% immature forms

  • Plasma C-reactive protein >2 SD above the normal value

  • Plasma procalcitonin >2 SD above the normal value

Hemodynamic variables

  • Arterial hypotension (SBP <90 mmHg; MAP <70 mmHg; or an SBP decrease >40 mmHg in adults or >2 SD below normal for age)

Organ dysfunction variables

  • Arterial hypoxemia (PaO2/FIO2 <300)

  • Acute oliguria (urine output <0.5 ml/kg/hr for at least 2 hrs, despite adequate fluid resuscitation)

  • Creatinine increase >0.5 mg/dL

  • Coagulation abnormalities (INR >1.5 or a PTT > 60 secs)

  • Ileus (absent bowel sounds)

  • Thrombocytopenia (platelet count, <100,000/μL)

  • Hyperbilirubinemia (total bilirubin >4 mg/dL)

Tissue perfusion variables

  • Hyperlactatemia (<4 mmol/L)

  • Decreased capillary refill or mottling

Diagnostic criteria for sepsis in the pediatric population are signs and symptoms of inflammation plus infection with hyper- or hypothermia (rectal temperature >38.5 °C or <35 °C), tachycardia (may be absent in hypothermic patients), and at least one of the following indications of altered organ function: altered mental status, hypoxemia, increased serum lactate level, or bounding pulses.

INR, international normalized ratio; MAP, mean arterial pressure; PTT, activated partial thromboplastin time; SBP, systolic blood pressure; SD, standard deviation; WBC, white blood count.

Adapted from Levy MM, Fink MP, Marshall JC, et al: 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference, Crit Care Med 2003;31:1250–1256

Table 34-2.

Diagnostic criteria for severe sepsis.

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Table 34-2.

Diagnostic criteria for severe sepsis.
Severe sepsis is sepsis with tissue hypoperfusion or organ dysfunction as defined by the following criteria:
Hypotension
Lactate greater than the upper limits of normal ...

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