Sepsis; csuses, symptoms, treatment

Sepsis

The incidence of sepsis is increasing due to the ageing population,

the increased frequency of invasive surgery, higher bacterial resistance

and more immunosuppressed patients.

Any or all of the features of SIRS may be present,

together with an obvious focus of infection such as purulent sputum

from the chest with shadowing on CXR or erythema around an IV

line. However, severe sepsis may present as unexplained hypotension,

and the speed of onset may simulate major pulmonary embolism

or myocardial infarction.

A distinction should be made between community-acquired

and hospital-acquired infections, as the likely causative microorganism

may be different and this will direct the initial choice

of antibiotics. The aim of management is to identify and treat the

underlying cause.

Sepsis


Nosocomial infections are an increasing problem on critical care

units; cross-infection is a major concern, particularly with regard to

MRSA and multidrug-resistant Gram-negative organisms. The most

important practice in preventing cross-infection is thorough handwashing

after every patient contact. Limiting the use of antibiotics

helps to prevent the emergence of multidrug-resistant bacteria.

Management

Cultures should be taken from blood, urine, sputum, any vascular

lines and any wounds. Prompt administration of broad-spectrum

antibiotics that cover probable causative organisms (based on the

site of infection, previous antibiotic therapy and local resistance patterns)

is essential. The early stages of septic shock are often dominated

by hypotension with relative volume depletion due to marked

arteriolar and particularly venular dilatation. Sufficient IV fluid

should be given to ensure that the intravascular volume is not the

limiting factor in determining oxygen delivery.

Vasoactive drugs: These are often used in the ICU. The most

appropriate vasoactive drug should be chosen based on a full analysis

of the circulation and knowledge of the different inotropic, dilating

or constricting properties of these drugs (see Box 3.5). In most

cases, a vasoconstrictor such as noradrenaline (norepinephrine)

is necessary to increase systemic vascular resistance and BP, while

an inotrope (dobutamine) may be necessary to maintain cardiac

output.

Corticosteroids: Assessment of the pituitary–adrenal axis is difficult

in the critically ill but up to 30% of patients may have adrenal

insufficiency. Corticosteroid replacement therapy is controversial.

Recent evidence suggests that, although it is associated with earlier

resolution of shock, it has no effect on survival.

Disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC), also called consumptive

coagulopathy, is common in critically ill patients and often

heralds the onset of multiple organ failure.

It is characterised by an increase in prothrombin time, partial

thromboplastin time and fibrin degradation products, and a fall in

platelets and fibrinogen. It causes either widespread bleeding from

vascular access points, GI tract, bronchial tree and surgical wound

sites, or widespread evidence of thrombosis.

Management is supportive, with infusions of fresh frozen plasma

and platelets, while the underlying cause is treated.

Critical care discharge is a complex process and can be stressful for

patients. Ideally, they should be discharged to a suitable step-down

ward area during daytime working hours, and with full multidisciplinary

handover. A period of physical and emotional rehabilitation

is needed after critical illness, and this may be prolonged.

WITHDRAWAL OF CARE

Withdrawal of support is appropriate when it is clear that the patient

has no realistic prospect of recovery or of surviving with a quality

of life that he or she would value. In these situations, intensive

care will only prolong the dying process and is therefore futile.

Nevertheless, when active support is withdrawn, management

should remain positive and be directed towards allowing the patient

to die with dignity and as free from distress as possible. Patients’

views are paramount and increasing use is being made of advance

directives or ‘living wills’. Communication with the patient, if possible,

and the family is of crucial importance at this time.

OUTCOMES OF INTENSIVE CARE

Although mortality is affected by case mix, typically 20% of patients

will die in the ICU and a further 30% die before leaving hospital.

Long-term physical and psychological effects are common despite

best treatment.

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