Sepsis Treatment & Management Options

Sepsis is a serious complication of infections. It occurs when there is an abnormal and extreme response by the body’s immune system to an infection, resulting in widespread inflammation and organ damage throughout the body. Critically ill patients with severe sepsis need to be managed in intensive care units by specialists in critical care medicine. However, even mild sepsis is potentially life-threatening and requires immediate medical attention. Please continue reading to find out how healthcare providers treat sepsis.

What is sepsis, septic shock, and systemic inflammatory response syndrome (SIRS)?

Sepsis and septic shock are known by many names, such as septicemia, blood poisoning, and systemic inflammatory response syndrome (SIRS). By definition, sepsis is a life-threatening inflammatory response and organ dysfunction caused by an abnormal response to bacterial infections and, less commonly, viral and fungal infections.

The main features of human septic shock are hypotension (dangerously low blood pressure) and cardiovascular, cellular, and metabolic dysfunction. In other words, septic shock is a type of severe sepsis in which circulatory abnormalities increase the risk of death.

Sepsis can start with an infection in any part of the body, such as a skin infection, community-acquired pneumonia, urinary tract infection, or abdominal infection. Risk factors for sepsis include diabetes, liver disease, alcoholism, severe burns, human immunodeficiency virus (HIV/AIDS), cancer, and a weakened immune system.

Diagnosing and treating sepsis syndrome in a timely manner is critical to prevent potentially fatal complications such as acute respiratory distress syndrome, kidney failure, gangrene (tissue death), permanent brain damage, disseminated intravascular coagulation, endocarditis (damage to the heart valves), and immune system compromise.

What are the symptoms of sepsis?

The symptoms of sepsis can include high fever, fast heart rate, fast breathing rate, rash, swelling, difficulty breathing, abdominal pain, dizziness, confusion, low urine output, and dangerously low blood pressure.

How do doctors diagnose sepsis?

Doctors diagnose sepsis based on the patient’s history, physical exam, and laboratory parameters (blood tests, urine tests, and imaging studies). They use a scoring system called Sequential Organ Failure Assessment (SOFA) to predict the risk of mortality. A widely used clinical screening tool for patients with suspected sepsis is called quick SOFA or qSOFA, which measures three clinical parameters:

Respiratory rate 22 per minute or higher
Glasgow Coma Scale (GSS) less than 13
Systolic blood pressure 100 mmHg or lower

Any patient who meets two of these three criteria receives escalated therapy and referral to intensive care medicine.

The criteria for diagnosing septic shock includes:

A need for vasopressor therapy to maintain a mean arterial pressure of 65 mmHg or higher (vasopressors are drugs that make the blood vessels tighter and increase blood pressure)
A serum lactate level of more than 2 mM even after adequate fluid resuscitation

What is the treatment option for severe sepsis?

The Surviving Sepsis Campaign (SSC) by the Society of Critical Care Medicine publishes up-to-date guidelines on managing sepsis and septic shock. The management for individual patients varies depending on the clinical picture. In general, acutely ill patients diagnosed with sepsis are treated with:

Resuscitation

Intravenous fluids (normal saline) are used to correct hypotension (low blood pressure). If the patient has poor fluid responsiveness, i.e., if hypotension persists despite adequate resuscitation with IV fluids, the patient is admitted to a critical care facility and vasopressors, such as noradrenaline, are given.

Oxygen is given to maintain saturation over 95%. Mechanical ventilation may be necessary for patients with acute respiratory distress syndrome.

Early goal-directed therapy is used in patients with severe sepsis and septic shock in the intensive care unit. This involves adjusting the cardiac output to balance oxygen demand and oxygen delivery. Early goal-directed therapy can also involve a blood transfusion, specifically a red blood cell transfusion, to improve oxygen delivery to the tissues.

Antimicrobial therapy

Effective antimicrobial therapy that targets the causative pathogen (bacteria, viruses, or fungi) is given as soon as possible, ideally within an hour of admission. Blood cultures are obtained before administering intravenous antibiotics so that the cultured bacteria can be tested for sensitivity to the appropriate antibiotics.

Fluid balance

The patient’s urine output is recorded along with the amount of fluid resuscitation administered. A urinary catheter may or may not be required. Renal replacement therapy may be used in patients with septic shock to decrease the levels of circulating inflammatory substances.

Tight glucose control

If blood sugar levels are high, intravenous insulin is given to control them.

Source identification

Sepsis and septic shock patients need immediate medical attention to correct their physiological parameters, as listed above. However, equally important is for infectious diseases experts to identify and manage the underlying cause of the sepsis. This is done by obtaining a thorough medical history, performing a full physical examination, and ordering appropriate laboratory and imaging tests to identify the source of infection. However, in approximately 1 out of 4 sepsis patients, no source is identified. If an infection source can be found, it is managed appropriately, for example, by drainage of a pleural effusion in patients with lung infections, surgery to drain intra-abdominal abscesses or debridement of infected skin wounds.

What are the 6 treatments for sepsis?

The 6 treatments for sepsis refer to a bundle of six tasks called the Sepsis Six developed by the UK Sepsis Trust. These six tasks include oxygen, cultures, antibiotics, fluid resuscitation, lactate measurement, and monitoring of urine output. Treatment begins ideally within one hour in the emergency department. Implementation of the Sepsis Six bundle by emergency medicine has been found to lower the risk of death in patients with severe sepsis by over 46% when delivered within one hour.

What are the 4 in 3 rapid interventions for sepsis?

The 4 in 3 rapid interventions for sepsis refers to four measures that should be administered in the first 3 hours. The Surviving Sepsis Campaign recommends the following four measures in the first 3 hours:

Obtain a blood culture before starting antibiotics
Obtain a lactate level
Start broad-spectrum antibiotics
Administer IV fluids for hypotension (mean arterial pressure < 65) or lactate > 4

The shorter the delay in following these guidelines, the better the outcome. Note that three hours is a guideline. Even short delays in instituting these measures can lead to poor outcomes. Therefore, time is of critical importance when treating sepsis.

References: