Recognizing and Treating Sepsis in Critically Ill Patients

Introduction:

Sepsis is a life-threatening condition that requires emergency treatment, and the patient should be admitted to the intensive care unit (ICU). The most important key to successfully treating sepsis is the early diagnosis of the symptoms. Treatment includes recognizing the source of the infection and draining it, followed by fluids and administering broad-spectrum antibiotics.

What Is Sepsis?

Sepsis is a condition in which, due to an infection, the body responds improperly. Severe sepsis occurs when there is organ dysfunction. Septic shock occurs when there is decreased blood pressure even after fluid resuscitation. Systemic inflammatory response syndrome (SIRS) is when there are more than two organ failures.

What Are the Signs of Sepsis?

The signs of sepsis are:

• The body temperature of internal organs is more than 38.3 °C (degree Celsius).

• Heart rate is more than 90 BPM (beats per minute).

• Significant edema (increased retention of fluid in the body).

• Increased blood sugar levels which are more than 126 mg/dL (milligrams of sugar per deciliter).

• Leukopenia (decreased white blood cells) or leukocytosis (increased white blood cells).

• Decreased platelet counts.

• Increased plasma C-reactive protein and plasma procalcitonin.

• Decreased blood pressure is when the systolic blood pressure (SBP) is less than 90 mmHg (millimeters of mercury).

• Decreased oxygen level in the arterial blood.

• Acute oliguria (sudden low urine output) is less than 0.5 ml/Kg/hr (milliliters per kilogram per hour) and occurs even after fluid resuscitation.

• Increased creatinine levels which are more than 44 μmol/l (micromoles per liter).

• Absent bowel sounds.

• Hyperbilirubinemia (increased bilirubin levels).

• Low levels of capillary refills occur due to heart or lung dysfunction.

The signs of severe sepsis with organ dysfunction include:

• Low urine output which is less than 0.5 ml/Kg/hr for more than two hours.

• Acute lung injury despite pneumonia (lung infection).

• Increased creatinine levels by more than 176 mmol/l.

• Increased levels of bilirubin more than 34 mmol/l.

• Increased levels of lactate of more than 4 mmol/l.

• Decreased platelet count.

• INR (international normalized ratio, a type of coagulation test) of more than 1.5.

How Is Sepsis Recognized in a Critically Ill Patient?

Early recognition of sepsis is a very important step to have good outcomes. The diagnosis includes;

• In the case of patients already affected by diabetes (a metabolic disorder in which there are increased levels of sugar in the blood), arthritis (pain in the joint along with inflammation), or ischaemic heart disease (decreased levels of blood flow to the heart due to narrow blood vessels) the cause for feeling sick is not related to these diseases.

• The healthcare provider has to cover all the systems and should look for signs of infections such as weakness, lethargy, chills, fever, headache, increased heartbeat, sweating, and confusion.

• The health care provider has to identify organ dysfunction, which is important for the administration of antibiotics. The organs which can involve along with symptoms are:

  1. Nervous System: Confusion, psychosis, and altered consciousness.

  2. Cardiovascular System: Hypotension, tachycardia, altered pulmonary artery occlusion pressure (PAOP), and central venous pressure (CVP).

  3. Respiratory System: Abnormal increased breathing, decreased oxygen saturation (SaO2), and partial pressure of oxygen (PaO2).

  4. Urinary System: Low urine output and increased creatinine levels.

  5. Hepatic System: Jaundice (characterized by yellowish skin, nails, and sclera of the eye due to increased bilirubin levels), decreased albumin levels, and increased enzymes.

Therefore, identifying the organs of dysfunctions plays an important role in determining the severity of the sepsis and in treatment.

• Total screening swabs should be done, which include sputum, urine, pus, and drains.

• Blood cultures should also be done.

How Is Sepsis Treated in Critically Ill Patients?

After diagnosing the sepsis, the patient should be moved to an area where the availability of supplemental oxygen therapy and central venous pressure monitoring is present. The treatment includes:

• Successful antibiotic therapy depends on the isolation of the pathogen. A broad-spectrum antibiotic should be prescribed and should be continued for seven to ten days, even if the infection was not the source.

• Invasive devices, such as catheters (long flexible tubes inserted into the bladder for urine collection), should be removed.

• Any pus collection should be drained, and infected tissue should be debrided.

• Fluid therapy should be initiated, and circulatory volume should be increased. In the case of sepsis-induced tissue hypoperfusion associated with hypovolemia, crystalloids of 20 ml/kg (milliliter per kilogram) for over five to ten minutes should be started.

• Central venous pressure in the case of patients with spontaneous breathing should be around 8 mmHg, and in the case of ventilated patients, it should be around 12 mmHg.

If the patient remains hypoperfused or hypotensive even after fluid resuscitation for six hours, the patient is considered to be in a septic shock, and the patient should be shifted to an intensive care unit (ICU). The treatment for septic shock includes:

• Fluid therapy with crystalloids is given. In the case of heavy crystalloids, albumin can be given. Fluid therapy should improve hemodynamics (blood flow, pulse pressure, heart rate, and arterial pressure).

• Central venous pressure should be maintained around 8 mmHg, and in the case of ventilated patients, it should be maintained around 12 mmHg.

• The mean arterial pressure (MAP) should be maintained above 65 mmHg.

• Noradrenaline is used as a standard vasopressor (drugs that cause vasoconstriction).

• Ionotropic drugs such as Adrenaline can be used to change the heart’s contractions.

• Steroids such as Hydrocortisone 200 mg per 24 hours should be given in case of failure to treat hypotension with the help of vasopressors or adequate fluids.

• The hemoglobin should be maintained around 7 to 9 g/dl.

• The patient should be ventilated according to the ARDS net protocol in case of tidal volumes (air in the lungs that passes in and out) less than 6 ml/kg (milliliter per kilogram).

• Blood glucose levels should be maintained below 140 mg/dl.

• If acidosis (increased levels of acid in the body) affects the heart system, Bicarbonates should be used.

Conclusion:

Sepsis shock is a life-threatening condition and has a morbidity rate of 38 %. The success of treating sepsis depends on the rate of diagnosis. Treatment should mainly involve maintaining the blood pressure, mean arterial pressure, fluid resuscitation, use of corticosteroids, vasopressors, inotropes, and use of broad-spectrum antibiotics.