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Sepsis and Septic Shock

SOURCE

Source: Kang-Birken SL. Sepsis and septic shock. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=133893876. Accessed May 22, 2017.

DEFINITION

  • Systemic inflammatory response syndrome secondary to infection.

  • Definitions of terms related to sepsis in Table 1.

TABLE 1.Definitions Related to Sepsis
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TABLE 1. Definitions Related to Sepsis
Condition Definition
Bacteremia (fungemia) Presence of viable bacteria (fungi) in the bloodstream
Infection Inflammatory response to invasion of normally sterile host tissue by the microorganisms
Systemic inflammatory response syndrome Systemic inflammatory response to variety of clinical insults that can be infection but also of noninfectious etiology. Response manifested ≥2 of following conditions: temperature >38°C (100.4°F) or <36°C (96.8°F); heart rate >90 beats/min; respiratory rate >20 breaths/min or PaCO2 <32 torr; WBC >12,000 cells/mm3, <4000 cells/mm3, or >10% immature (band) forms.
Sepsis

SIRS secondary to suspected or documented infection.

Additional criteria include general variables (altered mental status, positive fluid balance of >20 mL/kg over 24 hours, hyperglycemia >120 mg/dL [>6.7 mmol/L]); inflammatory variables (plasma C-reactive protein/procalcitonin >2 SD above normal value); hemodynamic variables (arterial hypotension <90 mm Hg (<12.0 kPa) or MAP <70 mm Hg (<9.3 kPa), elevated mixed venous oxygen saturation of >70% (>0.70); CI >3.5 L/min (>0.058 L/s); organ-dysfunction variables (arterial hypoxemia; acute oliguria of <0.5 mL/kg/h or 45 mL/h for at least 2 h, creatinine increase >0.5 mg/dL (>0.44 μmol/L), coagulation abnormalities, paralytic ileus, platelets <100,000 /mm3 (<100 × 109/L), bilirubin >4 mg/dL (>68 μmol/L); tissue-perfusion variable (hyperlactatemia >1 mmol/L, decreased capillary refill)
Severe sepsis Sepsis associated with one or more organ dysfunctions, hypoperfusion, or hypotension. Hypoperfusion and perfusion abnormalities may include, but are not limited to, arterial hypoxemia (PaO2/FiO2<300) lactic acidosis, oliguria, increase in creatinine, coagulation abnormalities (INR>1.5), and elevated bilirubin
Septic shock Sepsis with persistent hypotension despite fluid resuscitation (intravenous uid of 30 mL/kg) or hyperlactatemia >1 mmol/L

CI, cardiac index; HR, heart rate; INR, international normalized ratio; RR, respiratory rate; SD, standard deviation; SIRS, systemic inflammatory response syndrome; T, temperature; WBC, white blood cell (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.

Reprinted with permission from Wells BG, DiPiro JT, Schwinghammer TL, et al. Pharmacotherapy Handbook. 10th ed. New York, NY: McGraw-Hill; 2017.

ETIOLOGY

  • Sites of infection that most frequently lead to sepsis:

    • Respiratory tract (39–50%)

    • Urinary tract (5–37%)

    • Intra-abdominal space (8–16%)

  • Caused by:

    • Gram-positive bacteria (37–47% of cases)

      • Common gram-positive pathogens:

        • Staphylococcus aureus

        • Streptococcus pneumonia

        • Coagulase-negative staphylococci.

        • Enterococcus species.

    • Gram-negative bacteria (38% of cases)

      • Most common isolates: Escherichia coli, Klebsiella spp., and Pseudomonas aeruginosa

      • P. aeruginosa associated with a higher mortality ...

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