- The spectrum of microorganisms associated with sepsis has changed from predominantly gram-negative bacteria in the late 1970s and 1980s to gram-positive bacteria as the major pathogens since the late 1980s.
- Candidemia is a major cause of morbidity and mortality. Candida albicans remains the most common pathogen (45.6%); however, non–albicans Candida species collectively is more frequently isolated (54.4%).
- Sepsis presents a complex pathophysiology, characterized by the activation of multiple overlapping and interacting cascades leading to systemic inflammation, a procoagulant state, and decreased fibrinolysis.
- Mortality rates with sepsis are higher for older patients with preexisting disease, intensive care unit care, and multiple organ failure.
- Prompt initiation of broad-spectrum, parenteral antibiotic therapy is required due to the high incidence of complications and mortality with sepsis.
- A significant volume of fluid leaks from the vasculature occurs with sepsis, and initial fluid resuscitation with large volumes of fluid is required. There is no difference in clinical outcomes between colloid and crystalloid fluid resuscitation.
- Norepinephrine is generally preferred over dopamine as the vasopressor to correct hypotension in septic shock.
- Early goal-directed therapy during the first 6 hours, consisting of hemodynamic monitoring with a central venous catheter, volume resuscitation, inotropic therapy, and red blood cell transfusions, demonstrated a significant clinical outcome benefit with a 16% absolute reduction in 28-day mortality.
- A blood glucose level less than 150 mg/dL (8.3 mmol/L) is recommended for the majority of critically ill patients to reduce morbidity and mortality without the detrimental effects associated with hypoglycemia.
- IV hydrocortisone is recommended for adult patients with septic shock whose blood pressure is unresponsive to fluids and vasopressors.
On completion of the chapter, the reader will be able to:
Define the following terms: systemic inflammatory response syndrome, sepsis, severe sepsis, and septic shock.
Describe the typical clinical presentation including signs, symptoms, hemodynamic measure, and laboratory tests for each condition above.
Describe the microbial pathogens of severe sepsis.
Describe the mechanism of sepsis, including the components involving inflammatory cytokines and other mediators and the coagulation system.
Describe the early goal-directed therapy of sepsis.
Describe the significance of prompt initiation of broad-spectrum antibiotics.
Determine appropriate fluid resuscitation for sepsis with colloids or crystalloids.
Recommend an appropriate antibiotic regimen for treatment of sepsis based on patient characteristics and primary site of infection.
Determine the role of vasoactive agents in supporting the physiologic function of a patient with sepsis, and select the appropriate vasoactive agents based on the details of a patient’s condition.
Explain the benefits of glycemic control in patients with sepsis.
Recommend the appropriate use of corticosteroids in severe sepsis and septic shock.
Describe an appropriate monitoring program for patients with sepsis.
Sepsis and severe sepsis continue to pose major healthcare burden. The incidence of sepsis in the United States increased from 82.7 cases per 100,000 population in 1979 to 240.4 cases per 100,000 population in 2000, for an annualized increase of 8.7 percent.1 Severe sepsis increased from 200 cases per 100,000 ...