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Chapter 82: Sepsis and Septic Shock

Trisha N. Branan; Susan E. Smith; Christopher M. Bland; S. Scott Sutton

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LEARNING OBJECTIVES

LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Compare and contrast the definitions of syndromes related to sepsis.

  2. Identify the pathogens associated with sepsis.

  3. Discuss the pathophysiology of sepsis as it relates to pro- and anti-inflammatory mediators.

  4. Identify patient symptoms as early or late sepsis and evaluate diagnostic and laboratory tests for patient treatment and monitoring.

  5. Assess complications of sepsis and discuss their impact on patient outcomes.

  6. Design desired treatment outcomes for septic patients.

  7. Formulate a treatment and monitoring plan (pharmacologic and nonpharmacologic) for septic patients.

  8. Evaluate patient response and devise alternative treatment regimens for nonresponding septic patients.

INTRODUCTION

image Sepsis occurs across a continuum of physiologic stages in response to infection which manifests as systemic inflammation, coagulation, and tissue hypoperfusion, potentially leading to organ dysfunction.1 The Third International Consensus Definitions for Sepsis and Septic Shock were published in 2016 and included updated nomenclature to standardize sepsis terminology. Previous definitions focused largely on inflammatory changes that may not necessarily be associated with organ dysfunction. Currently, sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response represented by an increase of at least 2 points in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) (Table 82–1). Septic shock is defined as a subset of patients with further increases in mortality resulting from underlying circulatory, cellular, and/or metabolic abnormalities. These patients require the use of vasopressor support in addition to adequate volume resuscitation to maintain a mean arterial pressure of at least 65 mm Hg and have an elevated serum lactate level greater than 2 mmol/L. Adult patients with suspected sepsis may be screened using a bedside clinical scoring system known as the quickSOFA (qSOFA) to rapidly identify patients who may need further diagnostic workup and intervention (Table 82–2).2,3

Table 82–1The SOFA Score
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Table 82–1 The SOFA Score
SOFA Score 1 2 3 4

Respiration

PaO2/FiO2, mm Hg

 

< 400

 

< 300

 

< 200

 

< 100
      ___with respiratory support___

Coagulation

Platelets x 103/mm3

 

< 150

 

< 100

 

< 50

 

< 20

Liver

Bilirubin, mg/dL (μmol/L)

 

1.2–1.9

(20–32)

 

2.0–5.9

(33–101)

 

6.0–11.9

(102–204)

 

≥ 12.0

(> 204)

Cardiovascular

Hypotension

 

MAP < 70 mm Hg

 

Dopamine ≤ 5

or dobutamine (any dose)a

 

Dopamine > 5.1–15

or epinephrine ≤ 0.1

or norepinephrine ≤ 0.1

 

Dopamine > 15

or epinephrine > 0.1

or norepinephrine > 0.1

Central nervous system

Glasgow Coma Score

 

13–14

 

10–12

 

6–9

 

< 6

Renal

Creatinine, mg/dL (μmol/L) or urine output

 

1.2–1.9

(110–170)

 

2.0–3.4

(171–299)

 

3.5–4.9

(300–400)

or < 500 mL/day

 

...

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