Name = Sepsis
DiseasesDB = 11960
ICD10 = ICD10|A|40| |a|30 - ICD10|A|41|0|a|30
ICD9 = ICD9|995.91
MedlinePlus = 000666
MeshID = D018805
Sepsis is a serious medical condition characterized by a whole-body inflammatory state (called a
systemic inflammatory response syndromeor SIRS) caused by infection.cite journal |author=Levy MM, Fink MP, Marshall JC, "et al" |title=2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference |journal=Crit. Care Med. |volume=31 |issue=4 |pages=1250–6 |year=2003 |month=April |pmid=12682500 |doi=10.1097/01.CCM.0000050454.01978.3B |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0090-3493&volume=31&issue=4&spage=1250] cite journal |author=Bone RC, Balk RA, Cerra FB, "et al" |title=Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine |journal=Chest |volume=101 |issue=6 |pages=1644–55 |year=1992 |month=Jun |pmid=1303622 |doi= 10.1378/chest.101.6.1644 |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=1303622] The body may develop this inflammatory response to microbesin the blood. The related layman's term is blood poisoning.
Sepsis is usually treated in the
intensive care unitwith intravenous fluidsand antibiotics. If fluid replacement is insufficient to maintain blood pressure, specific vasopressordrugs can be used. Artificial ventilationand dialysismay be needed to support the function of the lungs and kidneys, respectively. To guide therapy, a central venous catheterand an arterial cathetermay be placed. Sepsis patients require preventive measures for deep vein thrombosis, stress ulcers and pressure ulcers, unless other conditions prevent this. Some patients might benefit from tight control of blood sugar levels with insulin(targeting stress hyperglycemia), low-dose corticosteroidsor activated drotrecogin alfa(recombinant protein C).cite journal |author=Dellinger RP, Levy MM, Carlet JM, et.al, for the International Surviving Sepsis Campaign Guidelines Committee. |title=Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2008 |journal=Crit Care Med |year=2008 |volume=36 |issue=1 |pages=296–327 |pmid=18158437 |url=http://www.ccmjournal.com/pt/re/ccm/searchresults.htm |doi=10.1097/01.CCM.0000298158.12101.41 |doi_brokendate=2008-06-26]
Severe sepsis occurs when sepsis leads to organ dysfunction, low blood pressure (
hypotension) or insufficient blood flow ( hypoperfusion) to one or more organs (causing, for example, lactic acidosis, decreased urine production or altered mental status). Sepsis can lead to septic shock, multiple organ dysfunction syndrome(formerly known as multiple organ failure) and death. Organ dysfunction results from sepsis-induced hypotension (< 90 mmHg or a reduction of ≥ 40 mmHg from baseline) and diffuse intravascular coagulation, among other things. Bacteremiais the presence of viable bacteriain the bloodstream. Likewise, the terms viremiaand fungemiasimply refer to viruses and fungi in the bloodstream. These terms say nothing about the consequences this has on the body. For example, bacteria can be introduced into the bloodstream during toothbrushing.cite journal |author=Lockhart PB, Brennan MT, Sasser HC, Fox PC, Paster BJ, Bahrani-Mougeot FK |title=Bacteremia associated with toothbrushing and dental extraction |journal=Circulation |volume=117 |issue=24 |pages=3118–25 |year=2008 |month=Jun |pmid=18541739 |doi=10.1161/CIRCULATIONAHA.107.758524 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=18541739] This form of bacteremia almost never causes problems in normal individuals. However, bacteremia associated with certain dental procedures can cause bacterial infection of the heart valves(known as endocarditis) in high risk patients.cite journal |author=Wilson W, Taubert KA, Gewitz M, "et al" |title=Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group |journal=Circulation |volume=116 |issue=15 |pages=1736–54 |year=2007 |month=Oct |pmid=17446442 |doi=10.1161/CIRCULATIONAHA.106.183095 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=17446442] Conversely, a systemic inflammatory response syndrome can occur in patients without the presence of infection, for example in those with burns, polytrauma, or the initial state in pancreatitisand chemical pneumonitis. Septicemia is an ill-defined term referring to the presence of bacteria or their toxins in the blood. [EMedicineDictionary|septicemia] The term improperly mixes components of bacteremia and sepsis, and has been abandoned as a concept.
Signs and symptoms
In addition to symptoms related to the provoking infection, sepsis is characterized by evidence of acute
inflammationpresent throughout the entire body, and is therefore frequently associated with feverand elevated white blood cellcount ( leukocytosis). The modern concept of sepsis is that the host's immune response to the infection causes most of the symptoms of sepsis, resulting in hemodynamic consequences and damage to organs. This host response has been termed systemic inflammatory response syndrome(SIRS) and is characterized by hemodynamic compromise and resultant metabolic derangement.
This immunological response causes widespread activation of
acute phase proteins, affecting the complement systemand the coagulationpathways, which then cause damage to the vasculature as well as to the organs. Various neuroendocrine counter-regulatory systems are then activated as well, often compounding the problem. Even with immediate and aggressive treatment, this may progress to multiple organ dysfunction syndromeand eventually death.
United States, sepsis is the leading cause of death in non-coronary ICU patients, and the tenth most common cause of death overall according to data from the Centers for Disease Control and Prevention. [cite journal |author=Martin GS, Mannino DM, Eaton S, Moss M |title=The epidemiology of sepsis in the United States from 1979 through 2000 |journal=N Engl J Med |date=2003-04-17 |volume=348 |issue=16 |pages=1546–54 |pmid=12700374 |url=http://content.nejm.org/cgi/content/full/348/16/1546 |doi=10.1056/NEJMoa022139] Sepsis is common and also more dangerous in elderly, immunocompromised, and critically ill patients. It occurs in 1%-2% of all hospitalizations and accounts for as much as 25% of intensive care unit (ICU) bed utilization. It is a major cause of death in intensive care units worldwide, with mortality rates that range from 20% for sepsis to 40% for severe sepsis to >60% for septic shock.
Definition of sepsis
Heart rate> 90 beats per minute ( tachycardia)
Body temperature< 36 °C (96.8 °F) or > 38 °C (100.4 °F) ( hypothermiaor fever)
Respiratory rate> 20 breaths per minute or, on blood gas, a PaCO2 less than 32 mm Hg(4.3 kPa) ( tachypneaor hypocapniadue to hyperventilation)
White blood cellcount < 4000 cells/ mm³or > 12000 cells/mm³ (< 4 x 109 or > 12 x 109 cells/L), or greater than 10% band forms (immature white blood cells). ( leukopenia, leukocytosis, or bandemia)
Fever and leukocytosis are features of the
acute phase reaction, while tachycardiais often the initial sign of hemodynamic compromise. Tachypneamay be related to the increased metabolic stress due to infection and inflammation, but may also be an ominous sign of inadequate perfusion resulting in the onset of anaerobic cellular metabolism.
In children, the SIRS criteria are modified in the following fashion:cite journal |author=Goldstein B, Giroir B, Randolph A |title=International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics |journal=Pediatr Crit Care Med |volume=6 |issue=1 |pages=2–8 |year=2005 |pmid=15636651 |doi=10.1097/01.PCC.0000149131.72248.E6 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=1529-7535&volume=6&issue=1&spage=2]
Heart rate> 2 standard deviationsabove normal for age in the absence of stimuli such as pain and drug administration, OR unexplained persistent elevation for greater than 30 minutes to 4 hours. In infants, also includes Heart rate< 10th percentile for age in the absence of vagal stimuli, beta-blockers, or congenital heart diseaseOR unexplained persistent depression for greater than 30 minutes.
Body temperatureobtained orally, rectally, from Foley catheterprobe, or from central venous catheterprobe > 38.5°C or < 36°C. "Temperature must be abnormal to qualify as SIRS in pediatric patients."
Respiratory rate> 2 standard deviationsabove normal for age OR the requirement for mechanical ventilationnot related to neuromuscular disease or the administration of anesthesia.
White blood cellcount elevated or depressed for age not related to chemotherapy, or greater than 10% bands + other immature forms.
Note that SIRS criteria are very non-specific,cite journal |author=Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G |title=2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference |journal=Crit Care Med |year=2003 |month=Apr |volume=31 |issue=4 |pages=1250–1256 |url=http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200304000-00038.htm |doi=10.1097/01.CCM.0000050454.01978.3B] and must be interpreted carefully within the clinical context. These criteria exist primarily for the purpose of more objectively classifying critically-ill patients so that future clinical studies may be more rigorous and more easily reproducible.
To qualify as sepsis, there must be an infection suspected or proven (by culture, stain, or
polymerase chain reaction(PCR)), or a clinical syndrome pathognomonic for infection. Specific evidence for infection includes WBCs in normally sterile fluid (such as urine or cerebrospinal fluid(CSF), evidence of a perforated viscus (free air on abdominal x-ray or CT scan, signs of acute peritonitis), abnormal chest x-ray (CXR) consistent with pneumonia(with focal opacification), or petechiae, purpura, or purpura fulminans
The more critical subsets of sepsis are severe sepsis (sepsis with acute organ dysfunction) and septic shock (sepsis with refractory arterial
hypotension). Alternatively, when two or more of the systemic inflammatory response syndrome criteria are met without evidence of infection, patients may be diagnosed simply with " SIRS." Patients with SIRS and acute organ dysfunction may be termed "severe SIRS."
Patients are defined as having "severe sepsis" if they have sepsis plus signs of systemic
hypoperfusion: either end organ dysfunction or a serum lactate greater than 4 mmol/dL. Other signs include oliguriaand altered mental status. Patients are defined as having septic shockif they have sepsis plus hypotension after aggressive fluid resuscitation (typically upwards of 6 liters or 40 ml/kg of crystalloid).
Examples of end-organ dysfunction include the following:cite journal |author=Abraham E, Singer M |title=Mechanisms of sepsis-induced organ dysfunction |journal=Crit. Care Med. |volume=35 |issue=10 |pages=2408–16 |year=2007 |pmid=17948334 |url=http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200710000-00026.htm |doi=10.1097/01.CCM.0000282072.56245.91 |doi_brokendate=2008-06-26]
acute lung injury(ALI) (PaO2/FiO2 < 300) or acute respiratory distress syndrome(ARDS) (PaO2/FiO2 < 200)
****multifocal necrotizing leukoencephalopathy
**disruption of protein synthetic function: manifests acutely as progressive
coagulopathydue to inability to synthesize clotting factors
**disruption of metabolic functions: manifests as cessation of
bilirubinmetabolism, resulting in elevated unconjugated serum bilirubin levels ( indirect bilirubin)
**systolic and diastolic
heart failure, likely due to cytokinesthat depress myocyte function
**cellular damage, manifest as a
troponinleak (although not necessarily ischemic in nature)
More specific definitions of end-organ dysfunction exist for SIRS in pediatrics.
*Cardiovascular dysfunction (after fluid resuscitation with at least 40 ml/kg of crystalloid)
**hypotension with blood pressure < 5th percentile for age or systolic blood pressure < 2 standard deviations below normal for age, OR
**two of the following criteria:
metabolic acidosiswith base deficit> 5 mEq/L
lactic acidosis: serum lactate 2 times the upper limit of normal
***oliguria (urine output < 0.5 ml/kg/hr)
capillary refill> 5 seconds
***core to peripheral temperature difference > 3°C
*Respiratory dysfunction (in the absence of
cyanotic heart diseaseor known chronic lung disease)
**the ratio of the arterial partial-pressure of oxygen to the fraction of oxygen in the gases inspired (PaO2/FiO2) < 300 (the definition of
acute lung injury), OR
**arterial partial-pressure of carbon dioxide (PaCO2) > 65 torr (20 mmHg) over baseline PaCO2 (evidence of
hypercapnic respiratory failure), OR
**supplemental oxygen requirement of greater than FiO2 0.5 to maintain oxygen saturation ≥ 92%
Glasgow Coma Score(GCS) ≤ 11, OR
**altered mental status with drop in GCS of 3 or more points in a patient with
developmental delay/ mental retardation
plateletcount < 80,000/mm3 or 50% drop from maximum in chronically thrombocytopenic patients, OR
international normalized ratio(INR) > 2
creatinine≥ 2 times the upper limit of normal for age or 2-fold increase in baseline creatininein patients with chronic kidney disease
*Hepatic dysfunction (only applicable to infants > 1 month)
bilirubin≥ 4 mg/dl, OR
alanine aminotransferase(ALT) ≥ 2 times the upper limit of normal
In common clinical usage, sepsis specifically refers to the presence of a
serious bacterial infection(SBI) (such as meningitis, pneumonia, pyelonephritis, or gastroenteritis) in the setting of fever. Criteria with regards to hemodynamic compromise or respiratory failure are not useful clinically because these symptoms often do not arise in neonates until death is imminent and unpreventable.
It is difficult to clinically exclude sepsis in newborns less than 90 days old who have fever (defined as a temperature > 38°C (100.4°F). Except in the case of obvious acute viral
bronchiolitis, the current practice in newborns less than 30 days old is to perform a complete workup including complete blood countwith differential, blood culture, urinalysis, urine culture, and cerebrospinal fluid(CSF) studies and CSF culture, admit the newborn to the hospital, and treat empirically for serious bacterial infection for at least 48 hours until cultures are demonstrated to show no growth. Attempts have been made to see if it is possible to risk stratify newborns in order to decide if a newborn can be safely monitored at home without treatment despite having a fever. One such attempt is the Rochester criteria.
A study performed at Strong Memorial Hospital in
Rochester, New York, showed that infants ≤ 60 days old meeting the following criteria were at low-risk for having a serious bacterial illnesscite journal |author=Dagan R, Powell KR, Hall CB, Menegus MA |title=Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis |journal=J. Pediatr. |volume=107 |issue=6 |pages=855–60 |year=1985 |month=Dec |pmid=4067741 |url=http://www.jpeds.com/article/S0022-3476(85)80175-X/abstract |doi=10.1016/S0022-3476(85)80175-X] :
*generally well appearing
**full term (at ≥37 weeks gestation)
**no antibiotics perinatally
**no unexplained hyperbilirubinemia that required treatment
**no antibiotics since discharge
**no chronic illness
**discharged at the same time or before the mother
*no evidence of skin, soft tissue, bone, joint, or ear infection
*WBC count 5,000-15,000/mm3
*absolute band count ≤ 1,500/mm3
*urine WBC count ≤ 10 per high power field (hpf)
*stool WBC count ≤ 5 per high power field (hpf) "only in infants with diarrhea"
Those meeting these criteria likely do not require a lumbar puncture, and are felt to be safe for discharge home without antibiotic treatment, or with a single dose of intramuscular antibiotics, but will still require close outpatient follow-up.
medical historyand clinical examinationcan provide important elements regarding the cause and severity of sepsis.
The identification of the causative microbe in sepsis can provide useful information. Imaging (such as chest X-rays or CT scans) and laboratory techniques (such as urine microscopy or lumbar puncture) are often necessary to find the source of the infection. The exact causative organism is confirmed by microbiological culturing in the laboratory (
blood cultures and cultures from suspected sites of infections such as urine cultures, sputum cultures, and so on). However, this is a slow process as it takes a few days to grow up the cultures and correctly identify the pathogens. New molecular diagnostic tests are now available that uses genetic material from the pathogen to quickly (within hours) provide results. However, current practice is to directly prescribe broad spectrum antibiotics to the patient.
The effects of the condition on the function of the organs should be documented to guide therapy. This can involve measurement of blood levels of
lactate, blood gas sampling, and other blood tests. Because patients on the intensive care unit are predisposed to hospital-acquired infections(especially related to the presence of catheters), they may require surveillance cultures.
Sepsis in Adults and Children
The therapy of sepsis rests on
antibiotics, surgical drainage of infected fluid collections, fluid replacement and appropriate support for organ dysfunction. This may include hemodialysis in kidney failure, mechanical ventilationin pulmonary dysfunction, transfusion of blood products, and drug and fluid therapy for circulatory failure. Ensuring adequate nutrition—preferably by enteral feeding, but if necessary by parenteral nutrition—is important during prolonged illness.
A problem in the adequate management of septic patients has been the delay in administering therapy after sepsis has been recognized. Published studies have demonstrated that for every hour delay in the administration of appropriate antibiotic therapy there is an associated 7% rise in mortality. A large international collaboration was established to educate people about sepsis and to improve patient outcomes with sepsis, entitled the "
Surviving Sepsis Campaign." The Campaign has published an evidence-based review of management strategies for severe sepsis, with the aim to publish a complete set of guidelines in subsequent years. Early Goal Directed Therapy (EGDT), developed at Henry Ford Hospitalby E. Rivers, MD, is a systematic approach to resuscitation that has been validated in the treatment of severe sepsis and septic shock. It is meant to be started in the Emergency Department. The theory is that one should use a step-wise approach, having the patient meet physiologic goals, to optimize cardiac preload, afterload, and contractility, thus optimizing oxygen delivery to the tissues.cite journal |author=Rivers E, Nguyen B, Havstad S, "et al" |title=Early goal-directed therapy in the treatment of severe sepsis and septic shock |journal=N. Engl. J. Med. |volume=345 |issue=19 |pages=1368–77 |year=2001 |pmid=11794169 |url=http://content.nejm.org/cgi/content/full/345/19/1368 |doi=10.1056/NEJMoa010307] A recent meta-analysisshowed that EGDT provides a benefit on mortality in patients with sepsis.cite journal |author=Jones AE, Brown MD, Trzeciak S, "et al" |title=The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: a meta-analysis |journal=Critical care medicine |volume=36 |issue=10 |pages=2734–9 |year=2008 |month=October |pmid=18766093 |doi=10.1097/CCM.0b013e318186f839 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?doi=10.1097/CCM.0b013e318186f839]
In EGDT, fluids are administered until the
central venous pressure(CVP), as measured by a central venous catheter, reaches 8-12 cm of water (or 10-15 cm of water in mechanically ventilated patients). This may require around 6 liters of isotonic crystalloid solution, rapidly administered. If the mean arterial pressureis less than 65 mmHg or greater than 90 mmHg, vasopressors or vasodilators are given as needed to reach the goal. Once these goals are met, the mixed venous oxygen saturation (SvO2), i.e. the oxygen saturation of venous blood as it returns to the heart as measured at the vena cava, is optimized. If the SvO2 is less than 70%, blood is given to reach a hemoglobin of 10 g/dl and then inotropes are added until the SvO2 is optimized. Elective intubation may be performed to reduce oxygen demand if the SvO2 remains low despite optimization of hemodynamics. Urine output is also monitored, with a minimum goal of 0.5 ml/kg/h. In the original trial, mortality was cut from 46.5% in the control group to 30.5% in the intervention group. The Surviving Sepsis Campaign guidelines recommends EGDT for the initial resuscitation of the septic patient with a level B strength of evidence (single randomized control trial).
Most therapies aimed at the inflammation process itself have failed to improve outcome, however
drotrecogin alfa(activated protein C, one of the coagulation factors) has been shown to decrease mortality from about 31% to about 25% in severe sepsis. To qualify for drotrecogin alfa, a patient must have severe sepsis or septic shock with an APACHE IIscore of 25 or greater and a low risk of bleeding. [cite journal |author=Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ Jr |title=Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis |journal=N Engl J Med |date=2001-03-08 |volume=344 |issue=10 |pages=699–709 |pmid=11236773 |url=http://content.nejm.org/cgi/content/abstract/344/10/699 |doi=10.1056/NEJM200103083441001]
During critical illness, a state of
adrenal insufficiencyand tissue resistance (the word 'relative' resistance should be avoided) to corticosteroidsmay occur. This has been termed critical illness–related corticosteroid insufficiency.cite journal |author=Marik PE, Pastores SM, Annane D, "et al" |title=Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine |journal=Crit. Care Med. |volume=36 |issue=6 |pages=1937–49 |year=2008 |month=Jun |pmid=18496365 |doi=10.1097/CCM.0b013e31817603ba |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?doi=10.1097/CCM.0b013e31817603ba] Treatment with corticosteroids might be most beneficial in those with septic shockand early severe acute respiratory distress syndrome(ARDS), whereas its role in other patients such as those with pancreatitisor severe pneumoniais unclear. These recommendations stem from studies showing benefits from low dose hydrocortisonetreatment for septic shock patients and methylprednisolonein ARDS patients. [cite journal |author=Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellissant E |title=Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock |journal=JAMA |date=2002-08-21 |volume=288 |issue=7 |pages=862–71 |pmid=12186604 |url=http://jama.ama-assn.org/cgi/content/full/288/7/862 |doi=10.1001/jama.288.7.862] cite journal |author=Meduri GU, Headley AS, Golden E, "et al" |title=Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome: a randomized controlled trial |journal=JAMA |volume=280 |issue=2 |pages=159–65 |year=1998 |month=Jul |pmid=9669790 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=9669790] cite journal |author=Meduri GU, Golden E, Freire AX, "et al" |title=Methylprednisolone infusion in early severe ARDS: results of a randomized controlled trial |journal=Chest |volume=131 |issue=4 |pages=954–63 |year=2007 |month=Apr |pmid=17426195 |doi=10.1378/chest.06-2100 |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=17426195] cite journal |author=Sprung CL, Annane D, Keh D, "et al" |title=Hydrocortisone therapy for patients with septic shock |journal=N. Engl. J. Med. |volume=358 |issue=2 |pages=111–24 |year=2008 |month=Jan |pmid=18184957 |doi=10.1056/NEJMoa071366 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=18184957&promo=ONFLNS19] cite journal |author=Steinberg KP, Hudson LD, Goodman RB, "et al" |title=Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome |journal=N. Engl. J. Med. |volume=354 |issue=16 |pages=1671–84 |year=2006 |month=Apr |pmid=16625008 |doi=10.1056/NEJMoa051693 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16625008&promo=ONFLNS19] cite journal |author=Annane D, Sébille V, Bellissant E |title=Effect of low doses of corticosteroids in septic shock patients with or without early acute respiratory distress syndrome |journal=Crit. Care Med. |volume=34 |issue=1 |pages=22–30 |year=2006 |month=Jan |pmid=16374152 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?an=00003246-200601000-00004] However, the exact way of determining corticosteroid insufficiency remains problematic. It should be suspected in those poorly responding to resuscitation with fluids and vasopressors. ACTH stimulation testing is not recommended to confirm the diagnosis. Glucocorticoid drugs should be weaned and not stopped abruptly.
Sepsis and suspected sepsis in neonates
Note that in neonates, sepsis is difficult to diagnose clinically. They may be relatively asymptomatic until hemodynamic and respiratory collapse is imminent, so if there is even a remote suspicion of sepsis, they are frequently treated with antibiotics empirically until cultures are sufficiently proven to be negative. In addition to fluid resuscitation and supportive care, a common antibiotic regimen in infants with suspected sepsis is a
beta-lactamantibiotic (usually ampicillin) in combination with an aminoglycoside(usually gentamicin) or a third-generation cephalosporin(usually cefotaxime— ceftriaxoneis generally avoided in neonates due to the theoretical risk of causing biliary stasis.) The organisms which are targeted are species that predominate in the female genitourinary tract and to which neonates are especially vulnerable to, specifically Group B Streptococcus, "Escherichia coli", and "Listeria monocytogenes" (This is the main rationale for using ampicillin versus other beta-lactams.) Of course, neonates are also vulnerable to other common pathogens that can cause meningitisand bacteremiasuch as "Streptococcus pneumoniae" and "Neisseria meningitidis". Although uncommon, if anaerobic species are suspected (such as in cases where necrotizing enterocolitisor intestinal perforationis a concern, clindamycinis often added.
Infusion of the short chain fatty acid sodium butyrate inhibits high-mobility group box 1 protein (
HMGB1) preventing the lethality of severe sepsisin rats. [cite journal |author=Zhang LT, Yao YM, Lu JQ, Yan XJ, Yu Y, Sheng ZY |title=Sodium butyrate prevents lethality of severe sepsis in rats |journal=Shock |volume=27 |issue=6 |pages=672–7 |year=2007 |month=Jun |pmid=17505308 |doi=10.1097/SHK.0b013e31802e3f4c |url=]
Prognosis can be estimated with the MEDS score.cite journal |author=Shapiro NI, Wolfe RE, Moore RB, Smith E, Burdick E, Bates DW |title=Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule |journal=Crit. Care Med. |volume=31 |issue=3 |pages=670–5 |year=2003 |pmid=12626967 |doi=10.1097/01.CCM.0000054867.01688.D1 |url=http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200303000-00002.htm]
Systemic inflammatory response syndrome
* [http://www.survivingsepsis.org Surviving Sepsis Campaign]
* [http://www.sepsisforum.org International Sepsis Forum]
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