Sepsis

Original Editors - Leana Louw

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Description

Although the terms SIRS, sepsis and septic shock is often used interchangeably, it is separately defined and classified as follows:

Sepsis: A systematic response to an infection, presenting with  2 of the following:

• High grade (> 38˚C) or low grade (< 36˚C ) fevers
• Heart rate > 90/minute
• RR > 20/minute OR PaCO2 < 4.3kPa
• WCC > 12

SIRS:  Systemic inflammatory response syndrome (SIRS) is defined as a generalised inflammatory response, presenting with  2 of the following:

• High grade (> 38˚C) or low grade (< 36˚C ) fever
• Heart rate > 90/minute
• RR > 20/minute OR PaCO2 < 4.3kPa

Septic shock: Shock is defined as the exhaustion of the reserve tissue capacity of tissue respiration, or the failure of the supply to meet the demand in terms of oxygenation. When this is sepsis-induced (septic shock), it results in hypotension not responding to fluid resuscitation.

These can lead to multiorgan failure where the body is unable to maintain haemostasis without medical intervention, a common cause of death in the ICU setting.

Clinically Relevant Anatomy

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Mechanism of Injury / Pathological Process

Septic shock

The hypothalamic thermostat is reset by the fever caused by sepsis. In an attempt to cool down, it results in peripheral vasodilatoation and subsequent depletion of the visceral perfusion. Excess nitric oxide production is stimulated by endotoxins and this leads to uncontrolled vasodilatation and a “functional haemorrhade”. Increased cardiac output is thus unsuccessful at maintaining an adequate blood pressure. This can lead to hypoxic tissue damage.

Shock in general normally runs the following course:

Insufficient tissue perfusion → anaerobic metabolism → lactic acidosis → metabolic acidosis → cellular damage → organ failure.

Clinical Presentation

Septic shock

• Pyrexia
• Flushed presentation
• Tachypnea
• Hypotension
• Bounding pulse
• Restricted regional blood flow as the result of vasopressors
  

Diagnostic Procedures

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Outcome Measures

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Medical Management

Medical management is vital to prevent further inflammatory response by the cause of the sepsis. This is normally done by means of ventilatory and haemodynamic support.

Aims:

• Restoration of normal haemostasis
• Sustain tissue perfusion
• Avoid focussing on a single system
• Maintain oxygen delivery
• Keeping pH > 7.35

Strategies to improve oxygen delivery include:

• Respiratory support
• Inotropic support
• Vasodilators

Control of oxygen consumption is done by the following means:

• Respiratory support
• Sedation
• Paralysis
• Avoidance of pyrexia and stressors
• Supportive:
  • Blood transfusion (packed red blood cells)
  • Haemofiltration

Correction of metabolic acidosis (lactate-induced):

• Haemofiltration if pH < 7.2
• Changes to IPPV to improve PaCO2

Fluid management:

• Needs to be carefully administrated to avoid complications such as pulmonary oedema as a result of overload, as this will negatively affect oxygen delivery due to circulating volume problems.
• For optimal cardiac output:  PAWP = 18cmH2O and CVP = 10-12cmHO

Additional:

• Nutritional support is an important factor in the management of septic shock, as it can increase energy consumption up to 50%. It however negatively affects the utilization of nutrition, resulting in katabolism and subsequent muscle wasting.
• Antibiotics: Potential to exacerbate symptoms due to physiology described earlier
• Early initiated steroids, especially in cases with Gram-negativ septicaemia
  

Differential Diagnosis

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Physiotherapy management

Physiotherapy in the ICU

Physiotherapy interventions in the ICU setting normally consists of respiratory physiotherapy focussing on airway clearance technique and early mobilization. During acute sepsis or septic shock, patients are often too unstable for physiotherapy intervention, which only starts when the patient is haemodynamically stable.

A common result of these are critical illness neuropathy, and extensive rehabiltaiton should then be incorporated in the ICU, after discharge to the ward, as well as in the out-patient setting with the aim of getting the patient back to his baseline level of function and participation as per the ICF model.

Resources

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Case Studies / Key evidence

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References

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