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Diagnosis and Management of Sepsis : A review


Diagnosis and Management of Sepsis : A review

Dr.Tom Evans, professor of molecular microbiology at Glasgow Biomedical Research Centre, Glasgow has written a comprehensive review of Diagnosis and management of sepsis which has appeared in Journal of the Royal College of Physicians of London: Clinical Medicine.

The author has in addition to detailing aspects of Sepsis relevant to critical care specialists has outlined the features of sepsis that are of most relevance to acute general physicians.

The recent new consensus definition of the international task force for sepsis is ‘life-threatening organ dysfunction caused by a dysregulated host response to infection.’

Key points which have been emphasized in the article are

  • A new definition of sepsis allows identification using a quick SOFA score (qSOFA)

  • Septic shock can be recognised by the combination of hypotension and increased blood lactate >2 mM

  • Prompt administration of empirical antibiotics is essential in suspected sepsis

  • Use of the ‘Sepsis six’ bundle will ensure immediate management of patients with sepsis is optimal

  • Early recognition of sepsis is crucial to better management

The task force using large datasets (>1 million patient records),  found that an increase in 2 points or more for a patient suspected to have infection using the Sequential Organ Failure Assessment (SOFA) best predicted in-hospital mortality.Consequently, they developed a simpler clinical screening tool that performed very well in identifying adult patients with suspected infection who were likely to have poor outcomes, which they termed ‘quick SOFA’ (qSOFA). This measures three clinical parameters.

qSOFA criteria

Respiratory rate ≥22/min
Glasgow Coma Scale <15
Systolic blood pressure ≤100 mmHg

The task force defined Septic shock as ‘a subset of sepsis in which circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone. Operationally, they identified septic shock as being present when the two particular conditions were met as given below.

Criteria for septic shock

> A need for vasopressor therapy to maintain a mean arterial pressure ≥65 mmHg
> A serum lactate >2 mM, persisting after adequate fluid resuscitation

The pathogenesis of sepsis is complex and four key areas are endothelial dysfunction, coagulation abnormalities, alterations in cell function and dysregulated cardiovascular responses.

Management

Although survival of Sepsis has improved over the years but a specific molecular therapy is still not available to the treating doctors except Antimicrobials. Therefore immediate management of Sepsis includes –

1.Resuscitation

  • Adequate oxygen to maintain saturation in excess of 95% should be given.
  • It is considered standard care to give intravenous saline to all patients with sepsis.
  • Starch-based fluids should be avoided and there is no evidence to support the use of albumin.
  • Persistent hypotension despite adequate fluid resuscitation will  require  the use of vasopressors and noradrenaline is the preferred agent.

2.Prompt and appropriate antimicrobial therapy

  • Every effort should be made to give Antimicrobial drugs against likely causative pathogens quickly , ideally within 1 hour of admission.
  • Prior to administering antibiotics, blood cultures should be taken because identification and characterisation of antibiotic sensitivities of cultured pathogens are crucial in further management.

3. Accurate fluid balance

Urine output should be recorded, together with all fluids administered. A urinary catheter may be put if required for patient management but it is not essential.

4. Blood glucose

In the event of hyperglycaemia, blood sugar should be kept <10 mM with intravenous insulin but more aggressive blood sugar control is contraindicated.

5. Source control

  • Identification and management of the source of sepsis are also important.
  • Therefore history, full examination and appropriate radiological investigations should be done to identify a likely source of infection.
  • Prompt management of an infection source is vital, such as drainage of a pleural effusion, debridement of an infected wound, or surgical intervention to drain an intra-abdominal abscess.

For further reference log on to :

http://www.clinmed.rcpjournal.org/content/18/2/146

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Dr. Kamal Kant Kohli

Dr. Kamal Kant Kohli

A Medical practitioner with a flair for writing medical articles, Dr Kamal Kant Kohli joined Medical Dialogues as an Editor-in-Chief for the Speciality Medical Dialogues. Before Joining Medical Dialogues, he has served as the Hony. Secretary of the Delhi Medical Association as well as the chairman of Anti-Quackery Committee in Delhi and worked with other Medical Councils of India. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751
Source: self

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  1. All the above factors mentioned are old points that are further stratified with a renewed vigor. One important point about significance of Lactate is something worth noting and taking care of. Administration of glucose or other carbohydrates in sepsis may be cautiously given but fluid administration must be strictly monitored and a urethral catheter permits it precisely. I have always used catheterisation in all my cases and rest of therapeutic procedures must be administered aggressively. Vasopressors and administration of steroids are contentious issues. Insulin + Potassium therapy are other tools that have been used but not mandatory and need in majority but other measures can salvage the patient adequately. Fluid balance and urinary output measured adequately has been found very useful strategy.