Description
The body's reaction to infection causes sepsis, a potentially fatal organ malfunction. It needs quick identification, the right drugs, careful hemodynamic support, and infection source control. Understanding sepsis physiology and best practice guidelines is essential because the trend in management is away from protocolized therapy and toward suitable usual care.
Résumé
- Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection, responsible for a significant portion of ICU admissions globally. Early recognition, prompt disease stratification, and rapid treatment initiation are crucial for reducing mortality. Prioritizing oxygen delivery, rapid infection source control, and immediate antimicrobial therapy are key components of sepsis management.
- The World Health Organization (WHO) recognizes the importance of sepsis, noting that it contributes to at least one in five deaths worldwide and highlighting gaps in knowledge that hinder effective treatment. While the global burden of sepsis is challenging to ascertain due to incomplete reporting systems, estimates indicate significant regional variations based on economic status, with the majority of cases and deaths occurring in low and middle-income countries. Both community-acquired and healthcare-associated infections can lead to sepsis.
- Populations at higher risk of developing sepsis include the elderly, pregnant women, neonates, hospitalized patients (especially those in ICUs), and individuals with conditions like HIV/AIDS, liver cirrhosis, cancer, kidney disease, autoimmune diseases, and asplenia. Signs and symptoms of sepsis encompass fever, altered mental status, difficulty breathing, rapid heart rate, low blood pressure, and decreased urine output. The mnemonic "SEPSIS" (shivering, extreme pain, pale skin, sleepy, "I feel like I might die," short of breath) aids in recognizing potential cases.
- Sepsis progression ranges from simple SIRS (Systemic Inflammatory Response Syndrome) to severe sepsis with end-organ damage and septic shock with persistent hypotension and elevated lactate levels. The body's inflammatory response to infection, while intended to control pathogens, can also harm the host through the release of mediators like interleukins and TNF-alpha, ultimately affecting mitochondrial function. This mitochondrial dysfunction, stemming from insufficient oxygen delivery and excessive production of reactive species, contributes to the final common pathway of sepsis.
- The updated sepsis definition integrates the quick SOFA (qSOFA) score and the Sequential Organ Failure Assessment (SOFA) score to assess organ dysfunction. qSOFA incorporates systolic blood pressure, respiratory rate, and mental status, while SOFA evaluates respiratory, cardiovascular, liver, coagulation, renal, and neurological systems. Microbiological cultures, including blood cultures, are crucial for identifying the causative agent of infection, although results may take time to obtain. Molecular methods based on PCR can aid in quicker identification but may also have limitations.
- Septic shock, the most extreme form of sepsis, is characterized by unadulterated isoperfusion and impaired oxygen utilization, independent of arterial hypertension. Clinical signs of shock include skin changes (mottling, prolonged capillary refill), decreased urine output, and altered mentation. Management involves source control, antimicrobial therapy, and hemodynamic resuscitation, aiming to restore sufficient tissue perfusion pressure and normalize metabolism. Endpoints of resuscitation include clinical improvement, normalized mean arterial pressure, and reduced lactate levels.
- Fluid administration is an essential initial step in resuscitating septic shock patients, but fluid overload should be avoided. Assessing preload dependence is crucial for guiding fluid therapy. Surviving Sepsis Campaign guidelines recommend an initial bolus of 30 ml/kg of crystalloid fluid within the first three hours, followed by frequent reassessment. Balanced crystalloid solutions are preferred, and vasopressors, particularly norepinephrine, are used to maintain adequate mean arterial pressure.
- Surviving Sepsis Campaign guidelines recommend the use of qSOFA and lactate measurements, and they suggest admission to the ICU within six hours. Early assessment for infection and prompt antimicrobial administration are critical. The use of dynamic parameters over static parameters is recommended for assessing fluid responsiveness. Family involvement in decision-making regarding long-term care and outcomes is also emphasized. Lung-protective ventilation strategies, including low tidal volume ventilation and limited plateau pressure, are recommended for patients with sepsis-induced respiratory failure.
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À propos des intervenants
Dr Atchyuth R Gongada
Chef de service et consultant principal, service de soins intensifs et d'anesthésiologie, hôpitaux Apollo, Healthcity, Visakhapatnam
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