A Brief Synopsis of AFP's "Early Recognition and Management of Sepsis in Adults: The First Six Hours"

Early Recognition and Management of Sepsis in Adults: The First Six Hours
ROBERT L. GAUER, MD, Womack Army Medical Center, Fort Bragg, North Carolina
Am Fam Physician. 2013 Jul 1;88(1):44-53.
http://www.aafp.org/afp/2013/0701/p44.pdf

     Sepsis kills as many people in hospitals as heart attacks. The progression of sepsis goes from systemic inflammatory response syndrome (SIRS), to sepsis, to severe sepsis, to septic shock. SIRS is defined as at least two of the following; fever (above 38.5c), tachycardia (above 90 bpm), tachypnea (RR above 20) and leukocytosis or leukopenia (above 12 k/mm3 or less than 4 k/mm3). Sepsis is SIRS with the presence of an infection. Severe sepsis is sepsis with at least one sign of organ hypoperfusion/ dysfunction, including mottled skin, increased capillary refill time, decreases urinary output, increased lactate, DIC, platelet count less than 100k/mm3, ARDS/ acute lung injury, or cardiac dysfunction. Septic shock is defined as severe sepsis plus at least one of the following; a systemic mean blood pressure of less than 60 mm Hg, PCWP between 12-20 mm Hg, or the need for vasopressors. Refractory septic shock is defined when the need for dopamine goes above 15 ug/kg per min to maintain a mean bp above 60 mmHg (or norep, epi of >0.25 ug/kg per min).
     The pathophysiology of sepsis includes endothelial damage, vascular permeability, microvascular dysfunction, coagulation pathway activation and impaired tissue oxygenation. Risk factors include extremes of age, chronic illness, malnutrition, immunosuppression, etc. Fever is the most common manifestation.
     Early goal directed therapy must be done within the first 6 hours to benefit patient mortality. Supplemental oxygen, with possible ventilation and intubation, will maintain proper tissue perfusion. The CVP should be maintained between 8-12 mm Hg with colloids or crystalloids. MAP can be maintained at 65-90 mm Hg with vasoactive agents. If oxygen saturation falls below 70%, the patient can be transfused until the hematocrit is at or above 30%. Inotropic agents can help oxygen saturation as well.
     A full set of labs and cultures should be drawn. An echo can be done to detect endocarditis. A CT can check for a pulmonary embolus, pelvic infection, or renal abscess. Antibiotics should be used empirically based on the probable source of infection. Ongoing management includes corticosteroid therapy, glycemic control, low tidal volumes, hemoglobin maintenance, and oxygen saturation.