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Learning Center
New In Coagulation
Thursday, July 10, 2008
Evidence-Based Guidelines Issued to Detect and Treat Sepsis
News Author: Laurie Barclay, MD
Severe sepsis is common, with about 750,000 cases each year in the United States. Although the mortality rate for severe sepsis is 30% to 50%, this climbs to 80% to 90% for septic shock with multiple organ dysfunction.
In terms of the pathophysiology of severe sepsis, a cascade of inflammation and activation of the coagulation system associated with impaired fibrinolysis causes changes in microvascular circulation associated with organ dysfunction, severe sepsis, multiple organ dysfunction syndrome, and death.
Study Highlights
- Severe sepsis is usually initiated by a localized infection that triggers a systemic response called systemic inflammatory response syndrome.
- Sepsis is the combination of suspected or proven infection and the presence of at least 2 signs of systemic inflammatory response syndrome.
- Severe sepsis is defined as acute organ system dysfunction associated with infection.
- Septic shock is a subgroup of severe sepsis and is defined as sepsis-induced hypotension with systolic blood pressure of 90 mm Hg or less or a reduction of 40 mm Hg or more from baseline despite adequate fluid resuscitation, along with other perfusion abnormalities such as oliguria or lactic acidosis.
- The most common presenting symptom of severe sepsis is respiratory system dysfunction, followed by shock and renal system dysfunction.
- The most common site of infection is the lung, followed by intra-abdominal and urologic sources.
- In 22% to 33% of suspected sepsis cases, culture results are not positive for pathogens.
- Of all positive culture results, gram-positive bacteria are identified in 25% to 50% of cases and gram-negative bacteria in 22% to 37% of cases.
- Pneumonia is the most common trigger for severe sepsis, followed by peritonitis and urinary tract infection with or without pyelonephritis.
- Deficiencies that may lead to suboptimal care of patients with sepsis include inconsistency in early diagnosis, inadequate volume resuscitation, inadequate or late use of antibiotics, failure to support cardiac output, failure to control hyperglycemia, failure to use low tidal volumes in acute lung injury, and failure to treat renal insufficiency.
- The IHI and Surviving Sepsis Campaign completed a systematic review of evidence for therapies applied to severe sepsis and septic shock that resulted in publishing of clinical guidelines.
- Quality measures were also developed.
- The sepsis resuscitation bundle has 5 items to be instituted as soon as possible and scored during the first 6 hours: measuring serum lactate level; obtaining blood cultures; using broad-spectrum antibiotics; managing hypotension and/or lactate level greater than 4 mmol/L with crystalloid or colloid equivalent and vasopressors; and, for persistent hypotension, maintaining central venous pressure greater than 8 mm Hg and maintaining central venous oxygen saturation of 70% or greater or a mixed venous oxygen saturation of 65% or greater.
- The sepsis management bundle has 4 items to be accomplished as soon as possible and scored during the first 24 hours: using low-dose steroids in accordance with ICU policy, using drotrecogin alfa (activated) per ICU protocol, maintaining glucose control at or above the lower limit of normal but less than 150 mg/dL, and maintaining inspiratory plateau pressures of less than 30 cm H20 for mechanically ventilated patients.
- Compliance with the resuscitation bundle has been associated with a 26% reduction in hospital mortality.
- Similarly, protocol-driven management of severe sepsis has been associated with reductions in mortality of 12% to 18%.
- A database and worksheets are available from the IHI to assist with measuring adherence to the sepsis bundles.
Donna Castellone
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About the Author
Donna Castellone,
MS, MT(ASCP)SH
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