Sepsis: Early Dectection,  Management, Treatment

Definitions of sepsis have changed overtime. It used to be defined as “a systemic inflammatory response syndrome to infection” with two or more of the following criteria:^2,3

• heart rate of more than 90 beats/minute 
• core temperature of more than 38°C or less than 36°C
• respiratory rate of more than 20 breaths/minute 
• partial pressure of carbon dioxide (PaCO₂) of less than 32 mmHg 
• white blood cell count of more than 12,000/mL or less than 4,000/mL or more than 10% immature neutrophils

A most recent definition of sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. The term ‘septic shock’ refers to sepsis that includes an elevated lactate level of more than 2 mmol/L as an additional factor.³

Sepsis-related Organ Failure Assessment Score – SOFA, is a grading score for defining acute organ dysfunction. This score allocates points according to pathological change in six different organ systems. An increase in the total SOFA score by at least two points indicates acute organ dysfunction, and the diagnosis of sepsis is met if an infection is identified in parallel.³

Septic shock is diagnosed if, in addition, there is hypotension (mean blood pressure of at least 65 mmHg can be reached only using vasopressors, despite adequate fluid management) and the serum lactate levels are more than 2 mmol/L.³

A simplified screening tool called qSOFA can also be used in Emergency Departments, wards, care homes, for early recognition of organ dysfunction because of infection:³

• altered mental status
• respiratory rate of more than 22 breaths/minute
• systolic blood pressure of less than 100 mmHg

When two of the three qSOFA criteria are met, organ dysfunction should be suspected, and the classic SOFA score should be applied.³

Delayed treatment can have fatal outcomes for septic patients, especially if they deteriorate into septic shock. Septic shock is associated with persistent hypotension and associated with multiple organ failure.⁴ When hypotension sets in — patient mortality increases about 7.6 percent.⁵

Studies suggest metabolic markers such as low etCO₂ levels correlated with acidosis.⁶ Detecting acidosis can prompt clinical decisions for early intervention — Including aggressive resuscitation in septic patients.⁷ The Vital Sync™ remote monitoring solution can provide a rapid, visual way to see etCO₂ levels when linked to the Microstream™ capnography which combines etCO2, SpO2, respiratory rate, and pulse rate data into one value to indicate the patient’s respiratory status.

When bedside monitoring isn’t an option, the Vital Sync™ remote patient monitoring platform offers clinicians a way to remotely monitor patients. Whether you are operating from a telemedicine command center or transferring patients from general care to ICU, this solution helps you detect critical patient changes - early. In both scenarios, continuous patient monitoring capability stays with patients throughout the continuum of care.

In the fight against sepsis, the Vital Sync™ trend analysis tool combined with Microstream™ capnography helps you track subtle changes in patient hemodynamics.  Plus, the Early Warning Score (EWS) technology combined with vital sign assessments helps you spot patient deterioration so you can intervene sooner. 

The recent Covid-19 pandemic is a respiratory infection that may present with mild, moderate, or severe (critical) illness. The effects on the respiratory system are well-known, with most people requiring hospital admission developing pneumonia of varying severity; however, virtually all other organ systems can be affected. This is consistent with a combination of direct viral invasion and sepsis.⁸ 

Recent studies have shown that COVID-19 patients who were severely ill or had died were older and/or had sepsis and/or had problems with blood clotting or had pre-existing conditions, such as heart disease and diabetes.⁹

As physicians know how to treat sepsis, these findings can help physicians determine treatment plans for their more severely ill COVID-19 patients. 

The Surviving Sepsis Group Covid-19 subcommittee (panel of 36 experts from 12 countries) issued recommendations based on available literature on the management of critically ill patients with the coronavirus in the ICU. There are four main best practices highlighted:¹⁰

• Healthcare workers performing aerosol-generating procedures (e.g. intubation, bronchoscopy, open suctioning, etc.) on patients with Covid-19 should wear fitted respirator masks, such as N-95, FFP2 or equivalent – instead of surgical masks – in addition to other personal protective equipment, such as gloves, gown and eye protection   
• Aerosol-generating procedures should be performed on ICU patients with Covid-19 in a negative pressure room, if available. Negative pressure rooms are engineered to prevent the spread of contagious pathogens from room to room
• Endotracheal intubation of patients with Covid-19 should be performed by healthcare workers with experience in airway management to minimize the number of attempts and risk of transmission 
• Adults with Covid-19 who are being treated with non-invasive positive pressure ventilation or a high flow nasal canula should be closely monitored for worsening respiratory status and intubated if necessary 

The following algorithms summarise clinical best practice recommendations for the management of patients with Covid-19:

Reading all recommendations and full rationale is recommended and available in the paper published by Waleed Alhazzani et al (2019).¹⁰

Sepsis is a serious illness with high morbidity and mortality. A better understanding of pathophysiology of sepsis led to a new definition highlighting the host response to infection as a crucial aspect. A faster detection of high-risk patients with qSOFA score and an early and standardized approach in managing sepsis are essential.

Those patients who’ve survived sepsis and septic shock are more vulnerable to getting other infections, any type of infection. This higher risk results from weakening of the immune system in the first few weeks and months following the initial bout of sepsis. It is for this reason that social distancing and self-isolation is even more important during this pandemic.¹¹

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