What is Sepsis?

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

Grading Sepsis

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

Managing Sepsis

Sepsis is treatable, and early diagnosis and timely implementation of targeted interventions improves outcomes. In fact, research shows that if sepsis is treated aggressively within the first hour (The Golden Hour) medical evidence has shown that the risk of death is halved, and survival rates can be more than 80%.1,2

Current guidance recommends implementation of qSOFA as a screening tool in suspected organ dysfunction, plus monitoring leukocytes, heart rate, and temperature for surveillance in patients endangered by infections.3

The Surviving Sepsis Campaign, published care bundles that focus on ‘time of presentation’, as the time of triage in the emergency department (or if presenting from another care organization, from the earliest chart of vitals consistent with sepsis/septic shock) and required the following actions:3

  • Measure lactate level. Re-measure if the initial level is more than 2 mmol/L
  • Obtain blood cultures prior to the administration of antibiotics
  • Administer broad-spectrum antibiotics
  • Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate of at least 4 mmol/L
  • Apply vasopressors if the patient is hypotensive during or after fluid administration to maintain mean arterial pressure of at least 65 mmHg

Sepsis related to COVID-19

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.

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.5

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:6

  • 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).6

Conclusion

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.7

About the author

My name is Andreia Trigo RN BSc MSc, I am a nurse consultant with over a decade of experience in anaesthesia, sedation and pain management.

This involves patient care, as well as lecturing at post grad level on these topics, presenting at conferences and co-developing a very successful sedation course at SedateUK. My passion for creating safer environments for patients and professionals led me to collaborate with Medtronic and share my knowledge and expertise with our professional community.

 

The content of this article is written by a blogger with whom Medtronic has a relationship. However, the contents represent the personal objective views, comments and techniques of the blogger and are not statements from Medtronic. To the extent this material might contain images of patients or any material where a copyright is held by a third party, all necessary written permissions from the patient or copyright holder, as applicable, with respect to use, distribution or copying of such images or copyrighted materials has been obtained by the blogger.

  • 1. Sepsis Research (2020) What is Sepsis. Available at https://www.sepsisresearch.org.uk/statistics/

  • 2. Deepankar Datta, et al (2016) Early PREdiction of Severe Sepsis (ExPRES-Sepsis) study: protocol for an observational derivation study to discover potential leucocyte cell surface biomarkers Available at https://bmjopen.bmj.com/content/6/8/e011335

  • 3. Daniela Berg, et al (2018) Recent advances in understanding and managing sepsis. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173111/

  • 4. https://www.global-sepsis-alliance.org/news/2020/4/7/update-can-covid-19-cause-sepsis-explaining-the-relationship-between-the-coronavirus-disease-and-sepsis-cvd-novel-coronavirus

  • 5. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext 

  • 6. Waleed Alhazzani et al (2019) Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19) Available at: https://www.esicm.org/wp-content/uploads/2020/03/SSC-COVID19-GUIDELINES.pdf?fbclid=IwAR29riGtoS1tDvRWTELXs0NPG_mPUvO4KArqdDDGSMPfzx5cKLa_CPRKCEg

  • 7. https://www.sepsis.org/news/the-connection-between-covid-19-sepsis-and-sepsis-survivors/