The Diagnosis & Management Of Sepsis
In recent years, sepsis-related hospital admissions have risen, probably due to the combined effects of pathogens’ resistance to antibiotics, improved reporting and an ageing, more vulnerable population.
In severe sepsis infections, the mortality rate is one patient in five. Worse, as many as seven in ten patients do not survive septic shock. Overall, sepsis causes approximately a fifth of UK in-patient hospital deaths, similar in proportion to terminal acute myocardial infarction cases.
Sepsis happens when the immune system responds abnormally to a bacterial, viral, fungal or parasitic infection. Ultimately, the trauma damages tissue and internal organs, most commonly in the respiratory, gastrointestinal and genitourinary systems.
In particular, the very young and old are at risk of developing sepsis. Exacerbating factors include chronic illness, immunosuppression and malnutrition. Hospitalisation, recent surgery and indwelling catheters or similar medical appliances can also elevate the risk.
Challenges in diagnosis
Diagnosing sepsis tends to be challenging because the symptoms are non-specific and vary in line with the cause(s). Yet often, effective care requires a diagnosis before the test results from culture samples become available. Therefore, differential diagnosis is necessary, requiring medical professionals to distinguish between two or more conditions or diseases that might be the cause. As well as patients’ symptoms, doctors have to consider the history of any underlying illness, antibiotic use and recent surgery.
Differential diagnoses, i.e. diseases which can cause similar symptoms, include:
- Acute blood loss.
- Acute myocardial infarction.
- Acute pancreatitis.
- Acute pulmonary embolus.
- Adrenal insufficiency.
- Diabetic ketoacidosis.
- Reaction to a transfusion.
Notably, detecting sepsis in post-surgical patients and new mothers is even less straightforward. This potential difficulty arises due to typical changes in blood composition and body temperature, coupled with expected discomfort or pain.
Characteristically, the first symptoms of sepsis are fever, chills and shivering, with increased heart rate and rapid breathing. At this stage, it is notoriously easy to misdiagnose ‘flu, a chest infection or gastroenteritis.
According to estimates, delays in diagnosis arise in around a third of cases. However, if left untreated, the patient will deteriorate rapidly. Severe symptoms include fainting and dizziness, disorientation, nausea and vomiting, diarrhoea, reduced urination and cold, clammy skin.
There is no specific therapy for the condition; patient outcomes rely on early recognition and appropriate clinical management. Thankfully, the mortality rate of sepsis patients has decreased over recent years.
Timely Treatment and Management
Initially, sepsis treatment centres on resuscitation and respiratory stabilisation. At this stage, intensive care and nursing staff should administer supplemental oxygen. Subsequently, treatment ought to consist of identifying the infection and administering antibiotics. At the same time, in around three-quarters of cases, it will be necessary to drain a pleural effusion, debride an infected wound or intervene surgically to drain an abscess.
However, in around a quarter of all cases, no obvious source of infection is identifiable. Despite this uncertainty, the rapid administration of antibiotics to target the origins of each sepsis case yields clear benefits for the patients concerned. Currently, there are no firm recommendations regarding the exact timing of antibiotic administration. Nevertheless, the consensus is that treatment should commence as soon as possible.
Ideally, the first dose of antibiotics ought to be within one hour of admission. Significantly, estimates suggest that for each hour of delay, the risk of mortality increases by eight per cent.
If patients’ symptoms include hypotension, fluids (saline) administration may be necessary, along with vasopressor therapy such as norepinephrine. Hypotension is the most common reason for the increased morbidity and mortality in sepsis patients.
Delays in administering fluids can cause tissue hypoxia and multiple organ dysfunction. Crucially, staff should assess the patient’s response to fluid resuscitation through blood pressure, tissue perfusion and urine output. Within twelve hours, a positive fluid balance of three to four litres is optimal for survival. However, even with prompt and appropriate treatment, some patients may not survive deep-seated infections such as abscesses that resist antibiotics and aggravate the condition.
Given sufficiently prompt treatment, the likelihood of positive patient outcomes increases significantly. Furthermore, recent updates to sepsis and septic shock definitions may make identifying sepsis patients more straightforward, particularly in the worst cases. As a result, today’s medical professionals should be able to prescribe and administer the appropriate treatment in time. For instance, if a patient’s respiratory rate is greater than 22 breaths per minute, their systolic blood pressure is lower than 100mmHg and the Glasgow Coma Scale assessment of less than 15*, doctors should suspect sepsis and treat accordingly.
Statistics show that if medical staff implement a treatment protocol known as Early Goal-Directed Therapy for Sepsis within six hours of suspected diagnosis, in-hospital mortality reduces by around 45 per cent.
Finally, sepsis survivors have higher mortality rates from other conditions after discharge from hospital. Affected individuals are more likely to suffer post-traumatic stress disorder, physical disability and long-term lung or cognitive dysfunction.
We acknowledge the valuable input of Dr Martin Stotz, an intensive care and anaesthesiology consultant currently in St Mary’s Hospital, London, as a source of some of the information or professional opinion(s) used in this article.