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| {{Infobox_Disease | | | __NOTOC__ |
| Name = {{PAGENAME}} |
| | {{Siren|Sepsis}} |
| Image = |
| | {{Sepsis}} |
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| | {{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh@perfuse.org] |
| DiseasesDB = 11960 |
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| ICD10 = {{ICD10|A|40| |a|30}} - {{ICD10|A|41|0|a|30}} |
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| ICD9 = {{ICD9|995.91}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = |
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| eMedicineSubj = |
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| eMedicineTopic = |
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| MeshID = D018805 |
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| }}
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| {{SI}}
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| Normal 0 false false false EN-US X-NONE X-NONE MicrosoftInternetExplorer4
| | {{SK}} Sepsis syndrome; Septic shock; Septicemia; Septic infection, Septic shock syndrome; Sepsis shock syndrome; Septic shock syndrome; Sepsis spectrum syndrome |
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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
| | ==[[Sepsis overview|Overview]]== |
| {{CMG}}; ''' [[User:Rakesh Engineer|Rakesh Engineer, M.D., Cleveland Clinic Foundation, Cleveland Ohio]] [mailto:ENGINER@ccf.org]
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| ==Overview== | | ==[[Sepsis definitions|Definitions]]== |
| See also: [[Septic shock]]
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| '''Sepsis''' is a serious medical condition characterized by a whole-body [[Inflammation|inflammatory]] state caused by [[infection]].
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| Traditionally the term sepsis has been used interchangeably with septicaemia and septicemia ("blood poisoning").<ref>Stedman's Medical Dictionary. URL: [http://www.emedicine.com/asp/dictionary.asp?keyword=septicemia http://www.emedicine.com/asp/dictionary.asp?keyword=septicemia]. Accessed on: June 30, 2007.</ref> However, these terms are no longer considered synonymous; septicemia is considered a subset of sepsis.<ref>Stedman's Medical Dictionary. URL: [http://www.emedicine.com/asp/dictionary.asp?keyword=sepsis http://www.emedicine.com/asp/dictionary.asp?keyword=sepsis]. Accessed on: June 30, 2007.</ref>
| | ==[[Sepsis pathophysiology|Pathophysiology]]== |
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| ==Differential diagnosis of underlying casues== | | ==[[Sepsis causes|Causes]]== |
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| *[[Anthrax]]
| | ==[[Sepsis differential diagnosis|Differentiating Sepsis from other Diseases]]== |
| *[[Gangrene]]
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| *[[Gram negative bacteremia]]
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| *[[Necrotizing enterocolitis]]
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| *[[Lemierre syndrome]]
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| *[[Melioidosis]]
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| *[[Neisseria meningiditis]]
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| *[[Peritonitis]]
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| *[[Pseudomonas aeruginosa]]
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| *[[Vibrio vulnificus]]
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| == Signs and symptoms == | | ==[[Sepsis epidemiology and demographics|Epidemiology and Demographics]]== |
| Symptoms of sepsis are often related to the underlying infectious process. When the infection crosses into sepsis, the resulting symptoms are that of [[systemic inflammatory response syndrome]] (SIRS): general inflammation, [[fever]], elevated [[white blood cell]] count ([[leukocytosis]]), and raised heart rate ([[tachycardia]]) and breathing rate ([[tachypnea]]). A capillary leak syndrome can develop with severe swelling and [[edema]] and third spacing of fluids.
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| General symptoms can include flu like symptoms as well as shaking chills or [[rigors]].
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| The immunological response that causes sepsis is a systemic inflammatory response causing widespread activation of [[inflammation]] and [[coagulation]] pathways. This may progress to dysfunction of the [[septic shock|circulatory system]] and, even under optimal treatment, may result in the [[multiple organ dysfunction syndrome]] and eventually [[death]].
| | ==[[Sepsis risk factors|Risk Factors]]== |
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| == Epidemiology == | | ==[[Sepsis natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| In the United States, sepsis is the leading cause of death in non-coronary [[Intensive Care Unit|ICU]] patients, and the tenth most common cause of death overall according to data from the [[Centers for Disease Control and Prevention]].<ref>Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003 Apr 17;348(16):1546-54. PMID 12700374 [http://content.nejm.org/cgi/content/abstract/348/16/1546 Full Text].</ref> Sepsis is common and also more dangerous in elderly, immunocompromised, and critically ill patients. It occurs in 1%-2% of all hospitalizations and accounts for as much as 25% of [[intensive care medicine|intensive care unit]] (ICU) bed utilization. It is a major cause of death in intensive care units worldwide, with mortality rates that range from 20% for sepsis to 40% for severe sepsis to >60% for [[septic shock]].
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| == Definition of sepsis == | | ==Diagnosis== |
| Sepsis is considered present if infection is highly suspected or proven and two or more of the following [[systemic inflammatory response syndrome]] (SIRS) criteria are met:<ref>Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992 Jun;101(6):1644-55. PMID 1303622.</ref> | | [[Sepsis diagnostic criteria|Diagnostic Criteria]] | [[Sepsis history and symptoms|History and Symptoms]] | [[Sepsis physical examination|Physical Examination]] | [[Sepsis laboratory findings|Laboratory Findings]] | [[Sepsis electrocardiogram|Electrocardiogram]] | [[Sepsis chest x ray|Chest X Ray]] | [[Sepsis CT|CT]] | [[Sepsis MRI|MRI]] | [[Sepsis echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Sepsis other imaging findings|Other Imaging Findings]] | [[Sepsis other diagnostic studies|Other Diagnostic Studies]] |
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| * [[Heart rate]] > 90 beats per minute
| | ==Treatment== |
| * Body temperature < 36 (96.8 °F) or > 38 °C (100.4 °F)
| | [[Sepsis medical therapy|Medical Therapy]] | [[Sepsis primary prevention|Primary Prevention]] | [[Sepsis secondary prevention|Secondary Prevention]] | [[Sepsis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Sepsis future or investigational therapies|Future or Investigational Therapies]] |
| * [[Hyperventilation]] (high respiratory rate) > 20 breaths per minute or, on [[blood gas]], a P<sub>a</sub>CO<sub>2</sub> less than 32 mm Hg
| | ==[[Sepsis mandatory reporting|Mandatory Reporting]]== |
| * [[White blood cell]] count < 4000 cells/mm³ or > 12000 cells/mm³ (< 4 x 10<sup>9</sup> or > 12 x 10<sup>9</sup> cells/[[litre|L]]), or greater than 10% band forms (immature white blood cells).
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| Consensus definitions however continue to evolve with the latest expanding the list of signs and symptoms of sepsis to reflect clinical bedside experience.<ref>Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G; SCCM/ESICM/ACCP/ATS/SIS. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003 Apr;31(4):1250-6.</ref>
| | ==Case Studies== |
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| The more critical subsets of sepsis are severe sepsis (sepsis with acute organ dysfunction) and septic shock (sepsis with refractory arterial [[hypotension]]). Alternatively, when two or more of the systemic inflammatory response syndrome criteria are met without evidence of infection, patients may be diagnosed simply with "[[SIRS]]." Patients with SIRS and acute organ dysfunction may be termed "severe SIRS."
| | [[Sepsis case study one|Case #1]] |
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| Patients are defined as having "severe sepsis" if they have sepsis plus signs of systemic hypoperfusion; either end organ dysfunction or a serum lactate greater than 4 mmol/dL. Patient are defined as having [[septic shock]] if they have sepsis plus hypotension after an appropriate fluid bolus (typically 20 ml/kg of crystaloid).
| | ==Related Chapters== |
| | *[[Anaphylactic shock]] |
| | *[[Cardiogenic shock]] |
| | *[[Meningococcemia]] |
| | *[[Neurogenic shock]] |
| | *[[Shock (medical)|Shock]] |
| | *[[Systemic inflammatory response syndrome]] (SIRS) |
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| The criteria for diagnosing an adult with sepsis do not apply to infants under one month of age. In infants, only the presence of infection plus a "constellation" of signs and symptoms consistent with the systemic response to infection are required for diagnosis (Oski's Pediatrics, 2006).
| | [[Category:Disease]] |
| | | [[Category:Causes of death]] |
| == Treatment ==
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| The therapy of sepsis rests on [[antibiotic]]s, surgical drainage of infected fluid collections, fluid replacement and appropriate support for organ dysfunction. This may include [[dialysis|hemodialysis]] in [[kidney]] failure, [[mechanical ventilation]] in [[lung|pulmonary]] dysfunction, transfusion of [[blood plasma|blood products]], and drug and fluid therapy for circulatory failure. Ensuring adequate nutrition, if necessary by [[parenteral nutrition]], is important during prolonged illness.
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| A problem in the adequate management of septic patients has been the delay in administering therapy after sepsis has been recognized. Published studies have demonstrated that for every hour delay in the administration of appropriate antibiotic therapy there is an associated 7% rise in mortality. A large international collaboration was established to educate people about sepsis and to improve patient outcomes with sepsis, entitled the "Surviving Sepsis Campaign." The Campaign has published an evidence-based review of management strategies for severe sepsis,<ref name="campaign">Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM; Surviving Sepsis Campaign Management Guidelines Committee. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004 Mar;32(3):858-73. Erratum in: Crit Care Med. 2004 Jun;32(6):1448. Correction of dosage error in text. Crit Care Med. 2004 Oct;32(10):2169-70. PMID 15090974.</ref> with the aim to publish a complete set of guidelines in subsequent years.
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| Early Goal Directed Therapy (EGDT), developed at [[Henry Ford Hospital]] by E. Rivers, MD, is a systematic approach to resuscitation that has been validated in the treatment of severe sepsis and [[septic shock]]. It is meant to be started in the Emergency Department. The theory is that one should use a step-wise approach, having the patient meet physiologic goals, to optimize cardiac preload, afterload, and contractility, thus optimizing oxygen delivery to the tissues.<ref name="EGDT">{{cite journal |author=Rivers E, Nguyen B, Havstad S, ''et al'' |title=Early goal-directed therapy in the treatment of severe sepsis and septic shock |journal=N. Engl. J. Med. |volume=345 |issue=19 |pages=1368-77 |year=2001 |pmid=11794169 |doi=}}</ref>
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| In EGDT, fluids are administered until the [[central venous pressure]] (CVP), as measured by a [[central venous catheter]] reachs 8-12 cm of water (or 10-15 cm of water in mechanically ventilated patients). If the [[mean arterial pressure]] is less than 65 mmHg or greater than 90 mmHg, vasopressors or vasodilators are given as needed to reach the goal. Once these goals are met the central venous saturation (ScvO2), i.e. the oxgyen saturation of venous blood as it returns to the heart as measured at the superior vena cava, is optimized. If the ScvO2 is less than 70%, blood is given to reach a hemoglobin of 10 g/dl and then inotropes are added until the ScvO2 is optimized. Elective intubation may be performed to reduce oxygen demand if the ScvO2 remains low despite optimization of hemodynamics. Urine output is also monitored, with a goal of 0.5 ml/kg/h. In the original trial, mortality was cut from 46.5% in the control group to 30.5% in the intervention group.<ref name="EGDT" /> The Surviving Sepsis Campaign guidelines recommends EGDT for the initial resuscitation of the septic patient with a level B strength of evidence (single [[randomized control trial]]).<ref name="campaign" />
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| Most therapies aimed at the inflammatory process itself have failed to improve outcome, however [[drotrecogin alfa]] (activated [[protein C]], one of the [[coagulation factor]]s) has been shown to decrease mortality from about 31% to about 25% in severe sepsis. To qualify for drotrecogin alfa, a patient must have severe sepsis or septic shock with an [[APACHE II]] score of 25 or greater and a low risk of bleeding.<ref>Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ Jr; Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001 Mar 8;344(10):699-709. PMID 11236773 [http://content.nejm.org/cgi/content/abstract/344/10/699 Full Text].</ref> Low dose [[cortisol|hydrocortisone]] treatment has shown promise for septic shock patients with relative [[adrenal insufficiency]] as defined by [[Cort-stim test|ACTH stimulation testing]].<ref>Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellissant E. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002 Aug 21;288(7):862-71. PMID 12186604.</ref>
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| Standard treatment of infants with suspected sepsis consists of supportive care, maintaining fluid status with intravenous fluids, and the combination of a beta-lactam antibiotic (such as ampicillin) with an aminoglycoside such as gentamicin.
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| ==Prognosis==
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| Prognosis can be estimated with the MEDS score.<ref name="pmid12626967">{{cite journal |author=Shapiro NI, Wolfe RE, Moore RB, Smith E, Burdick E, Bates DW |title=Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule |journal=Crit. Care Med. |volume=31 |issue=3 |pages=670-5 |year=2003 |pmid=12626967 |doi=10.1097/01.CCM.0000054867.01688.D1}}</ref>
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| == Related conditions/complications ==
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| * [[Infection]] is the invasion of normally sterile host tissues by a microbial [[pathogen]].
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| * [[Bacteremia]] is the presence of [[bacterium|bacteria]] in the [[blood]]. Bacteremia can occur in sepsis and other serious diseases such as infective [[endocarditis]], bacteremic pyelonephritis or pneumonia and meningitis but it may also be a harmless and transient condition.
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| *[[Viremia]] is the presence of [[Viruses]] in the blood.
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| * Septic joint is an infection of a [[joint]]; it is associated with bacteremia and trauma.
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| * [[Disseminated intravascular coagulation]] (DIC) can be the result of sepsis
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| * [[Acute tubular necrosis]] (ATN) leading to [[acute renal failure]], can be the result of hypoperfusion of the kidneys in sepsis (i.e. not enough blood gets to the kidney and they stop working properly)
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| * [[Arrhythmia]] is an abnormal heart rhythm; it can be the result of sepsis.
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| * [[Ileus]] or [[ischemic colitis]] can be the result (hypoperfusion) or cause of sepsis
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| * [[Multiple organ dysfunction syndrome]] can be the result of sepsis
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| * [[Meningitis]], infection of the tissue that covers the [[brain]] and [[spinal cord]], can be a complication or cause of sepsis
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| * [[Osteomyelitis]] is an infection of the bone; it can be the cause or result of sepsis
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| * [[Endocarditis]], infection of the inner surface of heart which is in contact with blood, can also be a complication or cause of sepsis
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| * [[Pyaemia]] — causes abscesses
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| == References ==
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| <references />
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| == See also ==
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| * [[Meningococcemia]]
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| * [[Septic shock]]
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| * [[Systemic inflammatory response syndrome]]
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| == External links ==
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| *[http://www.nlm.nih.gov/medlineplus/ency/article/001355.htm Septicemia] in the ''Medical Encyclopedia'', ''[[Medline Plus]]'' ("A service of the [[U.S. National Library of Medicine|United States National Library of Medicine]] [NLM] and the [[National Institutes of Health]] [NIH]"). Updated October 27, 2005. Accessed August 31, 2007.
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| *[http://www.survivingsepsis.org Surviving Sepsis Campaign]
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| *[http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious-disease/sepsis/ Sepsis] Cleveland Clinic Medical Reference
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| *[http://www.sepsisforum.org International Sepsis Forum]
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| *[http://www.advancesinsepsis.com ''Advances in Sepsis'' journal]
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| *[http://www.sepsis.com/ Sepsis.com]
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| *[http://www.medscape.com/resource/sepsis Medscape Sepsis Resource Center]
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| {{Bacterial diseases}}
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| {{Intensive care medicine}}
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| {{SIB}}
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