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{{Sepsis}}
{{Sepsis}}
{{CMG}};  '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.D.]] [mailto:psingh@perfuse.org]
{{CMG}};  '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh@perfuse.org]
 
{{SK}} sepsis syndrome; septic shock; septicemia
 
==Overview==
==Overview==
There are many complications associated with sepsis, especially because it is a systemic phenomenon. Sepsis is a severe condition, and the prognosis of the patient will depend greatly on the condition and overall health of the patient. Many factors, such as age, contribute to the overall prognosis.
There are many complications associated with sepsis, especially because it is a systemic phenomenon. Sepsis is a severe condition, and the prognosis of the patient will depend greatly on the condition and overall health of the patient. Many factors, such as age, hosts immune response, site of [[infection]], type of infection, appropriate [[antibiotic]] therapy, and restoration of circulation of perfusion contribute to the overall prognosis.<ref name="pmid26398704">{{cite journal| author=Kellum JA, Chawla LS, Keener C, Singbartl K, Palevsky PM, Pike FL et al.| title=The Effects of Alternative Resuscitation Strategies on Acute Kidney Injury in Patients with Septic Shock. | journal=Am J Respir Crit Care Med | year= 2016 | volume= 193 | issue= 3 | pages= 281-7 | pmid=26398704 | doi=10.1164/rccm.201505-0995OC | pmc=4803059 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26398704  }} </ref><ref name="pmid25776936">{{cite journal| author=Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R| title=Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis. | journal=N Engl J Med | year= 2015 | volume=  | issue=  | pages=  | pmid=25776936 | doi=10.1056/NEJMoa1415236 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25776936  }} </ref>
<ref name="pmid25668750">{{cite journal| author=Capp R, Horton CL, Takhar SS, Ginde AA, Peak DA, Zane R et al.| title=Predictors of Patients Who Present to the Emergency Department With Sepsis and Progress to Septic Shock Between 4 and 48 Hours of Emergency Department Arrival. | journal=Crit Care Med | year= 2015 | volume=  | issue=  | pages=  | pmid=25668750 | doi=10.1097/CCM.0000000000000861 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25668750  }} </ref><ref name="pmid26901543">{{cite journal| author=Williams JM, Greenslade JH, Chu K, Brown AF, Lipman J| title=Severity Scores in Emergency Department Patients With Presumed Infection: A Prospective Validation Study. | journal=Crit Care Med | year= 2016 | volume= 44 | issue= 3 | pages= 539-47 | pmid=26901543 | doi=10.1097/CCM.0000000000001427 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26901543  }} </ref><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><ref name="pmid26903335">{{cite journal| author=Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A et al.| title=Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). | journal=JAMA | year= 2016 | volume= 315 | issue= 8 | pages= 762-74 | pmid=26903335 | doi=10.1001/jama.2016.0288 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26903335  }} </ref> <ref>GitHub Contributors. Prognosticating in sepsis with decision aids: a living systematic review. GitHub. Available at https://github.com/openMetaAnalysis/Sepsis-prognosticating-with-decision-aids/blob/master/README.md. Accessed January 26, 2017.</ref>
 
==Natural History==
If left untreated sepsis can lead to multiorgan failure and eventually death.


==Complications==
==Complications==
*[[Disseminated intravascular coagulation]] (DIC) can be the result of sepsis.
*[[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). [[Acute kidney injury]] occurs in about 30% of patients and about 5% of patients need [[renal replacement therapy]].<ref name="pmid26398704">{{cite journal| author=Kellum JA, Chawla LS, Keener C, Singbartl K, Palevsky PM, Pike FL et al.| title=The Effects of Alternative Resuscitation Strategies on Acute Kidney Injury in Patients with Septic Shock. | journal=Am J Respir Crit Care Med | year= 2016 | volume= 193 | issue= 3 | pages= 281-7 | pmid=26398704 | doi=10.1164/rccm.201505-0995OC | pmc=4803059 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26398704  }} </ref>
*[[Arrhythmia]] is an abnormal heart rhythm; it can be the result of sepsis.
*[[Ileus]] or [[ischemic colitis]] can be the result (hypoperfusion) or cause of sepsis.
*[[Multiple organ dysfunction syndrome]] can be the result of sepsis.
*[[Meningitis]], infection of the tissue that covers the [[brain]] and [[spinal cord]], can be a complication or cause of sepsis.
*[[Osteomyelitis]] is an infection of the bone; it can be the cause or result of sepsis.
*[[Endocarditis]], infection of the inner surface of heart which is in contact with blood, can also be a complication or cause of sepsis.
*[[Pyaemia]] — causes abscesses.
==Prognosis==


* [[Infection]] is the invasion of normally sterile host tissues by a microbial [[pathogen]].
The serum lactate level may be more predictive of outcomes than the serum bicarbonate<ref name="pmid15025779">{{cite journal| author=Meregalli A, Oliveira RP, Friedman G| title=Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients. | journal=Crit Care | year= 2004 | volume= 8 | issue= 2 | pages= R60-5 | pmid=15025779 | doi=10.1186/cc2423 | pmc=420024 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15025779  }} </ref>.
* [[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.
*[[Viremia]] is the presence of [[viruses]] in the blood.
* Septic joint is an infection of a [[joint]]; it is associated with bacteremia and trauma.
* [[Disseminated intravascular coagulation]] (DIC) can be the result of sepsis
* [[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)
* [[Arrhythmia]] is an abnormal heart rhythm; it can be the result of sepsis.
* [[Ileus]] or [[ischemic colitis]] can be the result (hypoperfusion) or cause of sepsis
* [[Multiple organ dysfunction syndrome]] can be the result of sepsis
* [[Meningitis]], infection of the tissue that covers the [[brain]] and [[spinal cord]], can be a complication or cause of sepsis
* [[Osteomyelitis]] is an infection of the bone; it can be the cause or result of sepsis
* [[Endocarditis]], infection of the inner surface of heart which is in contact with blood, can also be a complication or cause of sepsis
* [[Pyaemia]] — causes abscesses


==Prognosis==
===Mortality===
Prognosis can be estimated with the MEDS (Mortality in Emergency Department Sepsis) 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> This MEDS score will be a calculation of the following criteria:
Mortality can be estimated with the MEDS (Mortality in Emergency Department Sepsis)score. More complicated scores such as the Apache, [[Sequential Organ Failure Assessment]] (SOFA), and Logistic Organ Dysfunction System (LODS) can be used as well.<ref name="pmid26901543">{{cite journal| author=Williams JM, Greenslade JH, Chu K, Brown AF, Lipman J| title=Severity Scores in Emergency Department Patients With Presumed Infection: A Prospective Validation Study. | journal=Crit Care Med | year= 2016 | volume= 44 | issue= 3 | pages= 539-47 | pmid=26901543 | doi=10.1097/CCM.0000000000001427 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26901543  }} </ref><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><ref name="pmid26903335">{{cite journal| author=Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A et al.| title=Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). | journal=JAMA | year= 2016 | volume= 315 | issue= 8 | pages= 762-74 | pmid=26903335 | doi=10.1001/jama.2016.0288 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26903335  }} </ref>
*Altered mental status
*Lower [[respiratory]] infection
*[[Granulocytic bands]] > 5% of WBC
*Patient older than 65
*[[Shock]] from sepsis
*[[Platelet]] count below 150,000
*Terminal illness with an immediate possibility of death within one month
*[[Hypoxia]]
*[[Tachypnea]]


===Point System<ref name="urlRisk Stratifying the Potentially Septic Patient in the ED">{{cite web |url=http://www.epmonthly.com/the-literature/evidence-based-medicine/risk-stratifying-the-potentially-septic-patient-in-the-ed/ |title=Risk Stratifying the Potentially Septic Patient in the ED |format= |work= |accessdate=2012-04-20}}</ref>===
=====Mortality in Emergency Department Sepsis(MEDS) Point System<ref name="pmid26901543" />=====
The precise scoring system for the MEDS score is as follows:
The components and their scores for the MEDS are described in the following table
*Rapidly progressing terminal co-morbid illness - '''6 points'''
{| class="wikitable"
*If the patient is older than 65 years of age - '''3 points'''
!Component
*If the granulocytic bands are greater than 5% - '''3 points'''
!Points
*If the patient has [[tachypnea]] or [[hypoxia]] - '''3 points'''
|-
*If the patient is in [[shock]] - '''3 points'''
|Rapidly progressing terminal co-morbid illness
*If the patient has a [[platelet]] count of less than 150,000 mm<sup>3</sup> - '''3 points'''
|6
*If the patient has an altered mental status - '''2 points'''
|-
*If the patient is a resident of a nursing home - '''2 points'''
|Age >65
*If the patient has a lower [[respiratory]] infection - '''2 points'''
|3
|-
|Granulocytic bands are greater than 5%
|3
|-
|If the patient has [[tachypnea]] or [[hypoxia]]
|3
|-
|If the patient is in [[shock]]
|3
|-
|If the patient has a [[platelet]] count of less than 150,000 mm<sup>3</sup>
|3
|-
|Altered mental status
|2
|-
|Resident of a nursing home
|2
|-
|Lower [[respiratory]] infection
|2
|}


===Point Correlation<ref name="urlRisk Stratifying the Potentially Septic Patient in the ED">{{cite web |url=http://www.epmonthly.com/the-literature/evidence-based-medicine/risk-stratifying-the-potentially-septic-patient-in-the-ed/ |title=Risk Stratifying the Potentially Septic Patient in the ED |format= |work= |accessdate=2012-04-20}}</ref>===
The total score will be added up and that total will correlate to the mortality percentage with a 95% confidence interval. The following are the point ranges associated with various mortality percentages.
The total score will be added up and that total will correlate to the mortality percentage with a 95% confidence interval. The following are the point ranges associated with various mortality percentages.
*'''0-4 points total''' - 0.6% mortality rate
*'''0-4 points total''' - 0.6% mortality rate
Line 52: Line 74:
*'''13-15 points total''' - 32% mortality rate
*'''13-15 points total''' - 32% mortality rate
*'''15+ points total''' - 40% mortality rate
*'''15+ points total''' - 40% mortality rate
The area under the [[receiver operating characteristic]] curve for the MEDs score is 0.92.<ref name="pmid26901543" />
===Septic shock===
Approximately 12% of of patients with sepsis progress to septic shock within 48 hours. Among variables studied (which did not include [[procalcitonin]], predictors of progression to septic shock were:<ref name="pmid25668750">{{cite journal| author=Capp R, Horton CL, Takhar SS, Ginde AA, Peak DA, Zane R et al.| title=Predictors of Patients Who Present to the Emergency Department With Sepsis and Progress to Septic Shock Between 4 and 48 Hours of Emergency Department Arrival. | journal=Crit Care Med | year= 2015 | volume=  | issue=  | pages=  | pmid=25668750 | doi=10.1097/CCM.0000000000000861 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25668750  }} </ref>
* Nonpersistent hypotension
* Bandemia at least 10%
* Lactate at least 4.0 mmol/L
* Past medical of coronary artery disease
* Female gender


==References==
==References==
{{reflist|2}}
{{reflist|2}}
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Latest revision as of 14:43, 22 May 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]

Synonyms and keywords: sepsis syndrome; septic shock; septicemia

Overview

There are many complications associated with sepsis, especially because it is a systemic phenomenon. Sepsis is a severe condition, and the prognosis of the patient will depend greatly on the condition and overall health of the patient. Many factors, such as age, hosts immune response, site of infection, type of infection, appropriate antibiotic therapy, and restoration of circulation of perfusion contribute to the overall prognosis.[1][2] [3][4][5][6] [7]

Natural History

If left untreated sepsis can lead to multiorgan failure and eventually death.

Complications

Prognosis

The serum lactate level may be more predictive of outcomes than the serum bicarbonate[8].

Mortality

Mortality can be estimated with the MEDS (Mortality in Emergency Department Sepsis)score. More complicated scores such as the Apache, Sequential Organ Failure Assessment (SOFA), and Logistic Organ Dysfunction System (LODS) can be used as well.[4][5][6]

Mortality in Emergency Department Sepsis(MEDS) Point System[4]

The components and their scores for the MEDS are described in the following table

Component Points
Rapidly progressing terminal co-morbid illness 6
Age >65 3
Granulocytic bands are greater than 5% 3
If the patient has tachypnea or hypoxia 3
If the patient is in shock 3
If the patient has a platelet count of less than 150,000 mm3 3
Altered mental status 2
Resident of a nursing home 2
Lower respiratory infection 2

The total score will be added up and that total will correlate to the mortality percentage with a 95% confidence interval. The following are the point ranges associated with various mortality percentages.

  • 0-4 points total - 0.6% mortality rate
  • 5-7 points total - 5% mortality rate
  • 8-12 points total - 19% mortality rate
  • 13-15 points total - 32% mortality rate
  • 15+ points total - 40% mortality rate

The area under the receiver operating characteristic curve for the MEDs score is 0.92.[4]

Septic shock

Approximately 12% of of patients with sepsis progress to septic shock within 48 hours. Among variables studied (which did not include procalcitonin, predictors of progression to septic shock were:[3]

  • Nonpersistent hypotension
  • Bandemia at least 10%
  • Lactate at least 4.0 mmol/L
  • Past medical of coronary artery disease
  • Female gender

References

  1. ↑ 1.0 1.1 Kellum JA, Chawla LS, Keener C, Singbartl K, Palevsky PM, Pike FL; et al. (2016). "The Effects of Alternative Resuscitation Strategies on Acute Kidney Injury in Patients with Septic Shock". Am J Respir Crit Care Med. 193 (3): 281–7. doi:10.1164/rccm.201505-0995OC. PMC 4803059. PMID 26398704.
  2. ↑ Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R (2015). "Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis". N Engl J Med. doi:10.1056/NEJMoa1415236. PMID 25776936.
  3. ↑ 3.0 3.1 Capp R, Horton CL, Takhar SS, Ginde AA, Peak DA, Zane R; et al. (2015). "Predictors of Patients Who Present to the Emergency Department With Sepsis and Progress to Septic Shock Between 4 and 48 Hours of Emergency Department Arrival". Crit Care Med. doi:10.1097/CCM.0000000000000861. PMID 25668750.
  4. ↑ 4.0 4.1 4.2 4.3 Williams JM, Greenslade JH, Chu K, Brown AF, Lipman J (2016). "Severity Scores in Emergency Department Patients With Presumed Infection: A Prospective Validation Study". Crit Care Med. 44 (3): 539–47. doi:10.1097/CCM.0000000000001427. PMID 26901543.
  5. ↑ 5.0 5.1 Shapiro NI, Wolfe RE, Moore RB, Smith E, Burdick E, Bates DW (2003). "Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule". Crit. Care Med. 31 (3): 670–5. doi:10.1097/01.CCM.0000054867.01688.D1. PMID 12626967.
  6. ↑ 6.0 6.1 Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A; et al. (2016). "Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)". JAMA. 315 (8): 762–74. doi:10.1001/jama.2016.0288. PMID 26903335.
  7. ↑ GitHub Contributors. Prognosticating in sepsis with decision aids: a living systematic review. GitHub. Available at https://github.com/openMetaAnalysis/Sepsis-prognosticating-with-decision-aids/blob/master/README.md. Accessed January 26, 2017.
  8. ↑ Meregalli A, Oliveira RP, Friedman G (2004). "Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients". Crit Care. 8 (2): R60–5. doi:10.1186/cc2423. PMC 420024. PMID 15025779.

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