Sepsis

Overview

Sepsis is a life-threatening medical emergency that occurs when the body's response to infection becomes dysregulated, leading to widespread inflammation and organ dysfunction. What begins as the body's attempt to fight infection can quickly spiral into a dangerous cascade of events that damages multiple organ systems. Without rapid treatment, sepsis can progress to septic shock and death within hours.

Often misunderstood as "blood poisoning" or "blood infection," sepsis is actually the body's overwhelming and life-threatening response to infection. While bacteria in the blood (bacteremia) can trigger sepsis, the condition can result from infections anywhere in the body, including the lungs, urinary tract, abdomen, or skin. The key feature is not the infection itself but rather the body's extreme reaction to it.

Sepsis affects more than 1.7 million adults in the United States annually and is responsible for approximately 270,000 deaths. It is the leading cause of death in hospitals and costs the U.S. healthcare system more than $24 billion annually. Despite these staggering numbers, public awareness of sepsis remains low, contributing to delays in recognition and treatment.

The challenge with sepsis lies in its rapid progression and variable presentation. Symptoms can mimic other conditions, and there is no single diagnostic test. This makes early recognition crucial but difficult. Every hour of delay in treatment increases mortality risk, making sepsis a true medical emergency where "time is tissue" - every minute counts in preventing irreversible organ damage.

Symptoms

Sepsis symptoms can vary widely and may initially seem like flu or other common infections. The key is recognizing the combination of infection signs with systemic symptoms indicating organ dysfunction.

Additional Warning Signs

• Decreased urine output (sign of kidney dysfunction)
• Extreme shivering or muscle pain
• Pale or mottled skin
• Feeling like you might die (sense of impending doom)
• Sleepiness, difficulty waking up
• Slurred speech
• Severe weakness or inability to stand

Stages of Sepsis

Sepsis exists on a continuum of severity, with each stage representing increasing organ dysfunction and mortality risk.

qSOFA (Quick SOFA) Criteria

Bedside criteria to identify patients at risk for poor outcomes:

• Respiratory rate ≥22 breaths per minute
• Altered mental status (Glasgow Coma Scale <15)
• Systolic blood pressure ≤100 mmHg

Two or more criteria suggest high risk for poor outcome.

Causes

Sepsis can result from any type of infection, but certain infections and pathogens are more commonly associated with its development.

Common Infection Sources

Common Pathogens

• Gram-positive bacteria (50%): Staphylococcus aureus, Streptococcus pneumoniae
• Gram-negative bacteria (40%): E. coli, Klebsiella, Pseudomonas
• Fungi (5%): Candida species
• Viruses (5%): Influenza, COVID-19, herpes viruses
• Mixed infections: Common in abdominal sepsis

Pathophysiology

Sepsis results from a complex interplay of factors:

1. Pathogen recognition: Immune system detects infection
2. Inflammatory cascade: Release of cytokines and inflammatory mediators
3. Endothelial dysfunction: Blood vessel damage and leakage
4. Coagulation abnormalities: Microclots form in small vessels
5. Organ dysfunction: Reduced blood flow and oxygen delivery
6. Immunosuppression: Paradoxical immune system shutdown

Risk Factors

While sepsis can affect anyone, certain factors significantly increase risk.

Immunosuppression

• HIV/AIDS
• Organ transplant recipients
• Chemotherapy or radiation therapy
• Long-term corticosteroid use
• Immunosuppressive medications
• Splenectomy (removed spleen)

Healthcare-Associated Factors

• Recent hospitalization: Exposure to resistant organisms
• Invasive devices: Central lines, urinary catheters, ventilators
• Recent surgery: Especially abdominal or emergency surgery
• Wounds or burns: Entry points for infection
• Previous sepsis: Increased risk of recurrence

Other Risk Factors

• Pregnancy and recent childbirth
• Malnutrition
• Alcohol or drug abuse
• Genetic factors affecting immune response

Diagnosis

Diagnosing sepsis requires high clinical suspicion, as there is no single definitive test. Rapid assessment and testing are crucial.

Clinical Assessment

• Vital signs: Temperature, heart rate, respiratory rate, blood pressure
• Mental status: Confusion, disorientation, decreased responsiveness
• Physical examination: Signs of infection source, organ dysfunction
• Medical history: Recent infections, surgeries, immune status

Laboratory Tests

Imaging Studies

• Chest X-ray: Pneumonia, ARDS
• CT scan: Abdominal infections, abscesses
• Ultrasound: Gallbladder, kidneys, soft tissue
• MRI: Spinal or brain infections

SOFA Score Components

Sequential Organ Failure Assessment evaluates six organ systems:

1. Respiratory: PaO2/FiO2 ratio
2. Coagulation: Platelet count
3. Liver: Bilirubin level
4. Cardiovascular: Blood pressure and vasopressor use
5. Central nervous system: Glasgow Coma Scale
6. Renal: Creatinine and urine output

Treatment

Sepsis treatment is time-critical and follows established bundles of care. The "golden hour" concept emphasizes immediate intervention.

Sepsis Bundle (First Hour)

1. Measure lactate level: Repeat if initial >2 mmol/L
2. Obtain blood cultures: Before antibiotics when possible
3. Administer broad-spectrum antibiotics: Within 1 hour
4. Begin rapid fluid resuscitation: 30 mL/kg crystalloid for hypotension or lactate ≥4
5. Apply vasopressors: If hypotensive during/after fluid resuscitation

Antibiotic Therapy

Supportive Care

• Fluid resuscitation: Balanced crystalloids preferred
• Vasopressors: Norepinephrine first-line for septic shock
• Oxygen therapy: Maintain SpO2 >92%
• Mechanical ventilation: For respiratory failure
• Renal replacement therapy: For acute kidney injury
• Blood products: As indicated for coagulopathy
• Glucose control: Avoid hypoglycemia and severe hyperglycemia
• Stress ulcer prophylaxis: In high-risk patients
• DVT prophylaxis: Unless contraindicated

Advanced Therapies

• Corticosteroids: For refractory septic shock
• ECMO: For severe respiratory or cardiac failure
• Continuous renal replacement: For unstable patients
• Immunoglobulin: In select cases

Monitoring and Goals

• Mean arterial pressure ≥65 mmHg
• Urine output ≥0.5 mL/kg/hr
• Central venous oxygen saturation >70%
• Lactate normalization
• Regular reassessment of organ function

Complications

Sepsis can lead to multiple serious complications, both acute and long-term.

Acute Complications

Organ-Specific Complications

• Cardiovascular: Myocardial dysfunction, arrhythmias
• Neurological: Encephalopathy, critical illness polyneuropathy
• Hepatic: Liver failure, cholestasis
• Hematologic: Thrombocytopenia, anemia
• Endocrine: Adrenal insufficiency, thyroid dysfunction
• Gastrointestinal: Ileus, stress ulcers, ischemia

Post-Sepsis Syndrome

Long-term effects affecting 50% of sepsis survivors:

• Physical weakness and fatigue
• Cognitive impairment (memory, concentration)
• Post-traumatic stress disorder (PTSD)
• Depression and anxiety
• Recurrent infections
• Chronic pain
• Organ dysfunction
• Reduced quality of life

Prevention

Preventing sepsis involves preventing infections and ensuring prompt treatment when infections occur.

General Prevention Measures

• Hand hygiene: Regular handwashing with soap and water
• Vaccinations: Stay up-to-date with recommended vaccines
• Wound care: Clean and monitor cuts, scrapes, and surgical sites
• Chronic disease management: Control diabetes, heart disease, etc.
• Healthy lifestyle: Good nutrition, exercise, adequate sleep
• Avoid tobacco: Smoking increases infection risk

Healthcare-Associated Prevention

• Infection control: Proper sterile techniques
• Device management: Remove catheters, lines when no longer needed
• Antibiotic stewardship: Appropriate use to prevent resistance
• Early mobilization: Reduce hospital-acquired infections
• Staff education: Recognition and rapid response

High-Risk Group Strategies

Early Recognition

• Know the signs and symptoms
• Don't delay seeking medical care
• Inform healthcare providers about recent infections
• Ask "Could this be sepsis?"

Prognosis

Sepsis prognosis depends on multiple factors including severity, timeliness of treatment, and patient characteristics.

Mortality Rates

• Sepsis: 10-20% mortality
• Severe sepsis: 20-40% mortality
• Septic shock: 40-60% mortality
• Multiple organ failure: >80% mortality

Factors Affecting Prognosis

• Time to treatment: Each hour delay increases mortality 7-8%
• Age: Worse outcomes in elderly
• Comorbidities: Pre-existing conditions worsen prognosis
• Site of infection: Lung and abdominal sources higher risk
• Causative organism: Fungal sepsis has worse outcomes
• Number of organ failures: More organs = worse prognosis

Recovery Timeline

• Acute phase: Days to weeks in ICU
• Hospital recovery: 2-4 weeks average
• Physical recovery: Months to years
• Cognitive recovery: Variable, may be permanent
• Full recovery: Only 50% return to pre-sepsis function

When to Seek Emergency Care

Sepsis is a medical emergency. Do not wait to see if symptoms improve.

High-Risk Situations

Be especially vigilant if you:

• Recently had surgery or invasive procedure
• Have a weakened immune system
• Are being treated for cancer
• Have chronic medical conditions
• Recently discharged from hospital
• Have an indwelling medical device
• Are over 65 or under 1 year old

What to Tell Healthcare Providers

• "I'm concerned about sepsis"
• Recent infections or procedures
• Current medications, especially immunosuppressants
• Chronic medical conditions
• Timeline of symptom development

Post-Sepsis Follow-up

After surviving sepsis, see your doctor if you experience:

• Recurring infections
• Persistent weakness or fatigue
• Memory or concentration problems
• Depression or anxiety
• New or worsening organ dysfunction

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