Overview
Definition:
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection
In surgical patients, sepsis often arises from intra-abdominal infections, surgical site infections, pneumonia, or catheter-related bloodstream infections
Sepsis bundles are a set of evidence-based interventions that, when performed collectively and in a timely manner, improve patient outcomes.
Epidemiology:
Sepsis is a leading cause of death in hospitalized patients worldwide
Surgical patients have a higher risk due to factors like invasive procedures, immunocompromise, and potential for anastomotic leaks or device-related infections
Incidence varies, but mortality rates can exceed 30% for severe sepsis and septic shock, emphasizing the critical need for rapid, standardized care.
Clinical Significance:
Prompt and appropriate management of sepsis in surgical patients is paramount to reduce morbidity and mortality
Implementing sepsis bundles ensures that essential life-saving interventions are delivered without delay, improving organ perfusion, controlling the source of infection, and preventing progression to septic shock and multi-organ failure
This is crucial for resident training and successful board examinations.
Clinical Presentation
Symptoms:
Fever or hypothermia
Increased heart rate
Rapid breathing
Confusion or disorientation
Decreased urine output
Extreme pain or discomfort
Clammy or sweaty skin
Shortness of breath or difficulty breathing
Feeling of impending doom.
Signs:
Hypotension (systolic BP < 90 mmHg or a decrease of 40 mmHg from baseline)
Tachycardia (> 90 beats/min)
Tachypnea (> 20 breaths/min)
Altered mental status
Cool, clammy skin
Mottled skin
Decreased capillary refill time
Elevated lactate levels
Signs of specific infection source (e.g., abdominal tenderness, wound discharge, cough with purulent sputum).
Diagnostic Criteria:
Sepsis-3 criteria: SOFA score increase of ≥ 2 points from baseline, suggestive of acute organ dysfunction
Suspected or confirmed infection
Septic shock: Sepsis with persistent hypotension requiring vasopressors to maintain mean arterial pressure (MAP) ≥ 65 mmHg and serum lactate > 2 mmol/L despite adequate fluid resuscitation.
Diagnostic Approach
History Taking:
Focus on recent surgery, instrumentation, or invasive lines
Inquire about pre-existing comorbidities
Ask about symptoms suggestive of infection (fever, chills, pain, dysuria, cough, wound issues)
Note recent antibiotic use
Assess for altered mental status or decreased oral intake.
Physical Examination:
Assess for signs of shock: vital signs (BP, HR, RR, SpO2, Temp), capillary refill, skin turgor, and mental status
Perform a thorough systemic examination, paying close attention to the surgical site, abdomen, chest, and any indwelling devices for signs of infection
Look for source control clues.
Investigations:
Lactate levels (critical indicator of hypoperfusion)
Complete blood count (CBC) with differential (leukocytosis or leukopenia)
Blood cultures (at least two sets from different sites, before antibiotics if possible)
Cultures from suspected infection sites (wound, urine, respiratory secretions, drain fluid)
Comprehensive metabolic panel (CMP) to assess organ function (renal, hepatic)
Coagulation profile (PT/INR, aPTT)
Arterial blood gas (ABG) for acid-base status and oxygenation
Imaging: CXR, CT abdomen/pelvis, ultrasound as per suspected source.
Differential Diagnosis:
Non-infectious inflammatory states (e.g., pancreatitis, burns, trauma)
Drug reactions
Anaphylaxis
Pulmonary embolism
Myocardial infarction
Gastrointestinal bleed
Dehydration
Hypoglycemia
Heatstroke.
Management
Initial Management:
Within the first hour (The "Hour-1 Bundle"): Measure lactate level
Obtain blood cultures before administering antibiotics
Administer broad-spectrum antibiotics
Begin rapid infusion of 30 mL/kg crystalloids for hypotension or lactate ≥ 4 mmol/L
Apply vasopressors if hypotensive during resuscitation to maintain MAP ≥ 65 mmHg.
Medical Management:
Antibiotics: Tailor based on suspected source, local resistance patterns, and culture results
Examples include piperacillin-tazobactam, carbapenems, or vancomycin depending on presentation
Dosing adjustments for renal/hepatic impairment are crucial
Fluid Resuscitation: Aggressive intravenous crystalloid administration (e.g., Lactated Ringer's or Normal Saline) to achieve hemodynamic stability
Target MAP ≥ 65 mmHg
Vasopressors: Norepinephrine is the first-line agent
Dopamine, vasopressin, or epinephrine can be added if refractory hypotension
Consider corticosteroids if septic shock is refractory to fluids and vasopressors.
Surgical Management:
Source control is critical
This may involve: drainage of abscesses (percutaneous or surgical)
Debridement of necrotic tissue (e.g., in necrotizing fasciitis or infected surgical sites)
Removal of infected foreign bodies (e.g., prosthetic devices, catheters)
Re-exploration for suspected anastomotic leak or intra-abdominal catastrophe
Prompt surgical intervention can significantly improve survival rates.
Supportive Care:
Hemodynamic monitoring: Arterial line for continuous BP monitoring
Central venous catheter for CVP monitoring (controversial)
Close monitoring of urine output
Mechanical ventilation if respiratory failure occurs
Nutritional support: Early enteral feeding is preferred when hemodynamically stable
Glucose control: Maintain blood glucose levels < 180 mg/dL
Renal replacement therapy if acute kidney injury develops
Mechanical prophylaxis for venous thromboembolism.
Complications
Early Complications:
Septic shock
Acute respiratory distress syndrome (ARDS)
Acute kidney injury (AKI)
Disseminated intravascular coagulation (DIC)
Adrenal insufficiency
Gut ischemia and ileus
Hypoglycemia.
Late Complications:
Post-sepsis syndrome (characterized by fatigue, weakness, cognitive dysfunction)
Chronic organ dysfunction (e.g., chronic kidney disease, pulmonary fibrosis)
Increased susceptibility to secondary infections
Malnutrition
Psychological sequelae (anxiety, depression, PTSD).
Prevention Strategies:
Strict adherence to infection control protocols
Prompt diagnosis and management of infections
Judicious use of invasive devices and removal when no longer needed
Implementing sepsis screening and early warning systems
Effective surgical technique and prompt management of surgical complications
Educating healthcare teams on sepsis recognition and management protocols.
Prognosis
Factors Affecting Prognosis:
Timeliness of intervention (especially antibiotic administration and source control)
Severity of organ dysfunction at presentation
Patient's comorbidities and immune status
Age
Etiology of infection
Development of septic shock
Response to initial resuscitation and vasopressors
Development of AKI or ARDS.
Outcomes:
Mortality rates are significantly reduced with adherence to sepsis bundles and timely, evidence-based management
Survivors of severe sepsis and septic shock often experience long-term sequelae (post-sepsis syndrome) requiring ongoing rehabilitation and multidisciplinary care
Early recognition and treatment improve survival and reduce the burden of long-term complications.
Follow Up:
Close monitoring of vital signs and organ function in the ICU and post-ICU ward
Regular assessment for signs of recurrent infection
Management of post-sepsis syndrome, including physical therapy, cognitive rehabilitation, and psychological support
Long-term follow-up with specialists as needed for chronic organ dysfunction
Patient education on recognizing early signs of worsening health.
Key Points
Exam Focus:
The Hour-1 Bundle (lactate, blood cultures, antibiotics, fluids, vasopressors) is a high-yield concept for DNB/NEET SS
Recognize the SOFA score for organ dysfunction assessment
Understand the definition of septic shock and its management
Emphasize the importance of source control in surgical sepsis.
Clinical Pearls:
Always consider sepsis in any patient with new-onset organ dysfunction, especially post-operatively
Do not delay antibiotic administration waiting for cultures if sepsis is strongly suspected
Aggressive fluid resuscitation is the cornerstone of initial management
Early surgical consultation for source control is vital for surgical patients.
Common Mistakes:
Delayed recognition of sepsis
Procrastination in administering broad-spectrum antibiotics
Inadequate fluid resuscitation
Failure to identify and control the source of infection
Over-reliance on single vital signs for assessing shock
Not performing serial lactate measurements to guide therapy.