Diagnosis and management of sepsis/septic shock – a review article

As the authors of this recently published review article acknowledge, sepsis is an increasingly common and serious illness that takes the lives of close to a third of those affected. Optimal care of patients with sepsis is delivered in an intensive care unit but rapid early diagnosis, vital for survival, occurs outside this setting, in hospital emergency rooms and wards or in the community.

It is important therefore that clinical staff working in these non-intensive care environments are kept abreast of most recent guidelines on identification and initial management of patients with sepsis. That is the ambition of this review article; the intended audience is clinical staff not working in intensive care. 

The article begins with consideration of the recently published (Feb 2016) Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). This defines sepsis as “life-threatening organ dysfunction caused by dysregulated host response to infection”. And septic shock is now defined as “a subset of sepsis in which particularly profound circulatory cellular and metabolic abnormalities are associated with greater risk of mortality than with sepsis alone”.

The additional category ”severe sepsis” that appeared in previous definitions was judged by the expert Sepsis-3 task force to be unhelpful and therefore omitted from this most recent definition. The pathophysiology of sepsis remains incompletely understood. 

The authors acknowledge the enduring influence of the Surviving Sepsis Campaign (SSC), an international collaborative effort established in 2002. They list key recommendations contained in the most recent guidelines from this group that were published in 2016. Among these is the recommendation that intravenous antibiotics should be started within one hour of sepsis recognition.

Recommended resuscitative measures (use of crystalloid, vasopressor drugs etc.) are also included. Throughout the article the authors also make reference to the so-called Sepsis Six bundle which reflects these recommendations. Sepsis Six is a check list of six actions (detailed in the article) that need to be completed within one hour of sepsis diagnosis. 

Early identification of sepsis is crucial and the authors highlight two examples of well-validated early warning scoring systems based on readily available clinical information (respiratory rate, heart rate, blood pressure, temperature, oxygen saturation and level of consciousness). They are the National Early Warning Score (NEWS) and the Modified Early Warning Score (MEWS). Detailed application of these scoring systems in rapidly identifying those at risk of sepsis and septic shock at triage is included in the review. 

Under the heading ”Investigations” the authors list appropriate laboratory blood tests. From this list, they discuss in a little detail the importance of two tests: serum lactate and microbiological culture of blood. The importance of sampling blood for culture before administration of antibiotics, if possible, is emphasized 

Under a further heading, ”Initial clinical management of sepsis” the authors discuss further detail of antibiotic and intravenous fluid therapy. There is also discussion of monitoring response to these treatments and the importance of lactate testing in this regard. The role of three drug classes (vasopressors, inotropes and corticosteroids), transfusion of blood products and blood glucose control is also discussed.