Sepsis is a life-threatening condition that has been around for thousands of years. Sepsis goes by many names including; Septicemia, Sepsis syndrome, Systemic inflammatory response syndrome or SIRS, and Septic shock.  Sepsis is one of the leading causes of death in the intensive care unit. Unfortunately, due to its broad symptoms and comorbidity, Sepsis can be difficult to diagnose. Sepsis was first described in 1,000 BC by Ibn Sīnā, an Islamic philosopher, as the putrefaction of blood and tissues with fever. Since then, the disease has been redefined by several notable scholars and scientists. As of the 1990s, sepsis was described as a systemic inflammatory response (SIRS) to a microbial infection. A SIRS is defined as two of the following occurring at the same time: Tachypnoea (rapid breathing) Tachycardia (rapid heartbeat) Pyrexia (fever) Hypothermia Leukocytosis (high white blood cell count) Leukopaenia (low white blood cell count) Neutrophilia (high amount of neutrophil granulocytes in the blood) However, there is some consideration of whether some of these responses should be used in the definition since these symptoms can be a response to an infection. Thus the definition of sepsis has been simplified to a life-threatening organ dysfunction caused by deregulated host response to infection.

Sepsis is defined by the presence of at least a body temperature above 101°F or below 96.8°F, a heart rate greater than 90 beats per minute and/or a respiratory rate greater than 20 breaths per minute. Cases of severe sepsis are defined by having sepsis symptoms along with one of the following symptoms: A major increase in urine Significant change in mental state Decrease in platelet count Difficulty breathing Abnormal heartbeat Abdominal pain HOW COMMON IS SEPSIS AND SEPTIC SHOCK? The incidence of sepsis worldwide is not well-known. It is estimated that approximately, 31.5 million cases of sepsis and 19.4 million cases of severe sepsis occur worldwide each year. Over 10% of these cases, or 5.3 million, resulting in death.  These statistics are approximations due to little data generated from low- and middle- income countries. Sepsis is also not reported in the WHO Global Burden of Disease report. Because sepsis is associated with a high prevalence of infectious diseases, it is speculated that regions with high infectious disease rates and deaths may contribute to sepsis burden.  Studies of hospital-treated sepsis in high-income countries have concluded that the incidence of sepsis is increasing. However, these findings may not be accurate due to the change in the definition of sepsis over the last few decades.

Clinical Diagnosis Sepsis and septic shock are identified clinically using the Sequential (Sepsis-Related) Organ Failure Assessment or SOFA. SOFA uses common clinical parameters to identify vital organs that are functioning incorrectly or failing in response to sepsis. SOFA can also be used for prognostic purposes, as an increase in SOFA score within the first two days implicates a 50% mortality rate. More recently, in 2016, quick SOFA or qSOFA was developed.  qSOFA uses clinical data that can be obtained easily and quickly at the patient’s bedside. These measures include: Altered level of consciousness (determined by a score equal to or less than 13 on the Glasgow Coma Scale) Systolic blood pressure less than  or equal to 100 mmHg Respiratory rate greater than or equal to 11 rpm When the patient exhibits two or more of the qSOFA criteria, qSOFA is just as effective as SOFA at identifying patients with sepsis and predicting poor outcomes. However, further validation of this testing method is needed. Another drawback to qSOFA is that it may be difficult to implement in undeveloped and developing countries.  In 2015, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) simplified the definition of sepsis to a life-threatening organ dysfunction or failure resulting from a dysregulated host response to an infection.

Early administration of antibiotics and source identification The first line treatment for septic shock is typically early administration of antibiotics and intake of several fluids such as red blood cells and ionotropic drugs. A combination of antimicrobial treatments is the best way to treat sepsis in the initial stages until the microbes responsible for the infection are identified. The appropriate and specific antibiotic to use can be determined from microbiological cultures. Only after initial treatment should vasopressors be administered. In addition to early administration of antibiotics is identifying the source of the infection using imaging. Oxygen and Mechanical Ventilation Another common treatment for sepsis is the administration of oxygen using a mask or early endotracheal intubation. Oxygen is provided in order to reduce oxygen consumption by the body induced by increased breathing. Early Antibiotic Treatment As mentioned earlier, treatment with antibiotics early can make a difference in sepsis severity. A study found that the likelihood of survival decreases 7.6% every hour in which the first antibiotic treatment is delayed, while progression of septic shock increases 8% each hour. However, other studies suggest that there may not be a significant difference in severity and when the initial antibiotic treatment is provided.  The standard of care for antibiotics is that they are given within the first 3 h if the patient is admitted from the emergency unit and 1 h if admitted to the ICU from another service.

Corticosteroids Corticosteroids may be used following fluid intake and treatment with vasoactive drugs if no improvement in lactate levels is seen after the first 6 h. The corticosteroids allow for the vasoactive drugs to be gently withdrawn from the system. It has also been shown that when low or high doses of corticosteroids are given over a long period of time, they reduce mortality rates and shortened the amount of time spent in shock (and thus reduce the time the patient needs to be on vasopressors). Blood Glycemia Regulation High blood sugar levels can promote the development of organ failure in extremely ill patients. Thus treatments to control blood sugar may be provided in conjunction with primary sepsis treatment. Glycemia is controlled by regulating nutrition and other blood sugar level influencers. Patients may also be treated with insulin infusion therapy that is both aggressive but maintains glycemia levels at 140 mg/dL. Just as hyperglycemia can be harmful to patients in critical condition, so can hypoglycemia. Low blood sugar increases mortality and can undermine glycemia regulation therapy. More important than preventing high or low blood sugar is to prevent major fluctuations in blood sugar. Supportive Measures In addition to adjunctive and primary therapies, support mechanisms are also needed to maintain the health of patients with sepsis or septic shock.