Sepsis Management Overview and CLINICAL ASSESSMENT

By SWA

Sepsis is a serious, potentially life-threatening condition that occurs when the body’s immune response to an infection goes out of control, leading to widespread inflammation that can damage tissues and organs.
If not treated quickly, sepsis can cause tissue damage, organ failure, and even death. It often arises from infections like pneumonia, urinary tract infections, skin infections, or infections in the abdominal area.

How Sepsis Affects the Body

When an infection triggers sepsis, the immune system releases chemicals to fight the infection, but these chemicals can cause a severe inflammatory response throughout the body. This inflammation can lead to blood clots, leaky blood vessels, and decreased blood flow, depriving organs and tissues of oxygen and nutrients.

Common Symptoms of Sepsis

Sepsis symptoms can be subtle at first, but they often worsen quickly. Here are the primary signs and symptoms:

  1. Fever or Low Body Temperature

    • Fever (above 100.4°F or 38°C) or, in some cases, a low body temperature (below 96.8°F or 36°C), especially in older adults or those with weak immune systems.

  2. Rapid Heart Rate and Breathing

    • Heart rate higher than 90 beats per minute (tachycardia).
    • Rapid breathing, often above 20 breaths per minute, or feelings of shortness of breath.

  3. Confusion or Disorientation

    • Sudden confusion, difficulty concentrating, or unusual drowsiness. This is often one of the first signs in elderly patients.

  4. Low Blood Pressure (Hypotension)

    • A dangerous drop in blood pressure that can cause dizziness or fainting and may require medical intervention.

  5. Extreme Discomfort and Clammy Skin

    • Some patients feel a general sense of severe discomfort, achiness, or an “I feel like I might die” sensation. Skin can also feel clammy or appear pale.

  6. Signs of Organ Dysfunction

    • Decreased urine output, indicating kidney stress or failure.
    • Shortness of breath, indicating possible lung involvement.
    • Abdominal pain or nausea, which may suggest gut-related involvement.
    • Jaundice (yellowing of skin/eyes) if the liver is affected.

Symptoms of Severe Sepsis and Septic Shock

If sepsis progresses, it can lead to severe sepsis or septic shock, where symptoms become more critical:

  • Extreme Low Blood Pressure: Despite fluid administration, blood pressure remains dangerously low, which can lead to shock.
  • Organ Failure: Multiple organs, such as the lungs, heart, kidneys, or liver, may start to shut down.
  • Skin Changes: Mottling (bluish-purple patches), pale or cool skin, or extremities that feel cold due to poor circulation.

When to Seek Medical Help

Sepsis is a medical emergency. If an infection is present and symptoms like high fever, rapid heart rate, confusion, low urine output, or extreme discomfort appear, it’s crucial to seek immediate medical care. Early diagnosis and treatment, including IV fluids, antibiotics, and supportive therapies, are essential to prevent serious complications.

Remembering Sepsis Symptoms: "TIME"

  • T – Temperature (high or low)
  • I – Infection (known or suspected)
  • M – Mental decline (confused, sleepy, difficult to rouse)
  • E – Extremely ill (feels like something is terribly wrong)

Early recognition and treatment of sepsis can make a life-saving difference.

Sepsis Management Overview

INITIAL SEPSIS CLINICAL ASSESSMENT

  • Quick-SOFA: SBP < 100 mmHg, GCS < 15, RR ≥ 20 (full SOFA if hospitalized/ICU).
  • SIRS Criteria: RR > 20, HR > 90, Temp > 38.3°C or < 36°C, WBC > 12k or < 4k or > 10% bands.
  • Other Signs: AMS, chills, flushed/clammy skin, hypoxia, oliguria, edema, ↓ BP.
  • Early Workup: Cultures x4, lactate, CBC, BMP, PCT, CXR.
  • Consider Risk Factors: Mechanical ventilation, ICU care, invasive lines, surgery, chronic illness, wounds, cancer, immunosuppression, age ≥ 65.
  • Differential Diagnosis (DDx): PE, MI, DKA, other shock (e.g., anaphylaxis, hemorrhage), adrenal insufficiency, overdose.

Sepsis Bundles

If high index of suspicion based on initial assessment, start Sepsis Bundles:

1. Administer antibiotics within 1 HOUR

  • Culture first: Blood x2 sites (aerobic/anaerobic), viral Cx if suspected, fungal Cx if immunosuppressed. Urine, wound, CSF, sputum Cx if needed.
  • Start broad-spectrum IV antibiotics. Consider combo therapy in high-risk patients (e.g., ICU, nosocomial, MDR risk).
  • De-escalate based on culture/sensitivity results.
  • Reassess daily for efficacy, prevent resistance, avoid toxicity, and reduce cost.

2. Additional Workup

  • ABG, serial lactate, CRP, coagulation studies, LFTs.
  • Invasive candidiasis assays, rapid bacterial/viral ID tests.
  • Additional imaging, U/S IVC compressibility index, source control.

Within 3 HOURS: Initial Resuscitation Bundle

  • Assess MAP, measure lactate.
  • Fluid Challenge: IVF crystalloid 30 ml/kg if hypotensive (MAP < 65 or SBP < 90) or lactate ≥ 4 mmol/L (36 mg/dL).

Within 6 HOURS: Septic Shock Bundle

  • Goals: MAP ≥ 65 mmHg, CVP 8-12 mmHg (12-15 if intubated), urine ≥ 0.5 ml/kg/hr, ScvO2 ≥ 70% or SvO2 ≥ 65%, lactate normalization.
    • Repeat lactate if initial was elevated.
    • Reassess MAP: If MAP < 65, assess fluid and perfusion. If needed, give additional fluid challenge.
    • Vasopressors if still hypotensive after fluids:
      • 1st Line: NE.
      • 2nd Line: Epi (+/- NE).
      • 3rd Line: DA, phenylephrine.
      • Consider dobutamine if myocardial dysfunction persists.
    • Repeat IVF crystalloid 30 ml/kg PRN per BP response, consider adding albumin.

Other Supportive Measures in Severe Sepsis

  • Oxygen if hypoxic (SpO2 < 94% or ScvO2 < 70%).
  • Mechanical Ventilation if ARDS (SaO2/FiO2 < 300); tidal volume target 6 ml/kg predicted weight, plateau pressure ≤ 30 cm H2O.
  • Central Line for CVP, ScvO2 if persistent ↓ BP or ↑ lactate in septic shock.
  • Hydrocortisone 200 mg/day (3-4 doses) only in refractory septic shock.
  • Insulin to maintain blood glucose < 180 mg/dL.

Notes

  1. Quick-SOFA/SIRS criteria: Positive if ≥ 2 criteria met.
  2. Fever not always present, esp. in elderly or immunocompromised.
  3. Avoid waiting for test results before treatment.
  4. Cultures often negative early in sepsis.
  5. Procalcitonin helps in differentiating bacterial vs. viral infection.
  6. ABGs may reveal alkalosis from hyperventilation, acidosis from hypoxia.
  7. Use care in fluid resuscitation if comorbidities (e.g., CHF, ESRD) present.
  8. Prioritize NE over dopamine in hypotension management.
  9. Central line no longer universal for all cases; use case-by-case.

This summary reflects current best practices adapted from the Surviving Sepsis Campaign guidelines.

 © 2000-2025 Sieglinde W. Alexander. All writings by Sieglinde W. Alexander have a fife year copy right. Library of Congress Card Number: LCN 00-192742 ISBN: 0-9703195-0-9


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