Early Recognition and Management of Sepsis in Adults: The First Six Hours

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What is sepsis? | Queensland Health

Sepsis is a medical emergency. More adults die from sepsis than breast, prostate and colorectal cancer combined.

A mosquito bite. A urinary tract infection. The flu. It might seem unlikely, but these conditions share a common trait – all three can potentially lead to sepsis.

In fact, any infection can potentially trigger sepsis, a condition caused by an abnormal response of the body to an infection.

Sepsis a life-threatening illness. In 2017-18, more than 20,000 people were treated for sepsis in Queensland hospitals; over 2,000 lost their lives. For adults who survive sepsis, half will be left with a permanent disability or impaired function. It is the leading cause of death and disability in children.

You might have heard of sepsis, but could you name its possible signs and symptoms? Knowing what to look for can help you seek medical help quickly. Early detection and treatment saves lives.

Here’s what you need to know about sepsis, how to spot the signs and symptoms, and when to ask, ‘Could this be sepsis?’.

What causes sepsis?

Sepsis is also known as septicaemia or blood poisoning. It occurs when the body’s response to an infection causes damage to healthy tissues and organs.

Sepsis can be caused by any type of infection – viral, fungal, or bacterial. It most commonly occurs with bacterial infections of the lungs, urinary tract (bladder, urethra, kidneys), abdomen, skin and soft tissues. It can lead to tissue damage, multiple organ failure and death.

What are the symptoms of sepsis?

There is no single symptom of sepsis. It can initially look like the flu, gastro, or a typical urinary, skin, or chest infection. Symptoms can vary from person to person and are different for adults and children.

You know yourself or your loved one best, and your instincts about their illness can help the medical team in their diagnosis and treatment. It’s important to know what to look for.

Adults with sepsis might experience one or more of the following symptoms:

• Fast breathing
• Fast heartbeat
• Skin rash or clammy/sweaty skin
• Weakness or aching muscles
• Not passing much (or any) urine
• Feeling very hot or cold, chills or shivering
• Feeling confused, disoriented, or slurring your speech
• Feeling very unwell, extreme pain or the ‘worst ever’.

Adults with sepsis might express that they feel like they are dying or that they have never been so sick and are worried about their health.

Sepsis is an emergency. If you or someone you are caring for experiences any of these symptoms, head straight to the nearest hospital emergency department and ask, ‘Could this be sepsis?’.

Children with sepsis might experience one or more of the following symptoms:

• Fast breathing
• Convulsions or fits
• A rash that doesn’t fade when pressed
• Discoloured or blotchy skin, or skin that is very pale or bluish
• Not passing urine (or no wet nappies) for several hours
• Vomiting
• Not feeding or eating
• A high or very low temperature
• Sleeping, confused or irritable
• Pain or discomfort that doesn’t respond to ordinary pain relief like paracetamol.

Sepsis is a life-threatening emergency, with more than 50 per cent of sepsis-related deaths in children occurring within 24 hours. If a child you are caring for experiences any of these symptoms, head straight to the nearest hospital emergency department and ask, ‘Could this be sepsis?’.

What to do if you suspect sepsis

Sepsis is an emergency that requires urgent medical intervention. Being aware of the signs and symptoms can help people to receive timely medical treatment.

Illnesses can change, and an infection might lead to sepsis after you have already been to see the doctor. Even if you have seen a doctor for your concerns, if the signs of sepsis arise, or the person is not getting better or is getting sicker, trust your gut feeling. Go to the nearest emergency department and ask your doctor or nurse, ‘Could this be sepsis?’.

Who is at increased risk of developing sepsis?

Anyone can develop sepsis. However, some people are more at risk than others. Those at higher risk include:

• Infants and children
• Older adults
• People of Aboriginal and Torres Strait Islander descent
• People with a weakened immune system or are being treated for cancer
• People who have just had surgery or given birth
• People with a wound or injury.

How is sepsis diagnosed and treated?

Sepsis is curable if identified and treated quickly and, in most cases, leads to a full recovery.

If sepsis is suspected, clinicians will run a range of tests to assess vital signs and identify the original infection. The patient may require medications, including antibiotics, and intravenous fluids to combat sepsis and stabilise the body.

Depending on the severity of the case, patients may require other supportive care such as intubation (mechanical assistance with breathing) or dialysis (if the kidneys have been affected). Surgery may also be required to remove infected tissue.

Can sepsis be prevented?

Sepsis can happen after surgery, an illness, or simply by being out and about in the community. It’s not always possible to prevent it. However, the risk of sepsis can be reduced by treating infections appropriately or avoiding them in the first place.

Remember to:

• Seek and follow medical advice for infections and illnesses
• Stay up-to-date with vaccinations
• Keep wounds and cuts clean as they heal
• Maintain general hygiene, including washing hands.

More information

Sepsis in children – Health conditions directory

When an everyday accident leads to sepsis – what we can learn from Sadie’s story

Sepsis: how trusting her instincts helped Mel save her baby daughter’s life

Australian Sepsis Network

Sepsis can kill a child within hours. Here’s how hospitals are fighting back

FORT WORTH, Texas — It might start out looking like not much more than an ordinary childhood fever.

But within days — within hours, sometimes — the complication known as sepsis can turn deadly. The patient’s blood pressure dives. Intense pain floods her body. Her organs begin to shut down.

The toll is frightening: Sepsis hospitalizes some 75,000 children and teens each year in the United States. Nearly 7,000 will die, according to one 2013 study. That’s more than three times as many annual deaths as are caused by pediatric cancers. And some of the children who survive sepsis may suffer long-term consequences, including organ damage and amputated limbs.

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Now dozens of hospitals nationwide, including here in Fort Worth, are launching an all-out campaign against sepsis, an infection-related complication which can take hold after a viral illness — or an injury as innocuous as a scraped arm or a bug bite. Their ambitious goal: Reduce both childhood sepsis deaths and diagnoses of severe sepsis at participating hospitals by 75 percent by the end of 2020.

“You go big or you go home,” said Amy Knight, chief operating officer for the Children’s Hospital Association, which organized the sepsis collaboration.

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The 44 hospitals participating in the effort so far — more are likely to join — have agreed to implement diagnostic and treatment protocols developed by dozens of experts. They will, for instance, screen all patients who show any signs that could be associated with sepsis and treat potential cases with quick infusions of antibiotics and intravenous fluids. And they’ll submit data on their cases to the collaboration — including how fast they got patients into treatment — in hopes of identifying best practices.

Some hospitals are also working on public education, such as teaching the warning signs of sepsis to parents of cancer patients, who are especially vulnerable to infection.

One key challenge: Training physicians and nurses to more quickly recognize the earlier stage, known as “warm sepsis,” which can masquerade as many other more common and far less worrisome childhood ills.

A child might develop a fever and a somewhat faster heart rate, but otherwise has good color and is chatting with the doctor. “And 10 minutes later, their blood pressure is out the bottom and they are in dire straits,” said Dr. Joann Sanders, chief quality officer at Cook Children’s Health Care System here in Fort Worth. “A kid who is well into sepsis is not that hard to recognize. That warm sepsis kid — that’s your challenge.”

A terrifying brush with death

Sepsis moved with terrifying speed in the case of Chloe Miller, who was diagnosed with septic shock last fall at age 12.

Chloe had gone to school near her home in Silver Spring, Md., that Friday with no signs of illness, although the teachers reported that she seemed somewhat tired, recounted her dad, Mark Miller. Her parents have learned to stay particularly attuned to even subtle changes in Chloe, who has autism and a seizure disorder and can’t communicate verbally.

By Saturday, the preteen was running a fever of 104 degrees. Acetaminophen did bring it down. But she was sleeping for long stretches, and becoming increasingly difficult to wake up. Alarmed, Chloe’s mother and grandmother decided to take her to a local emergency room late Saturday. They nearly had to carry her to the car.

The doctors and nurses there moved quickly, diagnosing Chloe with pneumonia and influenza and giving her antibiotics, intravenous fluids, and an escalating flow of oxygen for her alarmingly low blood pressure and oxygen readings, said Dr. Christiane Corriveau, the critical care physician who treated Chloe once she arrived by ambulance at Children’s National Medical Center in Washington, D. C., in the wee hours of Sunday morning. “I think everybody was concerned that this was more than just pneumonia — that her body was being taken over by the infection,” she said.

“When they said, ‘She’s out of the woods,’ it really hit me just how life-threatening this was.”

Despite the aggressive treatment, Chloe was already entering the final and most life-threatening stage of sepsis, called septic shock.

Miller distinctly recalls how unresponsive his daughter was in the intensive care unit, not flinching when she got a shot or an intravenous line. Also, that her breathing was unnervingly fast: “In and out and in and out and in and out.”

After getting blood and platelet transfusions, antibiotics, fluids and heart medications, among other treatments, Chloe was improving by Monday, Corriveau said. By Tuesday, her breathing had eased and her “blood pressures were beautiful.”

Miller, who works at Children’s National in a fundraising role, recalls lots of updates as clinicians combated his daughter’s low blood pressure and other symptoms. But it wasn’t until the worst of the crisis had eased that he first heard the word “sepsis” and learned what that diagnosis meant.

“When they said, ‘She’s out of the woods,’ it really hit me just how life-threatening this was,” he said.

A simple screening that can save lives

Sepsis, sometimes called blood poisoning, describes the body’s massive inflammatory response to an infection that infiltrates the blood stream. The body marshals all its efforts to protect the heart, lungs, and other vital organs, said Dr. Charles Macias, an emergency physician at Texas Children’s Hospital in Houston and one of the collaboration’s co-chairs.

A child’s heart rate typically increases, in order to pump more blood to boost oxygen levels to organs and other tissues, Macias said. The increased demand for oxygen speeds up his breathing. Blood pressure can drop, as some vessels may leak and others may dilate.

In 2012, a 12-year-old New York student named Rory Staunton developed sepsis and died several days after cutting his arm while playing basketball, heightening national attention to the issue. A few states, including New York, have since enacted protocols mandating that hospitals regularly screen patients for sepsis.  The Illinois version is dubbed Gabby’s Law, after a young girl who died from sepsis following a tick bite.

Some screening steps can be quite simple.

At Cook Children’s, a nurse will press down firmly on the child’s skin, for three seconds, said Stephanie Lavin, the hospital’s nurse quality leader for the sepsis initiative. The skin naturally turns lighter. But it should return to a normal shade within three seconds of releasing that pressure, she said. Any signs of poor blood flow — the jargon is capillary refill — indicates that the child is dehydrated or that blood has begun to shift away from the skin’s surface.

That skin check is part of Cook Children’s 18-point sepsis screening, a process that doesn’t take much longer than a minute and includes asking parents if their child has shown any signs of confusion. The screening is performed with any emergency room patient who complains of a fever or another symptom that could signal an underlying infection, such as abdominal pain.

Any child who scores 5 or higher on the 18-point scale gets oxygen, antibiotics, and intravenous fluids — even before the blood test results come back, according to Lavin. That turns out to be a lot of patients: About 150 to 190 a month in the ER are identified by that initial screen as potentially having sepsis.

Regular screening already is routine in some other departments, such as the surgery and cancer units. Beginning this spring, it will be expanded to nearly every unit of the hospital, Lavin said.

Some of the collaboration’s participants, including Cook Children’s, have already had been participating in smaller initiatives against sepsis. Other hospitals can join the national effort; the next deadline to sign up is June 30.

Rory’s mother, Orlaith Staunton, applauds the collaboration’s efforts. But she still advocates for a more standardized regulatory approach: She wants to require every hospital in the US to adhere to certain screening and treatment procedures.

Imagine, she said, that you’re driving down the road with an ill family member in the car. “This hospital happens to be very good at enforcing their own sepsis protocols. This one is not so good. I end up driving into the wrong hospital. Worst-case scenario, my child or my loved one dies,” said Staunton, who cofounded the Rory Staunton Foundation with her husband.

But Knight believes that the national collaborative model will work best, because it lets medical experts learn from one another. At Cook Children’s, for instance, doctors and nurses continue to tweak their screening system, in order to most rapidly flag that “warm sepsis” patient.

“Will we bring kids into the hospital and watch them overnight who don’t have sepsis?” asked Sanders, the chief quality officer. “Probably. But I’d rather do that to 90 kids and catch the 10 kids who are in early sepsis, and save their lives.”

What is sepsis? Signs and symptoms of blood infection explained – The US Sun

SEPSIS is a life-threatening reaction to an infection and happens when your immune system overreacts to an infection and starts to damage your body’s tissue and organs.

Former President of the United States Bill Clinton has reportedly been struck down with the illness.

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Sepsis, also known as blood poisoning, is a condition that is always triggered by another infection – be it a viral, bacterial, fungal or parasitic infectionCredit: Getty Images

It’s the primary cause of death from infection around the world – that’s more than bowel, breast and prostate cancer combined.

But what is sepsis and what are the signs of the blood infection you need to know? Here’s all the information you need.

What is sepsis?

The condition is always triggered by an infection – but it is not contagious and cannot be passed from person to person.

Most often the culprit is an infection we all recognise – pneumonia, urinary infections (UTIs), skin infections, including cellulitis, and infections in the stomach, for example appendicitis.

Typically, when a person suffers a minor cut, the area surrounding the wound will become red, swollen and warm to touch.

This is evidence the body’s immune system has kicked into action, releasing white blood cells to the site of the injury to kill off the bacteria causing the infection.

The white blood cells and platelets form blood clots in the tissues around the cut.

Blood vessels swell to allow more blood to flow, and they become leaky, allowing infection-fighting cells to get out of the blood and into the tissues where they are needed.

This causes inflammation, which appears to us as the red, warm swelling.

When sepsis happens, this system goes into overdrive.

The inflammation that is typically seen just around the minor cut, spreads through the body, affecting healthy tissue and organs.

The immune system – the body’s defence mechanism – overreacts and the result is it attacks the body.

It can lead to organ failure and septic shock, which can prove fatal.

Bacteria, viruses, fungi and parasites can all trigger sepsis – though the most dangerous culprit is bacteria.

In developing nations, the condition remains a leading cause of death.

Known by its colloquial name “blood poisoning”, sepsis is also often referred to as a “flesh-eating disease”.

What is septicaemia?

The terms sepsis and septicaemia both refer to a blood infection that’s typically caused by bacteria.

Even though the definitions are closely related, there are some small differences.

Sepsis occurs when your body reacts to a severe infection, whereas septicaemia is the name of the infection itself.

The NHS explains: “Sepsis can affect multiple organs or the entire body, even without blood poisoning or septicaemia.

“Sepsis can also be caused by viral or fungal infections, although bacterial infections are by far the most common cause.”

What are the three stages of sepsis?

Sepsis affects the body in three distinct stages.

Stage One

An infection invades a specific part of the body – pneumonia affects the lungs, for example – triggering the immune system into action.

The germs and toxins produced by the bacteria or virus leave the original site of infection and enter the bloodstream.

This causes the inflammatory response known as SIRS (systemic inflammatory response syndrome).

Stage Two

Individual organs throughout the body become affected and begin to deteriorate.

In severe cases, this can lead to organ failure.

Stage Three

More than one organ stops functioning, and the patient experiences cardio-circulatory failure that leads to a sudden drop in blood pressure.

This is known more commonly as septic shock.

Who is most at risk from sepsis?

Sepsis is a condition that fails to discriminate – it can affect old and young, those who lead healthy lives and those who don’t.

As with many life-threatening illnesses, the most vulnerable are newborns, young children and the elderly, as well as anyone with a weakened immune system.

Though it can affect us all, men are more susceptible than women, black people are more at risk than white, and the very young and very old are more likely to be affected than any other age group.

Those people battling diabetes, Aids, kidney or liver disease are also at greater risk due to their weakened immune systems.

And pregnant women and people who have suffered severe burns or physical injury are more likely to fall victim to the life-threatening condition.

What are the signs of sepsis you should never ignore?

If you, a loved one, or in the case of medical professionals their patient, feels “severely sick”, doesn’t appear to be themselves and shows any of the following symptoms, sepsis should be suspected:

– Weakness
– Loss of appetite
– Fever and chills
– Thirst
– Difficult or rapid breathing
– Rapid heart rate
– Low blood pressure
– Low urine output

If a person is suffering these symptoms and they are thought to have suffered an infection – pneumonia, abdominal infection, urinary infection, or a wound – sepsis is a likely cause.

What treatment is available and can you prevent sepsis?

If you suspect you or a loved one are suffering sepsis it must be treated as a medical emergency.

Think of the reaction you would have to a heart attack, stroke or major car crash – dial 999.

A person’s chances of surviving sepsis are highly dependent on their getting medical intensive care as soon as possible.

The longer it takes to receive medical care the more likely it is a patient will die.

Patients who appear to have a least one sign of sepsis must be seen by a senior doctor within 60 minutes, an NHS watchdog has said.

Given it is a condition triggered by an infection, preventing that initial infection can prevent sepsis.

But how can we prevent the many infections out there from infecting us?

Vaccinations

Vaccinating children against various illnesses can help protect not only them but also their grandparents.

The youngest and oldest in society are at greatest risk of a strain of bacteria known as pneumococcus bacteria.

This is the vicious strain responsible for triggering pneumonia, middle ear infection and meningitis, and can ultimately lead to sepsis.

Vaccinating babies and young children results in “herd immunity”, preventing infections from taking hold within communities, and spreading rapidly through the population.

Antibiotic use must be restricted

Antibiotic resistance is a growing health concern the world over.

The excessive use of the drugs for decades has led to a sharp increase in the number of bacteria that have mutated and developed the resist the medication.

The implication is that common and typically minor infections could become killers once more.

In order to prevent this from happening, it is vital that antibiotics are only used when absolutely necessary – and that the right type of antibiotic is prescribed to tackle the right infection.

Furthermore, it is important that the drugs are only prescribed for a limited period of time – taking them for prolonged periods of time can increase the risk of resistance building.

Wash those hands

Poor hygiene increases the risk of picking up infections.

And the risk of poor hygiene is more pronounced in areas where resources are lacking.

In these parts of the world, day-to-day things like giving birth and treating wounds, that are taken for granted in more prosperous nations, can prove fatal.

Promotion of good personal hygiene, hand washing and making sure clean water is more widely available have the potential to save millions of lives, by lowering the risk of sepsis.

What famous celebrities and politicians have sepsis?

It was reported that former President Bill Clinton was hospitalised with sepsis. After reports of his hospitalisation, sources familiar with Clinton stated that the former President was in good condition.

Doctors say the former president is “on the mend” and in good spirits.

“Clinton was admitted to the ICU for close monitoring and administered IV antibiotics and fluids,” according to a joint statement released by Dr Alpesh Amin, chair of medicine at UC Irvine Medical Center, and Dr Lisa Bardack, the ex-president’s personal primary physician.

Sepsis is considered a bigger threat than meningitis.

The rise has prompted the head of the UK Sepsis Trust to urge all parents to be as vigilant for sepsis as meningitis.

The number of people developing sepsis is increasing, with around 123,000 cases each year in England.

An estimated 37,000 deaths are associated with the condition, according to NHS England.

And according to The UK Sepsis Trust every year in the UK 250,000 people are affected by sepsis; 52,000 people die because of it (1,000
which are children) and 60,000 suffer permanent, life-changing after effects.

Sepsis and septic shock | Nature Reviews Disease Primers

What’s the difference between sepsis and septicaemia?

If you or someone you know is seriously ill, the last thing you want to worry about is medical terminology. But we often hear from people who have been given a diagnosis of ‘meningococcal septicaemia’ or ‘pneumococcal septicaemia’, only later to be told they had meningitis, or sepsis, or both. So what’s the difference?

These are all words we use to describe life-threatening infection. They can occur together, or separately. When bacteria invade the body, this can cause severe illnesses which may result in death.

• Septicaemia is when bacteria enter the bloodstream, and cause blood poisoning which triggers sepsis.
• Sepsis is an overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure and death.
• Meningitis is when infection reaches the lining around the brain and spinal cord (the meninges) which can cause dangerous swelling.

The name of the bacteria that causes the infection is sometimes used by doctors too. For example, meningococcal, pneumococcal and Group B Streptococcal bacteria are all important causes of meningitis, septicaemia and sepsis.

It isn’t just bacteria that can cause meningitis and sepsis, however – they can also be caused by viruses and fungi. You can find out more about the different causes here.

Still confused?

Don’t worry. The main thing to know is that the words are all related to a serious life-threatening response to infection. Doctors need to worry about the finer details, but you just need to know how to spot the symptoms, or how to get support if you are affected. Here’s how:

The truth is they are all very serious, and the main thing to worry about is acting quickly if someone is getting very ill very fast.

Many causes of life-threatening meningitis, septicaemia and sepsis can be prevented by vaccines, so it’s also important for children and teenagers to get the vaccines they are eligible for. You can find out more about UK and Ireland immunisation schedules here, or give our helpline team a call on 080 8800 3344 if you have any questions.

The NHS in the UK is slowly phasing out the use of the word septicaemia in some environments to only use ‘sepsis’. However, research tells that parents particularly still respond to and want to be informed about septicaemia. While that is still happening, we’ll continue to use all three words on our website and materials.

Sepsis – an overview | ScienceDirect Topics

Pathophysiology

Severe sepsis is a consequence of microbial antigenemia inducing a generalized activation of numerous host defense systems, including the adaptive and the innate immune responses of which the complement, coagulation, contact-phase and fibrinolytic systems are prominent contributors.^20,21 Activation of these proinflammatory and procoagulatory cascades results in release of proinflammatory cytokines, nitric oxide, endothelins, tissue-damaging proteinases, lipid mediators and hypotensive molecules such as kinins (see Figure 38.1). These mediators regulate cellular and humoral immune responses and are essential to an adequate and efficient host defense against infecting micro-organisms. However, excessive and dysregulated release of these mediators is the key event leading to the clinical features of sepsis and shock, namely circulatory collapse, organ failure, tissue necrosis and death. In addition to this systemic inflammatory response (SIRS), sepsis is also associated with an exacerbated release of anti-inflammatory mediators such as interleukin-10 (IL-10), IL-1 receptor antagonist (IL-1ra) and transforming growth factor-β (TGF-β). Consequently, in 1997 Bone et al coined the term ‘compensatory anti-inflammatory response syndrome’ (CARS) to illustrate this immunosuppressive response of SIRS patients.²² CARS is considered an adapted response to dampen the overzealous inflammatory response.²³ Multiple mechanisms, including release of anti-inflammatory cytokines, downregulation and shedding of cytokine receptors, induction of T-regulatory cells and myeloid-derived suppressor cells, as well as cell death, contribute to the immunosuppressive state in sepsis. Increased apoptosis has been observed in lymphocytes and dendritic cells in septic patients, whereas monocytes remain unchanged and neutrophils display decreased apoptosis.²⁴ The immunosuppressive state has been suggested to contribute to the susceptibility to secondary infections and/or reactivation of otherwise dormant viruses such as cytomegalovirus.^25,26

Gram-positive and Gram-negative bacteria produce numerous factors capable of activating the host systems involved in sepsis. Lipopolysaccharide (LPS), a major constituent of the outer membrane of Gram-negative bacteria, has long been recognized as the principal mediator of sepsis.²⁷ The cell wall of Gram-positive bacteria also contains potent proinflammatory components, including peptidoglycan and lipoteichoic acid.²⁸ LPS, lipoteichoic acid and peptidoglycan are all examples of microbial molecules that display pathogen-associated molecular patterns (PAMPs), which are detected by pattern recognition receptors (PRRs), primarily toll-like receptors (TLRs) and nucleotide-oligomerization domain leucin-rich repeat (NOD-LRR) proteins, expressed on immune cells.^29,30 This results in activation of the innate immune response and regulation of the adaptive immune response to infection. The PRRs are also important sensors of endogenous alarmins, i.e. intracellular proteins or mediators that are released from damaged cell and tissues. Together, endogenous alarmins and exogenous PAMPs are called damage-associated molecular patterns (DAMPs).²⁹ During sepsis, the microbial infection and damaged tissues result in high levels of DAMPs and consequently an overstimulation of immune cells resulting in the pathological cytokine storm seen in septic patients.

Streptococcus pyogenes and Staph. aureus express and secrete exotoxins with superantigenic activity that induce very powerful immune responses.³¹ Superantigens interact, without prior cellular processing, with the Vβ region of the T-cell receptor and the major histocompatibility complex (MHC) class II molecules on antigen-presenting cells. Cross-linking of T cells and antigen-presenting cells by superantigens results in potent activation of these cells and the excessive production of proinflammatory cytokines.³² Other virulence factors expressed by pathogenic bacteria include pili, M protein, hemolysins and proteases, which have all been shown to be important contributors to pathogenesis.^28,33,34 In addition, synergistic or additive effects have been shown for many of these virulence factors and it is increasingly evident that the pathogenesis of sepsis involves a complex interplay between multiple microbial factors, host cells and mediators.

One of the initial events in sepsis is the induction of proinflammatory cytokines; these trigger the cytokine cascade, complement and coagulation systems, resulting in injury to endothelium and vessels, and the release of proteases, arachidonic acid metabolites and nitric oxide (Figure 38.1). The leading proinflammatory mediators are IL-1, IL-6, IL-8 and IL-12, tumor necrosis factor (TNF)-α, interferon (IFN)-γ, macrophage migration inhibitory factor (MIF) and high mobility group box 1 (HMGB1).^35,36 IL-1 and TNF-α are commonly referred to as ‘early cytokines’ in the sepsis cascade. They induce potent pyrogenic and hypotensive responses, and the experimental administration of either cytokine reproduces the clinical symptoms of sepsis.^37–40 Similarly MIF, a pituitary- and macrophage-derived factor, behaves as a proinflammatory cytokine and has been shown to be a critical mediator of septic shock.⁴¹ However, in contrast to other known cytokines, MIF production is induced rather than suppressed by glucocorticoids, and MIF has been found to override the immunosuppressive effects of glucocorticoids.⁴² HMGB1 increases LPS-induced IL-1 and TNF-α, and is a late mediator of septic shock in mice.⁴³ Elevated levels of HMGB1 could be demonstrated in patient plasma up to a week after the diagnosis of severe sepsis or septic shock.⁴⁴ Although described as a proinflammatory cytokine,⁴⁵ recent studies have shown HMGB1 to enhance inflammatory responses by acting as a carrier of LPS,⁴⁶ CpG DNA⁴⁷ and proinflammatory cytokines such as IL-1β.⁴⁸ HGMB1 acts via interaction with TLR2, TLR4 and the receptor for advanced glycation end-products (RAGE), and is considered an endogenous alarmin.

A positive correlation between the development of shock in sepsis and activation of the coagulation response was reported some 30 years ago.²¹ Microbial factors can activate the coagulation cascade either directly or indirectly via induction of proinflammatory cytokines and subsequent expression of tissue factor on endothelial cells and monocytes, which is the main pathway for coagulation activation in sepsis (see Figure 38.1). A drastic reduction in the levels of important endogenous coagulation inhibitors, such as antithrombin III and activated protein C (APC), due to consumption, expression deficiency or proteolytic inactivation, further contributes to the procoagulatory state in sepsis. Sepsis and disseminated intravascular coagulation are associated with decreased antithrombin III and protein C, and a disruption of the balance between coagulation and fibrinolysis.²¹ Furthermore, there is a correlation between deficiency in these inhibitors and increased morbidity and mortality in sepsis.²¹ Dysregulated expression of antithrombin III and activated protein C also affects the inflammatory processes due to increased thrombin production which promotes upregulation of adhesion molecule expression and microvascular thrombosis, which further increases the inflammatory response through tissue ischemia and neutrophil/endothelium activation.

Activation of the complement and contact systems has also been linked to the sepsis process, mainly by the release of hypotensive mediators, anaphylatoxins such as C5a, and the consumption of coagulatory factors.^49,50 Herwald et al⁵¹ demonstrated that the fibrous surface components of Gram-positive and Gram-negative bacteria bind to and trigger assembly of the components of the contact system, resulting in the release of hypotensive kinins, hypocoagulatory state, and dysregulated fibrin and clot formation. Other virulence factors, such as the streptococcal M protein and the streptococcal proteinase, also interact with components of the contact system.⁵¹

90,000 CONGRESS AND CONFERENCE MATERIALS: VII RUSSIAN ONCOLOGY CONFERENCE

VII RUSSIAN ONCOLOGY CONFERENCE

BACTERIA: IMPORTANCE FOR DIAGNOSING SEPSIS.
PRACTICAL RECOMMENDATIONS FOR SOWING BLOOD

NS Bagirova
FSBI NMITs Oncology named after N.N. Blokhin, Ministry of Health of Russia, Moscow

Sepsis is a systemic inflammatory response to infection. A favorable outcome in sepsis depends on timely diagnosis, as well as on adequate and during the initiated antimicrobial therapy.

Microbiological diagnosis of sepsis is based on a blood test, that is, on the establishment of bacteremia. Bacteremia – the presence of microorganisms in the systemic circulation – is an essential prerequisite for the development of sepsis. A blood culture, in which it is possible to obtain the growth of a microorganism, is the only way that allows one to obtain data on the causative agent of sepsis, on its sensitivity to antimicrobial drugs.

Thus, timely microbiological diagnosis of bacteremia promotes early and adequate therapeutic actions that can prevent the development of sepsis and its subsequent stages associated with high mortality.

At the same time, the assessment of the clinical significance of the obtained blood culture results is a very difficult stage in the microbiological diagnosis of bacteremia. The reason for these difficulties, first of all, is the possible contamination (contamination) of the blood sample under study due to the ingress of microorganisms from the hands of medical personnel during venipuncture, from the patient’s skin, from the air of the room. It is impossible to exclude laboratory contamination inside during control seeding.

In addition to possible sample contamination, other factors affect blood culture results.There are the following indications for blood culture: hypothermia (body temperature less than 36 ° C) or fever (body temperature more than 38 ° C), leukocytosis (total number of leukocytes in the peripheral blood is more than 10×109 / l), febrile neutropenia. Obviously, in practice, blood for culture is often obtained after the onset of fever or chills. Bacteria are quickly removed from the blood, so blood for culture should be obtained as quickly as possible during the development of fever or chills, and it is completely unacceptable to “tie” the time of blood culture to the procedure for taking blood for biochemical and other studies only for the reason that it technically convenient for the medical staff.Microbiological examination of blood requires an individual approach to each patient, as well as the strictest adherence to the rules of asepsis and antiseptics during the procedure.

The volume of inoculated blood is one of the most important points in the microbiological diagnosis of bacteremia. The concentration of microorganisms in the blood of adults is usually less than 10 CFU / ml, and most often even less than 1 CFU / ml, so each additional milliliter of blood increases the likelihood of growth. A one-step culture of 10-20 ml of blood should be considered the most optimal volume in adult patients.Blood for inoculation must be taken at least 2 times a day with an interval of 5-10 minutes. with every episode of fever. If a catheter-associated infection is suspected, blood should be obtained first from a vein, then from an intravascular catheter at intervals of no more than 5 minutes. In children, the concentration of microorganisms in the blood is higher than in adults, usually more than 100 CFU / ml, and more often even more than 1000 CFU / ml, so the volume of inoculated blood may be small, but not less than 1 ml. Usually, 1-5 ml of blood is taken, although if culture is less than 1 ml, there is little chance of growth.

The ratio of blood and culture medium in the vial is also an important factor. The optimal blood / medium ratio should be between 1: 5 and 1:10. When blood is diluted with a medium, the possible growth of microbes is reduced by less than 5 times, which can probably be explained by the bactericidal properties of blood.

Vials with blood inoculated in them (blood culture) should be delivered to the laboratory immediately, and before that they can be at room temperature for a very short period of time without affecting microbial survival.Blood culture is defined as the collection of a certain volume of blood during a single venipuncture for inoculation in one or more vials from one syringe. Obtaining growth – positive blood culture, no growth within 5-7 days of incubation – negative blood culture. Storage of blood cultures in the refrigerator is not allowed. Failure to comply with transportation rules can be the reason for failure to detect growth.

Skin treatment and venipuncture are, of course, a crucial step in obtaining a blood culture.The main difficulty in interpreting the results of a blood sample is its possible contamination with skin microflora. One of the measures aimed at solving this problem is a thorough treatment of the skin with antiseptics. The procedure for obtaining a blood sample for microbiological examination is presented below.

Procedure Nurse Instructions
for blood sampling for microbiological research:

The following substances may be used to treat the patient’s skin and vials with a nutrient medium: 70% ethyl alcohol, 1-2% tincture of iodine, 10% povidone-iodine solution.

1. Wash hands before drawing blood.
2. Prepare the vials: remove the plastic protective strip from the vial cap; Wipe the surface of the rubber stopper of the bottle with a swab moistened with 70% ethyl alcohol or iodine solution, and leave the swab on the stopper for 60 seconds. (1 minute.).
3. Treat the patient’s skin at the site of the proposed venipuncture with a swab with 70% ethyl alcohol (exposure 30 sec.), Then apply 1-2% iodine tincture or 10% povidone-iodine solution in the form of a circle 1.5-2 cm in diameter with a swab (exposure 30 sec.). When using only 70% ethyl alcohol, the exposure is 60 sec.
4. Put on sterile, waterproof gloves.
5. Remove the tampon with the disinfectant from the patient’s skin and, during venipuncture, draw at least 10 ml of blood into the syringe for adult patients and at least 1-5 ml for children.
6. Remove the tampon with the disinfectant from the surface of the vial stopper and add an equal volume of blood to each vial (usually blood culture is performed in 2 vials).
   Attention! The volume of the culture medium in the vials can be different.The optimal blood / medium ratio is 1: 5–1: 10. Example: the volume of the culture medium (indicated on the bottle label) is 25 ml. When 5 ml of blood is added to the vial, the blood / medium ratio is 5: 25, that is, 1: 5.
7. If it is necessary to simultaneously inoculate blood from both a vein and an intravascular catheter, blood should be taken first from the vein, and then from the catheter, with an interval of no more than 5 minutes.
8. Blood vials should be taken to the laboratory immediately. Transportation of vials should be carried out only in containers.
9. Blood vials should be delivered to the laboratory with an accompanying standard sample letter to be completed by the attending physician. The procedural nurse additionally enters the following data: a) the time of blood sampling, b) the patient’s body temperature immediately before blood sampling, c) the volume of blood added to each of the numbered vials.

Non-observance by medical personnel of elementary hygiene rules entails the development of a whole chain of events that can cost the patient’s life: the blood sample being examined is contaminated → the microorganism that is the cause of severe local infection or sepsis is incorrectly identified → antimicrobial drugs for therapy are incorrectly identified → therapy ineffective → deterioration the patient’s condition → death.

90,000 5.6.6. Treatment of patients with sepsis and septic shock / ConsultantPlus

To screen patients with a high likelihood of developing sepsis, including considering the possibility of early admission to the ICU, the Quick SOFA (qSOFA) criteria (express SOFA) should be used, allowing to suggest the presence of sepsis by clinical signs without laboratory tests:

– a decrease in the level of consciousness to 13 or less points on the Glasgow coma scale;

– decrease in systolic blood pressure less than 100 mm Hg.Art .;

– NPV 22 and more.

Each of the characteristics is given one point. In the case of two or three points, the probability of the presence of infection in the variant of sepsis is about 80%, exceeding the diagnostic value of the classical SOFA scale, with a 3-14 times higher risk of death in comparison with the qSOFA index of less than two points.

An important differential criterion for the etiology of sepsis is a clinical blood test – with bacterial genesis, leukocytosis is noted, and with viral genesis, normo- or leukopenia and lymphopenia.

Tasks of intensive therapy for septic shock (except for etiotropic treatment):

1. Hemodynamic support (optimization of O2 delivery)

2. Metabolic support (minimization of extraction deficiency or increase in O2 consumption).

The key principle of the intensive care of the early phase of septic shock is the immediate initiation of hemodynamic support in patients with hypotension or increased serum lactate concentration (> 2 mmol / L). The initial measure of hemodynamic stabilization is infusion replacement therapy.In the absence of an effect from the initial infusion therapy, vasopressors are prescribed according to the principles outlined in section 5.6.5.

Microcirculatory-mitochondrial distress in septic shock is largely the cause of tissue oxygen consumption disorders. The target for intensive care is a central venous oxygen saturation (ScvO2) of 65 to 75%. In the absence of signs of tissue hypoperfusion, coronary heart disease and bleeding, it is recommended to maintain hemoglobin (Hb) at a level of 70 – 90 g / l.Transfusion of erythrocyte-containing blood components can be prescribed when the Hb concentration is less than 70 g / l.

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Sepsis is … What is Sepsis?

Sepsis (other.- Greek. σῆψις – putrefaction) is a serious, from a medical point of view, condition caused by the ingress of infectious agents into the blood (must be distinguished from the concept of bacteremia) and tissues of animals (including humans), for example, pyogenic microorganisms and their metabolic products – toxins. It is characterized by an inflammatory process not in any particular organ, but in the whole body ^{[1] [2]} . Although in non-professional speech, sepsis is often called blood poisoning , this kind of systemic inflammation can be caused by the entry of the pathogen not only into the blood, but also into urine, lungs, skin and other tissues.

Etiology

Colonies K. pneumoniae on MacConkey agar

Causative agents of sepsis: more often streptococci and staphylococci, less often – pneumococci, Escherichia coli, etc. Usually sepsis is a complication of a wound or inflammatory process. In its development in humans, an important role is played by a decrease in the body’s defenses due to a serious illness, surgery, large blood loss, and insufficient nutrition. A source of general infection can be suppuration in the wound or a complicated course of local purulent diseases (furuncle, carbuncle, phlegmon) – surgical sepsis; complications after childbirth or abortion, when the “entrance gate” of the infection is the uterine mucosa, – obstetric-gynecological sepsis; purulent processes or damage to the organs of the genitourinary system, stagnation and infection of urine – urosepsis; acute or chronic purulent diseases of the oral cavity organs – oral sepsis, etc.d.

Signs of illness

The clinical course of sepsis can be lightning fast (rapid development of manifestations within 1-2 days), acute (up to 5-7 days), subacute and chronic. Often, there is atypicality or “erasure” of its symptoms (so, even at the height of the disease, there may not be a high temperature), which is associated with a significant change in the pathogenic properties of pathogens as a result of the massive use of antibiotics. Sepsis can occur with the formation of local abscesses in various organs and tissues (infection from the primary focus) – i.e.n. septicopyemia, in which the course of sepsis depends on the location of the abscesses (for example, an abscess in the brain with corresponding neurological disorders), and without metastatic abscesses – the so-called. septicemia, often with a more violent course, with pronounced general symptoms. With the development of sepsis in newborns (the source is a purulent process in the tissues and vessels of the umbilical cord – umbilical sepsis), vomiting, diarrhea, complete refusal of the child from the breast, rapid weight loss, dehydration are characteristic; the skin loses its elasticity, becomes dry, sometimes of an earthy color; often local suppuration in the navel, deep phlegmon and abscesses of various localization are determined.

When diagnosing a distinction is made between:

• Systemic inflammatory response syndrome . It is characterized by a change in body temperature (both upward, more than 38 ° C, and downward – below 36 ° C), rapid heart rate (more than 90 beats per minute) and breathing (more than 20 breaths per minute), a change in the number of leukocytes in blood (less than 4 × 10 ⁹ or more than 12 × 10 ⁹ cells per liter of blood).
• Sepsis . With the same symptoms as in the case of systemic inflammatory syndrome, one of the known pathogens is found in one of the normally sterile tissues (blood, cerebrospinal fluid, urine …), signs of peritonitis, pneumonia, purpura and other local inflammatory processes are revealed.
• Severe sepsis . It is characterized in the same way as ordinary sepsis, but with hypotension, hypoperfusion, or dysfunction of individual organs.
• Septic shock. The most serious condition, after which every second patient suffers from death due to impaired blood supply to organs and tissues ^[3] . It is determined by the same symptoms as sepsis, when intensive resuscitation measures do not lead to the normalization of blood flow and blood pressure levels.Other signs of septic shock include slowed-down urine production and confusion.

Disease treatment

Aimed at combating the disease (large doses of antibiotics, taking into account the sensitivity of the pathogen and sulfa drugs) and increasing the body’s resistance (fortified and fortified high-calorie food, blood and protein transfusions, the use of specific serums, autovaccines and gamma globulin). Local treatment in the presence of wounds: timely removal of dead tissue and opening of purulent streaks, creation of a constant outflow of purulent discharge, treatment of wounds with antibiotics and antiseptics.

Combined treatment should be carried out in an intensive care unit for patients with purulent infection. Includes active surgical treatment of purulent foci (available for surgery) and general intensive multicomponent therapy. Surgical treatment consists in excision of all affected tissues, prolonged active drainage of the surgical wound and the fastest closure of wound surfaces by suturing or using skin grafting. After surgical treatment of a purulent focus, for its fastest cleansing and preparation for closure, osmotically active ointments on a water-soluble basis are used (hydrophilic ointment bases, for example: levosin, levomekol, dioxidine ointment), which have pronounced antiseptic and sorption properties.For large flat wounds, treatment is used in a controlled, microbial-free environment: the affected area of ​​the body is placed in a plastic isolator through which sterile air is blown.

Intensive therapy for sepsis includes the introduction of antibiotics and antiseptics, taking into account the sensitivity of the isolated microflora to them (at the stage of empiric therapy, that is, before obtaining an antibioticogram, a combination of II-III generation cephalosporins and aminoglycosides is usually used). They carry out detoxification therapy, anti-inflammatory treatment with glucocorticoids, correction of protein-energy losses (high-calorie nutrition, tube and parenteral nutrition), infusion therapy (transfusion of electrolytes, poly- and rheopolyglucin, fat and protein emulsions), use pressor amines (dopamine), with persisting hypotension oxygen therapy, carry out the correction of the impaired functions of various organs and systems, according to indications, heparin is prescribed, platelet mass and fresh frozen plasma are transfused.

Notes

1. ↑ Levy MM, Fink MP, Marshall JC, et al. (April 2003). 2001 SCCM / ESICM / ACCP / ATS / SIS International Sepsis Definitions Conference. Crit. Care Med. 31 (4): 1250-6. DOI: 10.1097 / 01.CCM.0000050454.01978.3B. PMID 12682500.

90 039 ↑ Bone RC, Balk RA, Cerra FB, et al. (Jun 1992). “Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.The ACCP / SCCM Consensus Conference Committee. American College of Chest Physicians / Society of Critical Care Medicine “. Chest 101 (6): 1644-55. DOI: 10.1378 / chest.101.6.1644. PMID 1303622.

90,039 ↑ Kumar, Vinay; Abbas, Abul K .; Fausto, Nelson; & Mitchell, Richard N. (2007). Robbins Basic Pathology (8th ed.). Saunders Elsevier. pp. 102-103 ISBN 978-1-4160-2973-1

Literature

• Shlapobersky V.Ya., Surgical sepsis. (Clinic and treatment), M., 1952
• Skvortsov M.A., Umbilical sepsis, in the book: Multivolume guide to pathological anatomy, vol. 3, M., 1960
• Bublchenko L.I., Haskin Sepsis G., infectious diseases, in the book: Multivolume guide to obstetrics and gynecology, vol. 3, book. 2, M., 1964.

Scientists have figured out how sepsis develops

Recently, scientists have linked the disruption of the functioning of organs in sepsis with the disruption of the functioning of mitochondria, which play the role of energy stations of the cell.They can synthesize some proteins for themselves and are similar to bacteria. Therefore, one of the scientific hypotheses suggests that once in ancient times, mitochondria themselves could be bacteria. Sepsis causes a decrease in the production of energy by these organelles, which adversely affects the life of the cell. Disruption of mitochondrial function is usually explained by oxygen starvation, acidification and immune imbalance, but not by the influence of bacteria.

Russian scientists from the Laboratory of Metabolism in Critical Conditions of the Research Institute of General Reanimatology in their study compared the amount of phenolic bacterial metabolites as an indicator of sepsis and mitochondrial metabolites as an indicator of organelle malfunction.Among the mitochondrial metabolites, the authors of the work paid special attention to itaconic acid as a possible marker of systemic inflammation.

Scientists obtained and analyzed 103 blood serum samples from patients with early and late sepsis and from healthy individuals. The results showed that the levels of microbial and mitochondrial metabolites in the blood of healthy people were consistently low. At the same time, in sepsis, the concentration of phenolic microbial metabolites in the blood was, on average, 30 times higher than without it, and increased in proportion to the severity of the condition.

Itaconic acid was found in the blood only at an early stage of sepsis, and the levels of other mitochondrial metabolites (for example, succinic acid) increased significantly already at a late stage, with the progression of organ dysfunction and a poor prognosis. In a series of experiments with mitochondria in vitro (in vitro), scientists were able to find out that certain phenolic metabolites of bacteria, characteristic of sepsis, can interfere with the production of energy in cells by suppressing certain enzymes, for example, succinate dehydrogenase.This leads to disruption of the functioning of organs.

“In this study, we have shown that one of the fundamental mechanisms for the development of sepsis is a violation of the functional unity of the human body with the bacterial microcosm, and this occurs at the level of low molecular weight metabolites. In other words, we have begun to decipher the “ancient language of communication” of small molecules of microbial origin with eukaryotic cells. In the future, new knowledge can be used for targeted regulation of bacterial metabolism aimed at protecting and restoring mitochondrial function.In practical medicine, these studies will help develop a new strategy for antimicrobial therapy, new targets for extracorporeal, that is, extraorganismic detoxification, as well as new diagnostic tests. Thanks to this, doctors will be able to save the lives of many difficult patients, ”commented the project manager Natalya Beloborodova, MD, head of the laboratory for metabolism in critical conditions at the V. A. Negovsky Research and Clinical Center for Reanimatology and Rehabilitation (Moscow).

90,000 A remedy for the treatment of sepsis has been created in Russia

Graduates of the Faculty of Chemistry of Moscow State University have developed a system that allows you to completely purify the blood from toxic substances that cause sepsis.

Sepsis is a systemic inflammatory response that occurs in response to a local infection. As one of the leading causes of death worldwide, it remains a global health problem in various countries.

The main threat in this sense is lipopolysaccharide – a fragment of the bacterial membrane, which is one of the most powerful toxins that causes an overly strong immune system response. Basically, sepsis develops precisely because of the poisoning of the body with lipopolysaccharides, which firmly bind to blood elements and plasma proteins, therefore it is very difficult to reduce their concentration.

Until now, no drug has existed for the treatment of sepsis.Doctors manage to reduce the number of deaths only thanks to modern extracorporeal methods of treatment – hardware purification of blood outside the body, for example, with the help of an “artificial kidney” or “artificial liver”.

Graduates of the Faculty of Chemistry of Moscow State University managed to create a treatment for sepsis, which is based on unique polymer sorbents – non-toxic and completely biocompatible. The authors of the development also proposed an original method for obtaining special porous polymers that purposefully purify the blood from lipopolysaccharides.

The development has already attracted investments, which made it possible to create a marketable product – the Efferon LPS medical product will enter the market in the near future. It is a cylindrical body filled with a sorbent and having ports for connecting blood lines (“adsorber”, “sorption column”).

With the help of a pump, the patient’s blood under low pressure is passed through a sorbent, some areas of the surface of which bind to lipopolysaccharides, while blood cells and large plasma proteins pass through.This allows you to cleanse the blood of toxic substances and return it to the body.

Tests of the new device have confirmed its complete safety and effectiveness. Roszdravnadzor also allowed the use of adsorbers in clinical practice, and this method has already entered the compulsory medical insurance system in Moscow, St. Petersburg and a number of other regions. In the future, the developers plan to conduct new research in the field of sorption technologies for blood purification.

90,000 Get tested for procalcitonin in Rostov-on-Don

At the DAVINCI CDC you can get tested for procalcitonin.

The analysis allows you to determine the level of procalcitonin in the blood. The study helps diagnose sepsis and control its course.

Study preparation rules:

You must quit smoking 30 minutes before donating blood.

When an analysis is prescribed:

• Diagnosis of sepsis and severe bacterial infections

• Monitoring the condition for sepsis or severe infection

• With systemic inflammation of bacterial origin (severe bacterial infections, sepsis), calcitonin begins to be produced not only by the cells of the thyroid gland, but also by cells of other organs (cells of the lungs, pancreas, liver, etc.).), which leads to an increase in the level of procalcitonin in the blood.

Days of scheduled research: Monday, Wednesday, Friday

Issuance of the result the next day.

Analysis can be submitted by CITO:

Issuance 4 hours after receiving the biomaterial by the laboratory.

Delivery by CITO:

at the address: Krasnoarmeiskaya, 132

from Mon to Sat until 15:00

at the address: Tolmacheva, 117

from Mon to Sat until 11:00

Details by phone:

+7 (863) 333-25-33

About Analysis:

It has been proven that the concentration of procalcitonin in the blood plasma increases in proportion to the severity of the infectious process.With a local inflammatory process (tonsillitis, diphtheria, gastritis, sinusitis, etc.), the increase in the level of procalcitonin is insignificant, with severe bacterial infections and sepsis, the concentration of procalcitonin in the blood increases significantly.