- Sepsis is the combination of a known or suspected infection and an accompanying systemic inflammatory response.
- Severe sepsis is sepsis with acute dysfunction of one or more organ systems; septic shock is a subset of severe sepsis.
- Severe sepsis is common, frequently fatal, and expensive. More than 750,000 cases occur annually in the United States.
- Effective management of patients with severe sepsis requires early identification, cardiopulmonary support, antibiotics, source control, and general supportive care.
- The prognosis of the patient with severe sepsis is related to the number of dysfunctional organs.
- Cardiopulmonary support consists of early and aggressive fluid resuscitation, maintenance of mean arterial pressure at 65 mm Hg or higher, and measures to maximize and maintain tissue oxygenation; judging the adequacy of tissue oxygenation is informed by measurement of the mixed venous oxygen saturation, and supportive therapy is most effective and beneficial when provided in the first hours of presentation.
- Patients should receive early intravenous empirical antibiotics directed at all possible sources of infection. Appropriate antibiotics decrease the mortality rate by 10% to 15% in patients with severe sepsis.
- Source control can be surgical or nonsurgical and is intended to remove or lessen the burden from the primary focus of infection.
- Despite appropriate antibiotics, source control, and organ support, the mortality rate in patients with severe sepsis remains at 28% to 50%.
- Specific antisepsis interventions have recently been introduced that target multiple pathophysiologic aspects of the sepsis cascade and can improve outcomes.
- To maximize outcomes, supportive measures must be introduced to ensure proper nutrition; maintain fluid, glucose, and electrolyte homeostasis; promote tissue oxygenation; and prevent complications.
Sepsis with acute organ dysfunction (severe sepsis) is common and frequently fatal and represents a significant health care burden. The incidence and associated mortality and morbidity rates of severe sepsis are commonly underestimated. This is a function of a number of factors. Severe sepsis is not generally reported as a primary diagnosis. For example, although steps are underway to address this issue, the most recent edition of the International Classification of Diseases, Ninth Revision, Clinical Modification lacks a diagnostic code for severe sepsis. Instead, severe sepsis is often coded as a complication of another disorder (e.g., cancer or pneumonia). Several recent publications have evaluated the epidemiology of severe sepsis in the United States.1,2 They have estimated that the annual incidence of severe sepsis in the United States is in the range of 240 to 300 cases per 100,000 population. Further, in 2003, there were approximately 750,000 cases of sepsis in the United States. In Europe, the incidence of severe sepsis exceeds 200,000 annually.3 Reported mortality rates in patients with severe sepsis range from 28% to 50% or higher.1,4 Thus, in the United States and Europe, at least 700 to 1300 patients die daily from severe sepsis. Patients with severe sepsis account for annual health care expenditures in excess of $16 billion in the United States and £5.2 billion in Europe.1...