ULTIMATE SEPSIS MANAGEMENTS

BACKGROUND

Sepsis is defined as the presence (probable or documented) of infection together with

systemic manifestations of infection. Severe sepsis is defined as sepsis plus sepsis-induced
organ dysfunction or tissue hypoperfusion.1 The severity is ranging from sepsis to septic
shock. More than 1,665,000 cases of sepsis occur in the United States each year, with a
mortality rate up to 50 percent1. Indeed, even with ideal treatment, mortality because of septic
shock is approximately 40 percent and can surpass 50 percent in very ill patients 2-5
Sepsis in
pregnancy remains an important cause of maternal death in the UK. In 2003–2005 there were 13
direct deaths from genital tract sepsis in pregnancy, five related to pregnancy complications prior
to 24 weeks of gestation and eight related to sepsis from 24 weeks of gestation, arising before or
during labour. Severe sepsis with acute organ dysfunction has a mortality rate of 20 to 40%,
which increases to 60% if septic shock develops.6

IDENTIFICATION OF SEPSIS

Initially, suspected infection along with signs of organ dysfunction, such that is
defined by JAMA International consensus in 2015, should be the main idea in defining
sepsis1. Use of qSOFA (quick Sepsis-Related Organ Failure Assesment) consisting of
respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100
mmHg or less from bedside clinical test with cutoff of at least 2 findings has been encouraged
to identify septic patients with poor prognosis, while further assesment of severity of organ
dysfunction may been assessed with various scoring systems that quantify abnormalities
according to clinical findings, laboratory data, or therapeutic interventions with the use of the
Sequential Organ Failure Assessment (SOFA) (originally the Sepsis-related Organ Failure
Assessment, below1:

1
 Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM,
Hotchkiss RS. The third international consensus definitions for sepsis and septic shock (sepsis-3). Jama. 2016 Feb 23;315(8):801-10.

Table 1. Risk factors for maternal sepsis in pregnancy as identified by the Confidential
Enquiries into Maternal Deaths

Septic Shock

Septic shock should best be defined as a subset of sepsis in which severity circulatory,
cellular, and metabolic abnormalities are associated with a greater risk of mortality than with
sepsis alone1. Patients with septic shock can be clinically identified by a vasopressor

2
requirement to maintain a mean arterial pressure of 65mmHg or greater and serum lactate
level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia1.

Lactate has been found to be a useful as an indirect marker of tissue perfusion, in

which elevated serum lactate (eg, >2 mmol/L) can be a manifestation of organ hypoperfusion
in the presence or absence of hypotension and is an important component of the initial
evaluation, since elevated lactate is associated with poor prognosis, moreover, a serum lactate
level ≥4 mmol/L is consistent with, but not diagnostic of, septic shock, and further can be
confrimed with additional laboratory studies that help characterize the severity of sepsis
include a low platelet count, and elevated international normalized ratio, creatinine, and
bilirubin6.