According to Jeffery, Mutsch and Knapp (2014), sepsis refers to a combination of systematic inflammatory response syndrome and documented infection. The term Systematic Inflammatory Response Syndrome (SIRS) refers to the presence of more than one of the following that include temperatures above 38.5ᵒC or below 35ᵒC, respiratory distress, heart rates higher than 90 beats/min, white blood count greater the 12000/mm³ or less than 400 mm³, and immature forms greater than 10 percent (Girbes, Beishuizen & Van Schijndel, 2008).
In cases of severe sepsis, signs of organ failure are reported. In septic shock, there is the existence of hypotension with special needs for pharmacological treatment. Sepsis is the third cause of human deaths only behind myocardial infarction and coronary disease. Sepsis consists of 10 percent of the total Intensive Care Unit (ICU) admissions. The rate of mortality depends on factors such as age, causative organism, occurrence of shock, delay of initial treatment, portal entry, how adequate early empiric antibiotic treatment is done, as well as the type and organization of the ICU. Hulscher, Natsch, Gyssens, Prins and Geerlings (2014) espouse that in clinical trials, it is as high as 30-35 percent while in epidemiological studies it is as high as 55 percent. According to Hulscher, Natsch, Gyssens, Prins and Geerlings (2014), sepsis is heavily associated with significant mortality and morbidity if not promptly detected and treated.
Early Treatment of Sepsis
The treatment of sepsis may vary depending on the cause and site of initial infection, the affected organs, and the damage extent. When sepsis is detected during its early stages before it affects vital organs, the condition may be treated at home using antibiotic tablets. Most individuals whose sepsis is discovered at this stage usually make it to full recovery (Tazbir, 2012). For individuals whose sepsis is severe thereby developing septic shock, they may need emergency treatment and should be admitted to the ICU. In the ICU affected body parts such as blood circulation and breathing may be supported, while the nurses and the entire medical staff concerned focus on the treatment of this infection.
Pharmacological treatment of sepsis is diverse and includes treatment in the ICU through the provision of comfort, sedative agents, optimal fluid management, as well as vasoactive and antimicrobial drugs. Though drugs such as drotrecogin alpha can be administered in patients with sepsis, Girbes, Beishuizen, and Van Schijndel (2008) suggest that the only sure way to ensure successful cure of a sepsis patient is the source of control where treatment is aimed at the cause of sepsis early, and the appropriate antibiotic treatment is administered. During initial early treatment, the goal is to ensure a centravenouse pressure of between 8 and 12 mmHG, mean arterial pressure of more than or equal to 65 mmHg, and urine output of more than or equal to 0.5 mLKg.
Causative Treatment of Sepsis
Causative treatment is also known as the source control and usually depends on the cause of the sepsis. In cases where the cause can be treated surgically such as in abdominal disasters like severely infected necrotizing treatment or bowel perforation, then surgery treatment remains the management cornerstone (Girbes, Beishuizen & Van Schijndel, 2008). For surgical and non-surgical treatment of severe sepsis, antibiotics can be of great help. In this regard, the survival rate of a patient can be improved through the timely administration of antibiotics. The choice of the antibiotic to be used depends on the focus and locality of the suspected infection and data from microbial laboratories and their geographic situation. The figure below shows the administration of procalcitonin.
Source: (Nebraska Medicine, 2015).
Symptomatic Treatment of Sepsis
When severe sepsis attacks, it is normally accompanied by vasodilation and tissue perforation that leads to reduced cardiac functions and cardiac performance. In addition, due to concomitant capillary leakage and systematic inflammation, patients normally lose fluids from their intravascular regions to extravascular areas. Consequently, the initial treatment should consist of replenishing the under filled vascular regions with fluid through fluid resuscitation.
Patients suffering from sepsis may require increased amounts of fluid in their bodies so that kidney failure and dehydration can be prevented. Therefore, between the first 24 and 48 hours, a patient should be given fluids intravenously in cases of septic shock or severe sepsis (Girbes, Beishuizen, & Van Schijndel, 2008). Through the intravenous infusion of fluids, the vascular volume becomes replenished. The speed and fine tuning of infusion helps in restoring cardiac functions through optimizing cardiac preload. Medical staff should closely monitor fluid infusions by taking into consideration parameters such as cardiac output, blood lactate levels, urine output, heart rate, and blood pressure to decide on the amounts of fluid that would benefit the patient. Crystalloid of between 500-100 ml and colloid of between 300-500 ml should be administered after every 3 hours (Girbes, Beishuizen, & Van Schijndel, 2008).
Vasoactive Drugs in Sepsis Treatment
Vasoactive drugs are especially useful in cases where fluid resuscitation fails to restore the required perfusion pressure in all the vital organs. Therefore, tuned pharmacological treatment may be required, and it should be aimed at correcting the circulatory abnormalities. Girbes, Beishuizen and Van Schijndel (2008) suggest that under these circumstances, a lifesaving treatment should be aimed at specific hemodynamic objectives. The Australian medical staff should titrate short-acting vasoactive drugs by affecting metabolic and circulatory parameters (Dellinger et al., 2013). Treatment in the ICU may be guided by direct circulatory parameters such as cardiac output, blood pressure, pulmonary arteries pressure, cardiac filling pressures, volumetric echo cardio-graphic dimensions, as well as metabolic parameters such as blood lactate levels and venous oxygen saturation.
The most frequently used vasoactive drugs in the ICU include catecholamine such as norepinephrine, epinephrine, and dopamine because of their apha-1 adrenoceptor-mediated and vasoconstrictive activities. However, Dellinger et al (2013) suggest that the administration of vasoactive drugs may produce side-effects such as increased myocardial oxygen consumption and proarrythmias, and hence they should only be administered in accordance with the ‘enough is enough’ principle and only when necessary.
Adjunctive Drug Intervention: Activated Protein C
According to Van Den Bosch, Hulscher, Natsch, Gyssens, Prins and Geerlings (2014), adjunctive therapy on patients with sepsis can only be effective when the source or cause of the infection have been detected and treated sufficiently. In this regard, the activated protein C (aPC) can be administered to improve the survival terms by activating protein C Zymogen. Through the Escherichia coli injection, the administration of aPC can be used to reduce mortality due to lower levels of protein C that normally results from a reduction in the natural anticoagulants such as antithrombin and protein C.
Low doses of steroids can be used to treat patients having a vasopressor-dependent septic shock. Patients who can benefit from this treatment are those whose systolic blood pressure may be less than 90 mmHg for a duration of one hour after vasopressor therapy and fluid replenishment. For patients who require vasopressors despite fluid replacement, they should be treated with hydrocortisone 200-300 mg/day within the first 7 days. Fludrocortisone can also be administered orally to patients with septic shock at 50µg once every 24 hours (Dellinger et al., 2013).
According to Girbes, Beishuizen, and Van Schijndel (2008), mortality in patients with severe sepsis can be lowered by administering intensive insulin therapy that helps in attaining glucose levels in the range of 4.4 and 6.1 mmoI/L. In this regard, the administration of intensive insulin therapy helps to reduce mortality rates by 10 percent.
Non-pharmacological Management of Sepsis
Diagnosis of Sepsis
Within the 45 minutes of antimicrobial therapy, appropriate clinical cultures should be obtained at the start of antimicrobials (grade 1C) from all infected areas. More than two sets of both anaerobic and aerobic bottles of blood cultures should be obtained with at least 1 drawn from each access device and the other 1 drawn percutaneously (Dellinger et al., 2013). The use of 1, 3beta-D-glucagon assay, anti-mannan and manna antibody assay, as well as invasive candidiasis should be employed to differentiate the cause of infection. Thereafter, imaging studies should be performed to confirm the potential cause of infection (UG) promptly.
For antibiotic therapy, intravenous antibiotics should be started within the first hour after recognizing there is a severe sepsis. Between the next 48 and 72 hours, the antimicrobial regimen should be assessed. For fluid therapy, crystalloid of between 500-100 ml and colloid of between 300-500 ml should be administered after every 3 hours (Dellinger et al., 2013). They should only be repeated on the patient’s response and tolerance to fluid resuscitation.
Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M., … & Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. (2013). Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Medicine, 39(2), 165-228.
Girbes, A. R., Beishuizen, A., & Van Schijndel, R. J. (2008). Pharmacological treatment of sepsis. Fundamental & Clinical Pharmacology, 22(4), 355-361.
Jeffery, A. D., Mutsch, K. S., & Knapp, L. (2014). Knowledge and Recognition of SIRS And Sepsis among Pediatric Nurses. Pediatric Nursing, 40(6), 271-278.
Nebraska Medicine. (2015). Procalcitonin (PCT) Guidance. Retrieved from: http://www.nebraskamed.com/careers/education-programs/asp/procalcitonin-pct-guidance.
Tazbir, J. (2012). Early recognition and treatment of sepsis in the medical-surgical setting. Medsurg Nursing, 21(4), 205-209.
Van Den Bosch, C. M., Hulscher, M. E., Natsch, S., Gyssens, I. C., Prins, J. M., & Geerlings, S. E. (2014). Development of quality indicators for antimicrobial treatment in adults with sepsis. BMC Infectious Diseases, 14(1), 345-355.