TREATING SEPSIS

Clinical Approach

Scenario 1

Beware of the missed injury:

A 64 year old female was admitted following a motor vehicle collision. In the emergency room she was complaining of a sore ankle and moderate abdominal pain. She had a bi-malleolar fracture of her ankle and was admitted to an orthopaedic service with reassurance.

24 hours after admission she developed worsening abdominal pain and became progressively oliguric. 2 hours later, she developed hypotension and hypoxemia. CT of her abdomen revealed a small bowel rupture at the duodenal-jejunal junction.

Scenario 2

A 37 year old male was admitted to intensive care with septic shock, jaundice, acute renal failure and a coagulopathy. He was ventilated, put on aggressive inotropic support and continuous venous-venous hemodiafiltration. The ICU team were baffled as to the cause. On day two, a friend of his who happened to be visiting offered the following information: “I don’t know if it is of any value doctor, but we were playing golf last week and, when he was about to take a shot from the edge of the water hazard, a rat ran up the inside of his trouser leg.”

This information was of critical importance: the combination of sepsis, jaundice and rat contact is strongly suggestive of Leptospirosis. The antimicrobial strategy was changed, Leptospira titres sent and returned positive, and the patient eventually recovered.

As a healthcare professional, whether you are a doctor, nurse or therapist, you are an intelligence gathering unit: the patient’s relatives and friends are goldmines of information.

Don’t believe a conveniently constructed history from colleagues. If a patient is admitted into intensive care from the ward in septic shock, this is indicative that somebody has failed to spot the signs of deterioration, failed to take corrective action. In this circumstance, it is my practice to treat all information presented to me by the primary care service with deep suspicion: the patient requires a fresh evaluation. I examine the patient from head to toe, interview the relatives and next of kin, talk to the nurses on the floor, evaluate the test data, formulate my own opinion and then look at the notes. It has been my experience since early in my career that if the first doctor who sees the patient gets the diagnosis wrong or misses a vital clue, then the patient is directed down a completely wrong path, which often leads to intensive care.

 Scenario 3

A 39 year old male is presents with right sided chest and abdominal pain. He has a temperature of 38.5 degrees, a white cell count of 2.2, a heart rate of 120 and a blood pressure of 100/35. His CXR reveals a dense infiltrate in his right base, and he is referred to and admitted by the medical team. The presumed diagnosis is pneumonia and he is treated with a cephalosporin and a macrolide. 18 hours after admission the patient becomes lethargic and hypotensive. His blood gas reveals hypoxemia and a severe metabolic acidosis. He is transferred to intensive care.

The patient is resuscitated and re-evaluated by the intensive care team. His abdomen is rigid. The surgical team are consulted. The diagnosis of perforated bowel and fecal peritonitis is confirmed on abdominal CT. He undergoes surgical decompression. The patient is ultimately discharged from intensive care 42 days later following a protracted and complicated course.

A thorough physical examination should be oriented toward determining the cause of the infection and identifying signs of systemic organ dysfunction owing to severe sepsis. It is essential to examine the patient from head to toe, front and back. Look for implanted devices, clues of lifestyle such as dirt, tattoos, needletracks, scars etc. Deconstruct the patient into zones – respiratory tract, abdomen, renal system, blood, skin, cardiovascular system, head and neck and central nervous system, in order of likelihood of infection.

Laboratory tests:

Hemoglobin, white blood cell count with differential, platelet count, complete chemistry profile, coagulation parameters, serum lactate, urine analysis, and arterial blood gases (metabolic acidosis and hypoxemia).  In addition, I always send serum amylase and lipase and liver function tests. An electrocardiogram and a chest radiograph should be obtained.

Cultures:

Appropriate cultures should be obtained prior to institution of antibiotics. These include blood cultures and cultures and stains appropriate to any organ system that might harbor the infection causing severe sepsis.  Cultures may confirm infection and are invaluable in guiding antibiotic selection. If no localizing signs are obvious – then check: blood, urine, and sputum.

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