By Leigh Vinocur, MD, FACEP Board-certified Emergency Physician, Adjunct Assistant Professor LSU Health-Shreveport
I vividly remember my first encounter in the Intensive Care Unit (ICU): A young woman who had ignored a ruptured appendix lay dying of sepsis. All her organs had shut down, she was bleeding from everywhere, and there was little anyone could do. I, naively, was astounded that in the then late 20th century, almost 100 years after the discovery of antibiotics, people could still die from such infections in America. I unfortunately learned all too often that no matter how many antibiotics we develop, once our bodies begin to fall to an unrelenting infection, our systems shut down and can not come back. Therefore, every infection needs to be taken seriously.
According to the CDC, sepsis one of the top 10 causes of death in the US. Often, people can recover from early to mild sepsis, but there is a 50% mortality rate for those that develop late severe sepsis.
Sepsis is a serious multi-system potentially life-threatening complication that can occur with any infection. Once sepsis develops, it causes a series of chemicals reactions in response to, usually, a bacterial infection spreading throughout the bloodstream. This triggers a series of inflammatory reactions, which can increase both blood clotting and bleeding, then in turn damage organs and blood vessels causing multi-organ failure – eventually leading to septic shock as blood pressure drops. Once this cascade of reactions is initiated, the problem goes beyond just treating the infection. Despite antibiotics, which may kill the offending bacteria, once a person becomes severely septic, it is often too late and the end result is death.
Early sepsis must have at least two of the following abnormal vital signs or symptoms:
- Fever over 101.3°F (38.5°C) or below 95°F
- Heart rate over 90 beats/minute
- Respiratory rate over 20 breaths/minute
- A confirmed or probable infection
Severe sepsis has symptoms:
- Mottled skin
- Decreased urine output
- Change in mental awareness or alertness
- Decreased platelet counts (which are particles in the blood that promote clotting)
- Difficulty breathing which usually requires being put on a ventilator
- Abnormal heart function usually leading to circulatory collapse and shock
This is the next phase of sepsis called septic shock.
Causes and Risk Factors
Any infection can potentially lead to sepsis if not treated properly. However, some of the more common infections that can lead to sepsis are pneumonias, abdominal infections from diverticulitis (a condition were outpouching of the colon forms small pockets where food can get stuck and cause infection), appendicitis, urinary tract infections, hospital-acquired infections from IV catheters or invasive procedures and implanted medical devices, such as artificial joints.
Those at greater risk are the very young and the very old, as well as those with compromised immune systems. It is especially common in patients in intensive care units who are already very ill. Contributing factors are believed to be our aging population, overuse of antibiotics and emerging resistant bacteria, and increasing numbers of survivors with weaker immune systems from multiple other disease, such as diabetes, transplants and cancer.
The diagnosis is usually made by clinical observations with a high degree of suspicion. The source is determined with multiple cultures to try to identify the bacteria. Patients will have blood cultures drawn, as well as cultures of respiratory secretions, wounds and catheters all sent to the microbiology lab to look for evidence and identification of infection. Other tests that are done are blood tests to look for clotting problems, liver and kidney failure, abnormal oxygenation, and any electrolyte imbalances.
Complications of Sepsis
The gravest complication of sepsis is circulatory collapse, which leads to multi-organ failure. A bleeding problem called DIC (disseminated intravascular coagulopathy) causes both bleeding and microscopic clotting in all the tiny blood vessels of the body, which can lead to gangrene in limbs indicating tissue death from low flow and poor oxygenation of all tissues.
New Research on the Horizon
Recent research is looking at a chemical marker in the blood called suPAR that may predict fatality of severe sepsis in emergency patients. However, the use of these are still in the future.
Precautions and Tips
Any infection has the potential to get worse and make you septic. Some tips that may help:
- Take all infections seriously.
- Make sure you quickly treat any potential infection.
- Take all your prescribed antibiotics until finished or consult your doctor to see if you must finish them.
- Don’t ignore any warning signs – you know yourself better than anyone else!
- If you feel you are getting worse or developing worse of severe pain while on antibiotics, immediately go to the ER.
- Be your own advocate and don’t be afraid to ask questions and challenge the doctor!
- If you really don’t feel comfortable, seek a second opinion.