Essentials of Sepsis Management

Key points

Definition and diagnosis

The most important aspect of intervention in sepsis is early recognition of the signs and symptoms of the condition. Reducing time to diagnosis and initiation of therapy for severe sepsis is considered a critical component of mortality reduction.³ The Society of Critical Care Medicine and the American College of Chest Physicians proposed standard definitions of this illness spectrum in a consensus published in 1992. The systemic inflammatory response syndrome describes an immune response

Source control

A specific, treatable source of sepsis should always be aggressively sought and addressed as rapidly as possible. Specifically, abscess drainage, wound exploration, debridement of necrotic tissue, removal of infected implanted device, or surgical control of infectious source should occur simultaneously with resuscitation and antibiotic administration. An identified source should always be sampled and cultured for targeted therapy. A rare exception for surgical intervention exists with

Fluid therapy and hemodynamic support

The ultimate goal of any hemodynamic intervention is the improvement of tissue perfusion and oxygenation. Subtle changes in a patient’s condition are valuable signs in early recognition of hypoxemia or acidosis. Adequate fluid resuscitation should ideally be achieved before the use of vasopressors, although these are sometimes necessary earlier in severe cases. Initial fluid resuscitation should consist of crystalloid resuscitation of 30 mL/kg per ideal body weight. Patients with evidence of

Antimicrobial therapy

The timely administration of appropriate antimicrobials is critically important to reduce morbidity and mortality from sepsis.26, 27, 28, 29 The choice of agents is based on multiple factors, including patient history, details and timing of surgical procedures, previous antibiotic exposure, and hospital antimicrobial susceptibility patterns. Cultures of blood, urine, pulmonary secretions, wound drainage, or other potential infectious sites should be performed before initiation of antibiotics.

Organ support and monitoring

A comprehensive discussion of the mechanism and therapies for shock is beyond the scope of this review, but the practitioner’s understanding of the essentials of managing septic shock is critical to patient survival. Knowledge of the shock syndrome has increased dramatically over the past several decades, and all advances point to the goal of prompt restoration of oxygen delivery. Invasive devices such as arterial blood pressure monitors, central venous catheters, and urinary catheters are

Nutrition and glucose control

Nutrition management in critically ill patients is an important and frequently overlooked aspect of care. Nutrition strategies that take into account information specific to the patient’s perioperative condition, first-hand knowledge of the patient’s operative history, and available nutritional access and support options should be in place. It is preferable that patients be fed enterally, which can be accomplished orally or via gastric or enteric feeding tube. If enteral feeding is not

Specific perioperative issues

Surgeons and those caring for surgical patients such as rapid response teams or critical care support teams should be aware of hospital protocols for resuscitation of acutely ill patients. Patients in the perioperative period frequently require pain control, and many agents can suppress respiratory drive if not closely monitored. Drug interactions can cause delirium, hypoxemia, tachycardia, and other signs similar to early sepsis that must be detected and treated appropriately to rescue

Nosocomial sepsis prevention

Prevention of secondary sepsis remains an important goal in surgical critical care. The nosocomial contributors of in-hospital sepsis are widely known but still poorly controlled. Rigorous infection control practices, as recommended by the SSC, should be enforced in any health care environment.⁴⁴ Multiple well-designed studies have demonstrated efficacy of focused interventions to reduce nosocomial infections.45, 46 Many health care facilities have specific policies to reduce nosocomial

Summary

This review outlines essentials of sepsis management in the surgical patient across the spectrum of care. Early recognition, aggressive fluid resuscitation, source control, and antibiotic therapy result in the best possible survival for patients suffering from sepsis. The Surviving Sepsis Guidelines should be reviewed and understood by any clinician caring for perioperative patients. Sepsis bundles, or protocols to enact evidence-based best practice, should be structured so that they can be