We attempted to identify all relevant studies irrespective of language or publication status (published, unpublished, in press, and in progress). We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004) using the terms “sepsis” and “septic shock”, and MEDLINE (1966 to June 2004), EMBASE (1974 to June 2004), and LILACS (www.bireme.br; accessed Aug 1, 2003) databases using the terms “septic shock”, “sepsis”, “septicaemia”, “endotoxin”,
SeminarSeptic shock
Section snippets
Epidemiology
The yearly incidence of sepsis is 50–95 cases per 100 000, and has been increasing by 9% each year.3 This disease accounts for 2% of hospital admissions; roughly 9% of patients with sepsis progress to severe sepsis, and 3% of those with severe sepsis experience septic shock,4 which accounts for 10% of admissions to intensive care units.5
The occurrence of septic shock peaks in the sixth decade of life.5 Factors that can predispose people to septic shock include cancer, immunodeficiency, chronic
Cause
Infections of the chest, abdomen, genitourinary system, and primary bloodstream cause more than 80% of cases of sepsis.3, 5, 6 Rates of pneumonia, bacteraemia, and multiple-site infection have increased steadily over time, whereas abdominal infections have remained unchanged and genitourinary infections have decreased.3, 5
The occurrence of gram-negative sepsis has diminished over the years to 25–30% in 2000. Gram-positive and polymicrobial infections accounted for 30–50% and 25% of cases,
Pathomechanisms
The definition of sepsis is often over-simplified as being the result of exacerbated inflammatory responses. However, pathogenesis involves several factors that interact in a long chain of events from pathogen recognition to overwhelming of host responses.
Diagnosis
Diagnosis of septic shock in patients with systemic inflammatory response syndrome means that the infection must be recognised and proof obtained of a causal link between infection and organ failure and shock (table 3, figure 4).
There may be a clinically obvious infection, such as purpura fulminans, cellulitis, toxic shock syndrome, community-acquired pneumonia in a previously healthy individual, or a purulent discharge from a wound or normally sterile cavity (eg, bladder, peritoneal or pleural
Treatment
Interventions that can prevent septic shock in some populations include prophylactic antibiotics,111, 112 maintenance of blood glucose concentrations between 4 and 6 mmol/L,113 selective digestive-tract decontamination,114 strategies for prevention of iatrogenic infections,115 and immune therapies such as vaccines116, 117 and intravenous immunoglobulin (table 4).118, 119 Enteral nutritional supplementation, especially with L-arginine, can reduce infection rate after elective surgery and in
Mortality
Short-term mortality from septic shock has decreased significantly in recent years. In one study, mortality fell from 62% in the early 1990s to 56% in 2000.5 Mortality varies from 35% to 70%, depending on factors such as age, sex, ethnic origin, comorbidities, presence of acute lung injury or acute respiratory distress syndrome or renal failure, whether the infection is nosocomial or polymicrobial, and whether a fungus is the causative agent.3, 4, 5, 6 Comparisons with matched patients without
The future
Septic shock remains a major source of short-term and long-term morbidity and mortality, and places a large burden on the healthcare system. The recent identification in people of molecules that sense microbial determinants has been an important step in understanding the molecular and cellular basis of sepsis. Characterisation of the links between inflammation, coagulation, and the immune and neuroendocrine systems have led to international guidelines recommending the use of drotrecogin alfa
Search strategy and selection criteria
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