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Sepsis and septic shock

What's new

Updated 2024 SCCM guidelines on the use of corticosteroids in septic shock.

Background

Overview

Definition
Sepsis and septic shock are syndromes characterized by dysregulated systemic inflammation and end organ dysfunction caused by an underlying infectious process.
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Pathophysiology
The most common infectious pathogens responsible for the development of sepsis are S. aureus (20.5%), Pseudomonas species (19.9%), fungi (19%), E. coli (16.0%), Klebsiella species (12.7%), and Acinetobacter (9%).
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Epidemiology
In hospitalized adult patients, the incidence of sepsis is estimated at 6.0%.
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Disease course
In patients with sepsis, continued activation of immune cells in response to an infection result in a dysregulated inflammatory response. The coagulation system is closely tied to the inflammatory response, with cross talk between the two systems. These pathophysiological changes cause the clinical manifestations of organ dysfunction, which may progress to multiple organ failure, and death.
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Prognosis and risk of recurrence
The overall mortality associated with sepsis, severe sepsis, and septic shock is 10-20%, 20-50%, and 40-80%, respectively.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of sepsis and septic shock are prepared by our editorial team based on guidelines from the Society of Critical Care Medicine (SCCM 2024), the Infectious Diseases Society of America (IDSA/SCCM 2023), the European Association of Urology (EAU 2023), the French Society of Emergency Medicine (SFMU/SFAR 2022), the Surviving Sepsis Campaign (SSC...
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Screening and diagnosis

Screening tools: as per SSC 2021 guidelines, do not use qSOFA compared to SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock.
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Diagnostic investigations

Hemodynamic assessment: as per SSC 2017 guidelines, obtain further hemodynamic assessment (such as assessment of cardiac function) to determine the type of shock, if the clinical examination does not lead to a clear diagnosis.
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  • Lactate levels

  • Microbiological testing

  • Evaluation of new fever in the ICU (temperature measurement)

  • Evaluation of new fever in the ICU (diagnostic imaging)

  • Evaluation of new fever in the ICU (microbiological testing)

  • Evaluation of new fever in the ICU (inflammatory markers)

Respiratory support

High-flow nasal oxygen therapy: as per SSC 2021 guidelines, consider administering high-flow nasal oxygen over noninvasive ventilation in adult patients with sepsis-induced hypoxemic respiratory failure.
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  • Mechanical ventilation

  • ECMO

Medical management

Timing for ICU admission: as per SSC 2021 guidelines, consider admitting adult patients with sepsis or septic shock to the ICU within 6 hours, if ICU admission is required.
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  • Goals of care

  • Fluid resuscitation (indications)

  • Fluid resuscitation (choice of fluids)

  • Vasopressors

  • Inotropes

  • Corticosteroids (SSCM)

  • Corticosteroids

  • Antimicrobial therapy (indications)

  • Antimicrobial therapy (choice of antibiotic agent)

  • Antimicrobial therapy (choice of antifungal agent)

  • Antimicrobial therapy (de-escalation)

  • Anticoagulants

  • IVIG

  • Management of fever

  • Management of hyperglycemia

  • Management of acidosis

  • Palliative care

Inpatient care

Monitoring of mean arterial pressure: as per SSC 2021 guidelines, set mean arterial pressure of 65 mmHg as an initial target in adult patients with septic shock on vasopressors.
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Nonpharmacologic interventions

Enteral nutrition: as per SSC 2021 guidelines, consider initiating early enteral feeding rather than a complete fast or only IV glucose in critically ill patients with sepsis or septic shock able to be fed enterally.
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  • Parenteral nutrition

  • Nutritional supplements

  • Intravenous vitamin C

Therapeutic procedures

RBC transfusion: as per SSC 2021 guidelines, use a restrictive (over liberal) transfusion strategy in adult patients with sepsis or septic shock.
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  • Hemoperfusion

  • RRT

Surgical interventions

Source control
As per SSC 2021 guidelines:
Identify rapidly or exclude a specific anatomical diagnosis of infection requiring emergent source control and implement any required source control intervention as soon as medically and logistically practical in adult patients with sepsis or septic shock.
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Remove intravascular access devices promptly that are possible source of sepsis or septic shock in adult patients with sepsis or septic shock, after other vascular access has been established.
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Specific circumstances

Patients with urosepsis: as per EAU 2023 guidelines, use the qSOFA score to identify patients with potential sepsis.
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Preventative measures

Thromboprophylaxis: as per SSC 2021 guidelines, administer pharmacologic VTE prophylaxis with LMWH rather than UFH in adult patients with sepsis or septic shock, if not contraindicated.
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  • Stress ulcer prophylaxis

Follow-up and surveillance

Transition of care: as per SSC 2021 guidelines, consider undertaking a handoff process of critically important information at transitions of care of adult patients with sepsis or septic shock.
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  • Hospital discharge

  • Referral for peer support programs

  • Referral for socioeconomic support

  • Follow-up

Quality improvement

Screening programs: as per SSC 2021 guidelines, implement performance improvement programs for sepsis in hospitals and health systems, including sepsis screening for acutely ill, high-risk patients
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and standard operating procedures for treatment.
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