Early recognition of sepsis

Sepsis Definitions - The Body's Overreaction

• Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection. Diagnosed via suspected infection plus an acute increase in SOFA score of ≥2 points.

• Septic Shock: A subset of sepsis with critical circulatory and metabolic abnormalities.

  • Persistent hypotension requiring vasopressors to maintain MAP ≥65 mmHg.
  • Serum lactate level >2 mmol/L despite adequate fluid resuscitation.

⭐ Lactate is a marker of tissue hypoperfusion; its elevation can identify high-risk patients even with normal blood pressure.

Screening Tools - Spotting Sepsis Early

• Goal: Rapidly identify patients with suspected infection who are likely to have poor outcomes. Key tools are SIRS and qSOFA for initial bedside assessment, especially in non-ICU settings.

• Hypotension (SBP ≤ 100 mmHg)
• Altered Mental Status (GCS < 15)
• Tachypnea (RR ≥ 22/min)

⭐ qSOFA is a risk stratification tool, not a diagnostic criterion for sepsis. It has better prognostic accuracy for in-hospital mortality than SIRS in patients outside the ICU.

• Clinical Workflow:

Organ Dysfunction - The Domino Effect

Sepsis triggers a systemic inflammatory cascade, leading to widespread endothelial damage and microvascular thrombosis, culminating in organ failure.

• Cardiovascular
  • Hypotension (SBP < 90 mmHg, MAP < 65 mmHg)
  • Tachycardia
  • ↑ Serum lactate (> 2 mmol/L)
• Respiratory
  • Tachypnea & increased work of breathing
  • Hypoxemia (PaO2/FiO2 ratio < 300)
  • Acute Respiratory Distress Syndrome (ARDS)
• Renal
  • Oliguria (< 0.5 mL/kg/hr for > 2 hrs)
  • ↑ Serum creatinine
• Central Nervous System (CNS)
  • Altered mental status (GCS < 15)
  • Delirium, confusion, or coma
• Hepatic
  • ↑ Bilirubin (> 2 mg/dL)
  • ↑ Transaminases (ALT/AST)
• Hematologic
  • Thrombocytopenia (Platelets < 100,000/μL)
  • Coagulopathy (INR > 1.5)

⭐ Lactate is not just a marker of tissue hypoxia but also contributes to cardiovascular depression and vasodilation.

Initial Workup - The First Hour

• Goal: Complete bundle within 1 hour of recognition.
• Administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.
• Start vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥65 mmHg.

⭐ Repeat lactate measurement within 2-4 hours if the initial level is elevated (> 2 mmol/L) to guide resuscitation.

High-Yield Points - ⚡ Biggest Takeaways

• The qSOFA score (GCS < 15, RR ≥ 22, SBP ≤ 100) is a key bedside tool to identify high-risk patients.
• An elevated serum lactate (> 2 mmol/L) signifies tissue hypoperfusion, a hallmark of septic shock.
• Suspect sepsis with a known infection plus any sign of new-onset organ dysfunction.
• Draw blood cultures before giving antibiotics, but do not delay treatment.
• SIRS criteria are sensitive but not specific; use them to raise suspicion for organ failure.
• Prompt recognition is the most critical factor in reducing sepsis mortality.