Sepsis Treatment: Hospital Protocols And Procedures

Sepsis is a life-threatening condition that arises when the body's response to an infection causes damage to its tissues and organs. It can be triggered by an infection anywhere in the body, and certain people are more at risk, including the very old, the very young, pregnant women, and people with weakened immune systems. Treatment for sepsis in a hospital setting typically involves close monitoring and treatment in an intensive care unit, with a focus on stabilizing the patient's breathing and heart action. Different medications are used to treat sepsis, including antibiotics, intravenous fluids, vasopressors, and oxygen support. Surgery may also be required to remove sources of infection. The early and thorough treatment of sepsis increases the likelihood of a full recovery, although long-term physical and emotional symptoms may persist in some individuals, known as post-sepsis syndrome.

Antibiotics

The choice of antibiotic treatment for sepsis depends on the cause of the initial infection and the organs affected. Sepsis often arises when the body's response to an infection results in damage to its own tissues and organs. This inappropriate response can cause a chain reaction, releasing chemicals that harm vital organs, including the kidneys, heart, brain, liver, and lungs.

In addition to antibiotics, supportive care is often provided in hospitals for patients with sepsis. This may include oxygen therapy, dialysis for kidney dysfunction, and surgery to remove sources of infection, such as pus, infected tissues, or dead tissues.

Intravenous fluids

The Surviving Sepsis Campaign guidelines suggest an initial fixed volume of 30 ml of IV fluid per kilogram of body weight. However, it is important to note that higher fluid volumes have been associated with harm in patients in intensive care units (ICUs). In such cases, intravenous fluid restriction did not result in a significant difference in the number of days alive without life support or after hospital discharge at 90 days.

The Early Goal-Directed Therapy (EGDT) protocol is a widely recognized approach to sepsis treatment, which includes the administration of IV fluids. In the Rivers et al. trial, patients in the EGDT group received approximately 1.5 liters more IV fluid than the usual care group within the first six hours of treatment. This protocol also includes the use of vasopressors to maintain a mean arterial pressure of at least 65mmHg.

While the effectiveness of early IV fluid administration in improving patient outcomes is still being evaluated, it is clear that the timely administration of IV fluids is crucial in the treatment of sepsis.

Vasopressors

Vasopressin is a second-line vasopressor. While it has shown promising preliminary data, strong evidence from recent studies suggests no benefit of its early administration. However, a post-hoc analysis of the VASST trial found that vasopressin was more effective in less severe shock, and adding it to NE might help reach the initial MAP target faster.

Other vasopressors have also been studied, such as terlipressin and selepressin. Terlipressin showed no difference in mortality compared to NE but had more adverse events, while selepressin improved several hemodynamic variables in animal studies, but a recent clinical trial showed no increase in vasopressor-free days when compared to a placebo.

The timing of vasopressor administration is important, with literature and SSC guidelines recommending early initiation. Some studies suggest that administering vasopressors during the first hour after diagnosis of septic shock may have a multimodal action and lead to better hemodynamic results and survival outcomes.

Oxygen support

Sepsis is a serious and potentially life-threatening complication of an infection. It requires urgent medical attention and early, thorough treatment to increase the likelihood of recovery. People with sepsis often require supportive care in a hospital intensive care unit (ICU), which may include oxygen support.

Oxygen therapy is one of the most frequently used interventions for critically ill patients with sepsis. The body's oxygen demand increases with sepsis, and if the level of oxygen in the blood is low, oxygen therapy is usually administered. Early goal-directed therapies, including effective oxygen delivery, are crucial for positive patient outcomes. Non-invasive modes of oxygen delivery, such as non-invasive positive pressure ventilation, should be used initially and escalated as needed based on the patient's clinical signs and symptoms.

The respiratory therapist must understand the unique challenges of oxygen delivery in sepsis and have a plan to treat hypoxemic respiratory failure. They should optimize cardiac output and oxygen content to ensure sufficient oxygen delivery. The patient's Hgb level must be closely monitored, and blood products may be used to attain the EGDT target Hgb level of 7 to 9 g/dL.

The specific approach to oxygen therapy may vary depending on the patient's condition. A minimum of a 2 L/min nasal cannula is recommended initially, followed by assessment. If higher oxygen levels are required, a non-rebreather mask at 15 L/min can be used. The patient's oxygen consumption and venous saturation are evaluated to determine the effectiveness of oxygen therapy.

While oxygen therapy is essential in sepsis, caution is also warranted. Animal studies and clinical data suggest that oxygen therapy can increase survival rates in sepsis. However, there are concerns about the toxic effects of hyperoxia (excess oxygen in body tissues). Hyperoxia can "poison" the brain, leading to symptoms like nausea, blurred vision, coughing, and convulsions. Additionally, oxygen therapy can aggravate existing oxidative stress and contribute to disseminated intravascular coagulation. Therefore, a balanced approach to oxygen supplementation is recommended to avoid both hypoxia (low oxygen levels) and hyperoxia.

Surgery

Any type of surgical procedure can expose your body to infection, which may lead to sepsis. Surgery may be required to treat sepsis if the infection has caused tissue damage. Surgery can help to remove sources of infection, such as pus, infected tissues, or dead tissues.

Surgical procedures can range from major operations, such as open-heart surgery, to minor procedures like a biopsy. An incision is made during surgery, which can introduce infection. This could be an infection of the incision itself (the opening in the skin) or an infection that occurs after the surgery, such as pneumonia or a urinary tract infection.

Infection after surgery can lead to sepsis. For example, an untreated urinary tract infection can spread to the kidney, causing further complications and potentially resulting in sepsis. Similarly, pneumonia, which can be caused by bacteria, viruses, or fungi, can develop after surgery and lead to sepsis.

It is crucial to seek immediate medical attention if sepsis is suspected after surgery. Early diagnosis and treatment significantly improve the chances of survival and recovery from sepsis.

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