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Chapter 106: Early Management of Sepsis and Septic Shock

Mark J. Peters; Joe Brierley

INTRODUCTION

Sepsis has been defined in adults and children in terms of changes in vital signs (heart rate, respiratory rate, temperature) and white cell count in the context of infection (Table 106-1). The systemic inflammatory response syndrome previously described the same response in the absence of confirmed infection (eg, after trauma or major surgery). Over the past decade, the Surviving Sepsis Campaign has made important efforts to develop consensus statements defining sepsis, sepsis syndrome, septic shock, and the SIRS in adults. The first set of guidelines were introduced in 2008 and were updated in 2012 and again in 2016 (Sepsis-3). These consensus statements included updated definitions for sepsis, sepsis syndrome, septic shock, and the systemic inflammatory response syndrome, as well as evidence-based guidelines and algorithms for the management of these conditions in adults. In this framework, sepsis is described as “a life-threatening organ dysfunction caused by a dysregulated host response to infection.” Although new consensus definitions have not yet been developed for the pediatric population, this description can be applied to patients of all ages.

TABLE 106-1CURRENT DEFINITIONS OF SEPSIS AND SEPTIC SHOCK FOR CHILDREN AND ADULTS
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TABLE 106-1CURRENT DEFINITIONS OF SEPSIS AND SEPTIC SHOCK FOR CHILDREN AND ADULTS
  Pediatric Definitionsa New Adult Definitionsb
SIRS

The presence of at least 2 of 4 criteria, 1 of which must be abnormal temperature or leukocyte count:

  • Core temperature of > 38.5°C or < 36°C

  • Leukocyte count elevated or depressed for age (not secondary to chemotherapy-induced leukopenia) or > 10% immature neutrophils

  • Tachycardia, defined as a mean heart rate > 2 SD above normal for age in the absence of external stimulus, chronic drugs, or painful stimuli; or otherwise unexplained persistent elevation over a 0.5- to 4-hr time period OR for children < 1 yr old: bradycardia, defined as a mean heart rate < 10th percentile for age in the absence of external vagal stimulus, β-blocker drugs, or congenital heart disease; or otherwise unexplained persistent depression over a 0.5-hr time period

  • Mean respiratory rate > 2 SD above normal for age or mechanical ventilation for an acute process not related to underlying neuromuscular disease or the receipt of general anesthesia

 Term no longer used
Sepsis SIRS in the presence of or as a result of suspected or proven infection

Life-threatening organ dysfunction caused by a dysregulated response to infection

Clinical criteria

Suspected or documented infection and an acute increase of ≥ 2 SOFA points (a proxy for organ dysfunction)
Severe sepsis Sepsis plus 1 of the following: cardiovascular organ dysfunction OR acute respiratory distress syndrome OR 2 or more other organ dysfunctions Term no longer used
Septic shock Sepsis and cardiovascular organ dysfunction

A subset of sepsis in which underlying circulatory and cellular metabolic abnormalities are profound enough to substantially increase mortality

Criteria

Sepsis and vasopressor therapy needed to elevate mean arterial pressure > 65 mm Hg, and lactate > 2 mmol/L ...

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