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- Life-threatening acute organ dysfunction caused by a dysregulated host response to infection
- Organ dysfunction is represented by an acute increase in the Sequential Organ Failure Assessment (SOFA) score of ≥2 points from baseline.
- Baseline SOFA score is assumed to be zero unless there is preexisting organ dysfunction.
- SOFA variables:
- Respiration: PaO2/FiO2 ratio
- Central nervous system: Glasgow Coma Scale score
- Cardiovascular: mean arterial pressure (MAP), vasopressor administration with type and rate of infusion
- Renal: serum creatinine, urine output
- Liver: bilirubin
- Coagulation: platelet count
- Quick SOFA (qSOFA) is a new bedside measure used to prompt further investigation of suspected infection or cause of organ dysfunction.
- qSOFA variables:
- Respiratory rate ≥22/min
- Altered mentation
- SBP ≤100 mm Hg
- Septic shock: subset of sepsis, profound circulatory, cellular, and metabolic abnormalities
- Clinically: vasopressor requirement to maintain MAP >65 mm Hg and serum lactate level >2 mmol/L (>18 mg/dL) in the absence of hypovolemia
- Continuum from sepsis to multisystem organ failure (MSOF) is affected by age-specific physiologic variables in children.
- SIRS in pediatric population requires that abnormality in temperature or WBC be present.
- Drug metabolism is reduced in children with sepsis. Monitor drug toxicity labs to prevent adverse effects.
Altered mental status may be presenting sign of infection.
- Is a leading global cause of mortality and critical illness
- Increasing incidence with decreasing in-hospital mortality
- 31 million cases with ~ 5 million deaths annually worldwide
Etiology and Pathophysiology
- Complex pathophysiology
- Multifactorial: Widespread endothelial dysfunction, complement activation, and activation of coagulation cascade leads to tissue hypoperfusion, early hemodynamic changes of sepsis resulting in organ dysfunction.
- An imbalance between proinflammatory and anti-inflammatory mediators leads to relative immunosuppression.
- Causative organisms (most commonly bacterial)
- Gram-positive bacteria (most common): Staphylococcus sp., Streptococcus sp., Enterococcus sp.
- Gram-negative: Escherichia coli, Klebsiella sp., Proteus sp., Pseudomonas sp., and anaerobic bacteria
- Fungi: Candida sp.
- Causative organism not identified in 1/3 of cases
- Nosocomial infections in 50% of cases
- Common sites of infection: upper/lower respiratory tract (most common), urinary tract, vascular and indwelling catheters, skin/soft tissue, central nervous system, gastrointestinal tract, bone, joint
- Extremes of age (very young or age >60 years)
- Comorbidities: COPD, cirrhosis, congestive heart failure (CHF), cancer, diabetes, and renal insufficiency/failure
- Immunosuppression, asplenia
- Primary bacteremia
- Complicated labor and delivery: premature labor and/or premature rupture of membranes, untreated maternal group B strep colonization
- Nosocomial factors: surgical site infections, vascular and indwelling catheters, mechanical ventilation
- Vaccination: pneumococcal vaccine in children and adults ≥65 years or immunocompromised; Haemophilus influenzae type B (infants, young children), influenza, meningococcal vaccine
- γ-Globulin for hypo- or agammaglobulinemia
- Regular hand washing, sterile technique for vascular and indwelling catheter placement
- Antibiotic prophylaxis for recommended surgical procedures
- Liberation from mechanical ventilation as soon as clinically appropriate
Commonly Associated Conditions
- Immunologic: neutropenia, HIV, hypo- or agammaglobulinemia, complement deficiency, splenectomy, immunosuppressants (corticosteroids, chemotherapy, TNF-α antagonists)
- Diabetes, alcoholism, malignancy, cirrhosis, burns, multiple trauma, IV drug abuse, malnutrition