Critical care
Early diagnosis is not always easy, however, because symptoms of sepsis – typically high temperature, chills, rash, rapid heart rate, rapid breathing, drowsiness and confusion – can be mistaken for other conditions.
Studies to determine whether vitamin C can be used to treat sepsis and septic shock have varying results.
Although mortality rates have declined significantly in the past 30 years, about 20% of people who contract sepsis will die from it. In cases where sepsis proceeds to septic shock, the mortality rate is about 40%. Septic shock is much more prevalent in intensive care units (ICUs), where patients are typically frail and elderly and may have chronic conditions, or have developed an infection as a result of surgery. One study found that, of 116 ICU patients with sepsis, 35.3% developed septic shock. Of those, 63.4% died.
“Some patients […] may just come in with a bit of confusion or delirium, which has a very wide number of causes.” Neill Adhikari
20% The Lancet 48
Although mortality rates have declined significantly in the past 30 years, this percentage of people who contract sepsis will die from it.
The continuing prevalence of the disease, combined with the high mortality rate, has prompted researchers to find new ways of tackling it. It is, however, a challenging task. There is no single diagnostic test for either sepsis or septic shock. Both, says Neill Adhikari, an intensivist at Sunnybrook Sciences Centre at the University of Toronto, have “consensus definitions”. In the case of sepsis, diagnosis relies on finding some evidence of organ dysfunction in a patient with a suspected or confirmed infection, such as problems breathing or low platelet levels. Key indicators that a patient has septic shock are the presence of high levels of lactic acid in the blood, and the need for medication to maintain blood pressure greater than or equal to a set target – often a mean arterial pressure of 60 or 65mm Hg.
Early diagnosis is not always easy If sepsis is diagnosed early, patients can usually be treated effectively with antibiotics, IV fluids, and supportive care as needed for any failing organs.
“Some patients, particularly if they’re immuno- compromised, because of a medical condition or because they’re elderly or frail, may just come in with a bit of confusion or delirium, which has a very wide number of causes,” says Adhikari. If sepsis progresses to septic shock, then as well as continuing to administer antibiotics and intravenous (IV) fluids, clinicians will administer vasopressor medication to narrow blood vessels and improve blood flow. In some cases, says Adhikari, it is also necessary to remove the source of infection: “Someone with septic shock because they’ve got a perforation in their colon as a result of inflamed bowel or diverticulitis is not going to get better with antibiotics alone – they need an operation. Someone with septic shock because of pneumonia, where there is empyema – fluid around the lung that has become infected – will need to have that infected fluid drained.” Yet there is still uncertainty about what treatments are most effective. While oxygen therapy, for example, is a standard treatment for ICU patients, there is concern, says Anders Perner, senior staff specialist and professor in intensive care at Rigshospitalet, University of Copenhagen, “that too little or too much oxygen may be harmful”. While clinical trials, he adds, have established a target range in which oxygen therapy is safe, it is still unclear whether patients with sepsis may benefit from a higher or lower target. While patients with septic shock are normally treated with IV fluids, higher fluid volumes have been associated with harm in patients in the intensive care unit (ICU). Perner was part of an international team to publish a new study investigating whether lower levels of fluid would be as effective in treating septic shock in those patients. In the trial, 770 patients were assigned to the restrictive-fluid group (receiving a median of 1,798ml of IV fluid) and 784 to the standard-fluid group (receiving a median of 3,811ml). Outcomes were the same in the two groups, with 323 deaths in the restrictive-fluid group and 329 deaths in the standard-fluid group. In other words, reducing the fluid intake did not improve outcomes, but neither did it worsen them.
This is in keeping with a general trend in treating septic shock, says Perner, who says that care in the ICU has been based on certain untested physiological assumptions, or evidence from other conditions. Clinicians, he says, have carried out “a lot of interventions that had never been tested in clinical trials in patients with septic shock, and over
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