Mortality from sepsis increases 8% every hour the treatment is delayed. About 80% of the sepsis related mortality is preventable with early diagnosis and treatment. Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection injuring it own tissues and organs. Worsening of sepsis into septic shock has the mortality rate of 54%. Over half of intensive care unit patients with sepsis have at least one organ system dysfunction and 20% have multiple organ dysfunction. Half of the mortality observed in intensive care unit is attributable to multiple organ dysfunction syndrome. Sepsis worsening and a risk of septic shock with organ failure or death or other poor outcomes including long-term physical, psychological, and cognitive disabilities, prolonged intensive care unit stay, and in-hospital mortality. Patients presenting with modest dysfunction can deteriorate further and fast which emphasizes the seriousness and need for prompt and appropriate interventions. Quick sequential organ failure assessment (q SOFA), is a bedside prompt that could be used in or outside of hospital settings including emergency departments, primary care clinics and skilled nursing facilities. Quick SOFA score of 2 or higher could identify adult patients with suspected infection, who are at greater risk for poor outcomes typically seen with worsening of sepsis. Score of >2 points on quick SOFA or full SOFA indicates organ dysfunction which is associated with an in-hospital mortality greater than10%. Worsening of SOFA over 72 hours statistically significant positive relationship to in-hospital mortality. Positive Glasgow coma scale score increases the risk of 30-day mortality. Similarly, older age and comorbidities increase the risk of 30-day mortality. Therefore, prevention, early detection and quick interventions is the key to prevent progression of sepsis to Multi-organ Dysfunction Syndrome.
Purpose
The purpose of this presentation is to describe: (a) clinical case studies, (b) evidence based guidelines on quick SOFA and Full SOFA for early detection of sepsis, and (c) and evidence based clinical guidelines for quick interventions to manage sepsis to prevent poor clinical outcomes related to multi-organ dysfunction syndrome.
Methods
Literature review was performed for evidence based clinical guidelines on prevention, assessment and clinical management of sepsis, septic shock and multiple organ dysfunction syndrome. Additional data was obtained from four clinical case studies related to sepsis, septic shock and multi-organ dysfunction syndrome. Clinical outcomes from the case studies were analyzed based on quick SOFA, full SOFA and implementation of 3-hour and 6-hour bundles for prompt clinical management of sepsis, septic shock and multiple organ dysfunction syndrome. Recommendations for evidence based clinical guidelines for empirical and targeted antibiotics were reviewed.
Results
The Surviving Sepsis Campaign Taskforce recommends the prompt utilization of quick SOFA, full SOFA, and implementation of evidence based 3-hour and 6-hour bundles for prompt clinical management of sepsis to prevent progression of sepsis to septic shock and multi-organ dysfunction syndrome. The evidence based clinical guidelines highlight the early identification and early treatment of sepsis to be the primary focus. The management of sepsis needs to focus on early initiation of antibiotics, hemodynamic stabilization and pulmonary stabilization. Combination empiric therapy is recommended for patients with suspected multidrug-resistant microorganisms, severe infections associated with respiratory failure and septic shock, and septic shock and bacteremia from pneumococci. Combination therapy with broad-spectrum agents is recommended to cover gram- positive, gram-negative, and anaerobic bacteria. Specific combination therapy is recommended for different types of infections that could lead to sepsis including urinary tract infections, pneumonia, abdominal/pelvic infections, skin infections and meningitis. For empirical therapy, vancomycin or linezolid is also recommended due to the prevalence of methicillin resistant staph aureus. Increased layers of combination therapy layers is recommended when pseudomonas is suspected. For targeted therapy, broad spectrum monotherapy is considered to be adequate for immunocompetent patients. The Surviving Sepsis Campaign Taskforce’s 3-hour and 6-hour bundles provide evidence based guidelines for hemodynamic stabilization. For pulmonary stabilization, the target is to have arterial oxygen saturation above 93% and central venous oxygen saturation of at least 70%, which is a good marker of tissue perfusion. Controlled, lung-sparing ventilation at low tidal volumes (6 mL/kg of body weight) and peak pressures no higher than 30 mbar whenever adequate oxygenation (>90% by pulse oximetry) cannot be achieved by hemodynamic stabilization and mask oxygen administration alone. Evidence based guidelines provide recommendations for specific baseline and ongoing laboratory and diagnostic testing. Evidence based guidelines provide recommendations for healthy lifestyle to minimize the risk factors for infection, sepsis and complications.
Conclusion
The importance of timing in early identification of sepsis and early treatment initiation is a gold prognostic factor for clinical outcomes related to sepsis. Quick SOFA is a reliable quick bedside prompt for early identification of suspected infection in hospital and non-hospital settings. Full SOFA is a good tool to assess for organ dysfunction. The management of sepsis needs to focus on early imitation of antibiotics, hemodynamic stabilization and pulmonary stabilization to prevent progression of sepsis to multi-organ dysfunction and subsequent poor clinical outcomes with multi-organ dysfunction syndrome. In primary care settings, patient education on healthy lifestyle is important to minimize the risk factors for preventable chronic illnesses to reduce the risk of complications with co-morbidities, infection, sepsis, and long-term physical, psychological, and cognitive disabilities as well as mortality related to sepsis.
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