IN SEPTIC SHOCK

A COMPARATIVE ANALYSIS OF OUTCOME OF USE OF

VASOPRESSIN WITH NORADRENALINE AND NORADRENALINE ALONE

IN SEPTIC SHOCK

Dissertation submitted in partial fulfillment of the Requirement for the award of the Degree of

DOCTOR OF MEDICINE

BRANCH I - GENERAL MEDICINE REG.NO: 201711120

MAY 2020

THE TAMILNADU

DR.M.G.R. MEDICAL UNIVERSITY

CHENNAI, TAMILNADU, INDIA

CERTIFICATE FROM DEAN

This is to certify that the dissertation entitled “A COMPARATIVE ANALYSIS OF OUTCOME OF USE OF VASOPRESSIN WITH NORADRENALINE AND NORADRENALINE ALONE IN SEPTIC SHOCK” is the bonafide work Dr.SETHUPATHI T in partial fulfillment of the university regulations of the Tamil Nadu Dr. M.G.R Medical University, Chennai, for M.D General Medicine Branch I examination to be held in MAY 2020.

Dr. K. VANITHA M.D., DCH., The Dean, Govt Rajaji Hospital, Madurai Medical College Madurai.

CERTIFICATE FROM DEAN

This is to certify that the dissertation entitled “A COMPARATIVE ANALYSIS OF OUTCOME OF USE OF VASOPRESSIN WITH NORADRENALINE AND NORADRENALINE ALONE IN SEPTIC SHOCK” is the bonafide work Dr.SETHUPATHI T in partial fulfillment of the university regulations of the Tamil Nadu Dr. M.G.R Medical University, Chennai, for M.D General Medicine Branch I examination to be held in MAY 2020.

Dr

.

CERTIFICATE FROM HOD

This is to certify that the dissertation entitled “A COMPARATIVE ANALYSIS OF OUTCOME OF USE OF VASOPRESSIN WITH NORADRENALINE AND NORADRENALINE ALONE IN SEPTIC SHOCK” is the bonafide work Dr.SETHUPATHI T in partial fulfillment of the university regulations of the Tamil Nadu Dr. M.G.R Medical University, Chennai, for M.D General Medicine Branch I examination to be held in MAY 2020.

DR. M. NATARAJAN M.D., Professor and HOD,

Department of General Medicine, Government Rajaji Hospital, Madurai Medical College,

Madurai.

CERTIFICATE FROM GUIDE

This is to certify that the dissertation entitled “A COMPARATIVE ANALYSIS OF OUTCOME OF USE OF VASOPRESSIN WITH NORADRENALINE AND NORADRENALINE ALONE IN SEPTIC SHOCK” is the bonafide work Dr.SETHUPATHI T in partial fulfillment of the university regulations of the Tamil Nadu Dr. M.G.R Medical University, Chennai, for M.D General Medicine Branch I examination to be held in MAY 2020.

Dr., K. SENTHIL M.D., Professor and Chief,

Department of General Medicine, Government Rajaji Hospital, Madurai Medical College,

Madurai.

DECLARATION

I, Dr SETHUPATHI T solemnly declare that, this dissertation “A COMPARATIVE ANALYSIS OF OUTCOME OF USE OF VASOPRESSIN WITH NORADRENALINE AND NORADRENALINE ALONE IN SEPTIC SHOCK” is a bonafide record of work done by me at the Department of General Medicine, Govt. Rajaji Hospital, Madurai, under the guidance of Dr. K. SENTHIL , M.D.

,

This dissertation is submitted to The Tamil Nadu Dr. M.G.R Medical University, Chennai in partial fulfillment of the rules and regulations for the award of Doctor of Medicine (M.D.), General Medicine Branch-I;

examination to be held in MAY 2020.

Place: Madurai

Date:

Dr. SETHUPATHI T

ACKNOWLEDGEMENT

I would like to thank Dr

. VANITHA

I wish to express my respect and sincere gratitude to my beloved teacher and head of department, Prof. Dr. M. NATARAJAN, M.D., Professor of medicine for his valuable guidance and encouragement during the study and also throughout my course period.

I would like to express my deep sense of gratitude, respect and

sincerethanks to my beloved unit chief and Professor of Medicine Dr. K. SENTHIL M.D., for his valuable suggestions, guidance and support

throughout the study and also throughout my course period.

I am greatly indebted to my beloved Professors Dr.G.BAGHYALAKSHMI, M.D., Dr.J.SANGUMANI, M.D., Dr.C.DHARMARAJ, M.D. DCH, and Dr. DAVID PRADEEP KUMAR, M.D. Dr. VIVEKANANTHAN M.D,

Dr. V.N ALAGAVENKATESAN M.D for their valuable suggestions throughout the course of study.

I extend my sincere thanks, Prof. DR. MOHAN KUMARESH MD., Head of the department of Biochemistry for their constant support, guidance, cooperation to complete this study.

I am extremely thankful to Assistant Professors of Medicine of my Unit Dr. KRISHNASAMY PRASAD M.D., Dr. PANDICHELVAN MD., for their valid comments and suggestions

I sincerely thank all the staffs of Department of Medicine and Department of biochemistry for their timely help rendered to me, whenever and wherever needed.

I extend my love and express my gratitude to my family and friends Co PGs, Dr.Karthik pandiyan , Dr.Kishore , Dr.Madhusudhanan and Dr.Aarthi, DR. Vignesh saravanan, Dr. Ram vivek, Dr. Arun Prasath, Dr. Sai Sathish, Dr. Suganthi for their constant support during my study period in times of need.

Finally, I thank all the patients, who form the most vital part of my work, for their extreme patience and co-operation without whom this project would have been a distant dream and I pray God, for their speedy recovery.

Above all I thank the Lord Almighty for his kindness and benevolence

ACKNOWLEDGEMENT

I would like to thank Dr

.

I wish to express my respect and sincere gratitude to my beloved teacher and head of department, Prof. Dr. M. NATARAJAN, M.D., Professor of medicine for his valuable guidance and encouragement during the study and also throughout my course period.

I would like to express my deep sense of gratitude, respect and

sincerethanks to my beloved unit chief and Professor of Medicine Dr. K. SENTHIL M.D., for his valuable suggestions, guidance and support

throughout the study and also throughout my course period.

I am greatly indebted to my beloved Professors Dr.G.BAGHYALAKSHMI, M.D., Dr.J.SANGUMANI, M.D., Dr.C.DHARMARAJ, M.D. DCH, and Dr. DAVID PRADEEP KUMAR, M.D. Dr. VIVEKANANTHAN M.D,

Dr. V.N ALAGAVENKATESAN M.D for their valuable suggestions throughout the course of study.

I extend my sincere thanks, Prof. DR. MOHAN KUMARESH MD., Head of the department of Biochemistry for their constant support, guidance, cooperation to complete this study.

I am extremely thankful to Assistant Professors of Medicine of my Unit Dr. KRISHNASAMY PRASAD M.D., Dr. PANDICHELVAN MD., for their valid comments and suggestions

I sincerely thank all the staffs of Department of Medicine and Department of biochemistry for their timely help rendered to me, whenever and wherever needed.

I extend my love and express my gratitude to my family and friends Co PGs, Dr.Karthik pandiyan , Dr.Kishore , Dr.Madhusudhanan and Dr.Aarthi, DR. Vignesh saravanan, Dr. Ram vivek, Dr. Arun Prasath, Dr. Sai Sathish, Dr. Suganthi for their constant support during my study period in times of need.

Finally, I thank all the patients, who form the most vital part of my work, for their extreme patience and co-operation without whom this project would have been a distant dream and I pray God, for their speedy recovery.

Above all I thank the Lord Almighty for his kindness and benevolence

CONTENTS

S.NO

CONTENTS

1

INTRODUCTION

2

AIM OF STUDY

3

REVIEW OF LITERATURE

4

MATERIALS AND METHODS

5

RESULTS AND OBSERVATIONS

6

DISCUSSION

7

CONCLUSION

8

LIMITATIONS

BIBLIOGRAPHY PROFORMA CONSENT FORM MASTER CHART

ETHICAL COMMITTEE APPROVAL LETTER ANTI PLAGIARISM CERTIFICATE

80 82 84 85 89 90

1

INTRODUCTION

Severe sepsis and septic shock carries a high mortality and places a large burden on the health care system. Sepsis is the second leading cause of death among patients in noncoronary intensive care units and the 10^th leading cause of death . Despite improved knowledge of its pathophysiology and considerable advances in its treatment, mortality from septic shock exceeds 50% . Most deaths are linked to refractory arterial hypotension and organ failure despite antibiotic therapy, fluid expansion, vasopressor and positive inotropic treatment. Recent case reports and small clinical trials suggest that low dose vasopressin may be an effective alternative to traditional high dose catecholamine therapy for increasing systemic vascular resistance and blood pressure in septic patients .

Vasopressin is a nonapeptide produced in the paraventricular and supraoptic nuclei of the hypothalamaus and released from the posterior pituitary. It has two distinct roles that underlie its two names. In health, its main effect is to act in the control of osmolarity. Stimulation of vasopressin receptors (V2) in the distal convoluted tubule of the kidney results in water reabsorption and a fall in osmolarity. It has very little effect on blood pressure in health. In shock states, vasopressin binds to receptors in vascular smooth muscle that leads to vasoconstriction and

2

maintenance of blood pressure. Interestingly, in shock states has very little effect on osmolarity.

In shock states vasopressin binds to G-protein-coupled V1 receptors on vascular smooth muscle that leads to increased intracellular calcium levels and vasoconstriction . For instance, there is a greater distribution of V1 receptors on renal efferent compared to renal afferent arterioles. This contrast adrenoreceptor which is present on renal afferent and efferent arterioles so that noradrenaline vasoconstricts both renal afferent and efferent arterioles. Therefore comparison vasopressin may increase renal perfusion and glomerular filtration rate more than noradrenaline

3 AIMS AND OBJECTIVES:

• To assess the SOFA score for patients with septic shock fulfilled by SIR'S criteria at the time of admission and 24 hours after Vasopressin and noradrenaline therapy.

• To assess the patients over a period of 24 hours and assess the improvement in SOFA score or Worsening of SOFA score

4

REVIEW OF LITERATURE

Bacteremia

Presence of bacteria in the blood, as evidenced by positive blood cultures.

Signs of possibly harmful systemic response Two or more of following conditions:

(1) fever (oral temperature >38°C [>100.4°F]) or hypothermia (<36°C [<96.8°F]);

(2) tachypnea (>24 breaths/min);

(3) tachycardia (heart rate >90 beats/min);

(4) leukocytosis(>12,000/μL), leukopenia (<4000/μL), or >10%

bands

Sepsis (or severe sepsis)

The harmful host response to infection;

systemic response to proven or suspected infection plus some degree of organ dysfunction, i.e.:

1. Cardiovascular: Arterial systolic blood pressure ≤90 mmHg or mean arterial pressure ≤70 mmHg that responds to administration of intravenous fluid

2. Renal: Urine output <0.5 mL/kg / hour for 1 h despite adequate fluid resuscitation

5

3. Respiratory: Pao2/Fio2 ≤250 or, if the lung is the only dysfunctional organ,

≤200

4. Hematologic: Platelet count <80,000/μL or 50% reduction in platelet count from highest value recorded over previous three days

5. Unexplained metabolic acidosis: A arterial pH ≤7.30 or a base deficit ≥5.0 mEq/L and a plasma lactate level >1.5 times upper limit of normal for .

Septic shock

Sepsis with hypotension (arterial blood pressure <90 mmHg systolic,or 40 mmHg less than the patient’s normal blood pressure) for at least one hour despite adequate fluid resuscitation or Need for the vasopressors to maintain systolic blood pressure ≥90 mmHg or mean arterial pressure ≥70 mmHg.

Refractory septic shock

Septic shock that lasts for more than one hour and does not respond to fluid or pressor Administration.

6 EPIDEMIOLOGY

Severe sepsis is a contributing factor in >200,000 deaths per year . The incidence of severe sepsis and septic shock has increased over past 30 years, and the annual number of cases is now >750,000 (~3 per 1000 population). Approximately two-thirds of the cases occurs in patients with significant underlying illness. Sepsis-related incidence and mortality rates increase with increasing age and preexisting comorbidity. The rising incidence of severe sepsis is attributable to the aging of the population, the increasing longevity of patients with chronic diseases, and the relatively high frequency with which sepsis has occurred in patients with AIDS. The widespread use of the immunosuppressive drugs, indwelling catheters, and mechanical devices has also played a role in sepsis. In the aforementioned international ICU prevalence study, the case–fatality rate among infected patients (33%) greatly exceeds that among uninfected patients (15%).

Invasive bacterial infections are prominent causes of death around the world, particularly among younger children. Careful screening for positive blood cultures found that community-acquired bacteremia accounted for at least one-fourth of deaths of children >1 year of age.

Nontyphoidal Salmonella species, Streptococcus pneumoniae, Haemophilus influenzae, and E. coli were the most commonly isolated

7

bacteria in sepsis. Bacteremic children often had associated HIV infection or were severely malnourished.

PATHOPHYSIOLOGY

Sepsis is triggered most often by bacteria or fungi that do not ordinarily cause systemic disease in immunocompetent hosts . To survive within the human body, these microbes often exploit acquired deficiencies in host defenses, indwelling catheters or other foreign matter, or obstructed fluid drainage conduits. Microbial pathogens, in contrast, can circumvent innate defenses because they (1) lack molecules that can be recognized by host receptors or (2),elaborate toxins or other virulence factors. In both cases, the body can mount a vigorous inflammatory reaction that results in sepsis or septic

shock yet fails to kill the invaders. The septic response may also be induced by microbial exotoxins that act as superantigens (e.g., toxic shock syndrome toxin) as well as by many pathogenic viruses.

Host Mechanisms for Sensing Microbes

Animals have exquisitely sensitive mechanisms for recognizing and responding to certain highly conserved microbial molecules.

Recognition of the lipid A moiety of lipopolysaccharide (LPS, also called endotoxin) is the best-studied example. A host protein (LPS-binding protein) binds lipid A and transfers the LPS to CD14 on the surfaces of monocytes, macrophages, and neutrophils. LPS then is passed to MD-2, a

8

small receptor protein that is bound to Toll-like receptor (TLR) 4 to form a molecular complex that transduces the LPS recognition signal to the interior of the cell. This signal rapidly triggers the production and release of mediators, such as tumor necrosis factor (TNF), that amplify the LPS signal and transmits it to other cells and tissues. Bacterial peptidoglycan and lipopeptides elicit responses in animals that are generally similar to those induced by LPS, although they interact with different TLRs. Having numerous TLR-based receptor complexes (10 different TLRs have been identified in humans) allows animals to recognize many conserved microbial molecules; others include lipopeptides (TLR2/1, TLR2/6), flagellin (TLR5), undermethylated DNA CpG sequences (TLR9), single- stranded RNA (TLR7,8), and double-stranded RNA (TLR3). The ability of some TLRs to serve as receptors for host ligands (e.g., hyaluronans, heparan sulfate, saturated fatty acids, high-mobility group box 1) raises the possibility that they also play a role in producing noninfectious sepsis-like states. Other host pattern-recognition proteins that are important for sensing microbes include the intracellular NOD1 and NOD2 proteins, which recognize discrete fragments of bacterial peptidoglycan; the inflammasome, which senses some pathogens and produces interleukin (IL) 1β and IL-18; early complement components (principally in the alternative pathway); mannose-binding lectin and C-

9

reactive protein, which activate the classic complement pathway; and Dectin-1 and complement receptor 3, which sense fungal β-glucan.

A host’s ability to recognize certain microbial molecules may influence both the potency of its own defenses and the pathogenesis of severe sepsis. For example, MD-2–TLR4 best senses LPS that has a bisphosphorylated, hexaacyl lipid A moiety (i.e., one with two phosphates and six fatty acyl chains). Most of the commensal aerobic and facultatively anaerobic gram-negative bacteria that trigger severe sepsis and shock (including E. coli, Klebsiella, and Enterobacter) make this lipid A structure. When they invade human hosts, often through breaks in an epithelial barrier, they are typically confined to the subepithelial tissue by a localized inflammatory response. Bacteremia, if it occurs, is intermittent and low grade because these bacteria are efficiently cleared from the bloodstream by TLR4-expressing Kupffer cells and splenic macrophages. These mucosal commensals seem to induce severe sepsis most often by triggering severe local tissue inflammation rather than by circulating within the bloodstream. One exception is Neisseria meningitidis. Its hexaacyl LPS seems to be shielded from host recognition by its polysaccharide capsule. This protection may allow meningococci to transit undetected from the nasopharyngeal mucosa into the bloodstream, where they can infect vascular endothelial cells and release large amounts of endotoxin and DNA. Host recognition of lipid A may nonetheless

10

influence pathogenesis, as meningococci that produce pentaacyl LPS were isolated from the blood of patients with less severe coagulopathy than was found in patients whose isolates produced hexaacyl lipid A;

underacylated N. meningitidis LPS has also been found in many isolates from patients with chronic meningococcemia. In contrast, gram-negative bacteria that make lipid A with fewer than six acyl chains (Yersinia pestis, Francisella tularensis, Vibrio vulnificus, Pseudomonas aeruginosa, and Burkholderia pseudomallei, among others) are poorly recognized by MD-2–TLR4. When these bacteria enter the body, they may initially induce relatively little inflammation. When they do trigger severe sepsis, it is often after they have multiplied to high density in tissues and blood. The importance of LPS recognition in disease pathogenesis was demonstrated by engineering of a virulent strain of Y.

pestis that makes tetraacyl LPS at 37°C to produce hexaacyl LPS; unlike its virulent parent, the mutant strain stimulated local inflammation and was rapidly cleared from tissues. These findings were subsequently replicated in F. tularensis. For at least one large class of microbes—

gram-negative aerobic bacteria—the pathogenesis of sepsis thus depends, at least in part, on whether the bacterium’s major signal molecule, LPS, can be sensed by the host.

Local and Systemic Host Responses to Invading Microbes Recognition of microbial molecules by tissue phagocytes triggers the

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production and/or release of numerous host molecules (cytokines, chemokines, prostanoids, leukotrienes, and others) that increase blood flow to the infected tissue (rubor), enhance the permeability of local blood vessels (tumor), recruit neutrophils and other cells to the site of infection (calor), and elicit pain (dolor). These reactions are familiar elements of local inflammation, the body’s frontline innate immune mechanism for eliminating microbial invaders. Systemic responses are activated by neural and/or humoral communication with the hypothalamus and brainstem; these responses enhance local defenses by increasing blood flow to the infected area, augmenting the number of circulating neutrophils, and elevating blood levels of numerous molecules (such as the microbial recognition proteins discussed above) that have antiinfective functions.

Cytokines and other mediators

Cytokines can exert endocrine, paracrine, and autocrine effects.

TNF-α stimulates leukocytes and vascular endothelial cells to release other cytokines (as well as additional TNF-α), to express cell-surface molecules that enhance neutrophil endothelial adhesion at sites of infection, and to increase prostaglandin and leukotriene production.

Whereas blood levels of TNF-α are not elevated in individuals with localized infections, they increase in most patients with severe sepsis or septic shock. Moreover, IV infusion of TNF-α can elicit fever,

12

tachycardia, hypotension, and other responses. In animals, larger doses of TNF-α induce shock and death.

Although TNF-α is a central mediator, it is only one of many proinflammatory molecules that contribute to innate host defense.

Chemokines, most prominently IL-8 and IL-17, attract circulating neutrophils to the infection site. IL-1β exhibits many of the same activities as TNF-α. TNF-α, IL-1β, interferon γ, IL-12, IL-17, and other proinflammatory cytokines probably interact synergistically with one another and with additional mediators. The nonlinearity and multiplicity of these interactions have made it difficult to interpret the roles played by individual mediators in both tissues and blood.

Coagulation factors

Intravascular thrombosis, a hallmark of the local inflammatory response, may help wall off invading microbes and prevent infection and inflammation from spreading to other tissues. IL-6 and other mediators promote intravascular coagulation initially by inducing blood monocytes and vascular endothelial cells to express tissue factor. When tissue factor is expressed on cell surfaces, it binds to factor VIIa to form an active complex that can convert factors X and IX to their enzymatically active forms. The result is activation of both extrinsic and intrinsic clotting pathways, culminating in the generation of fibrin. Clotting is also favored by impaired function of the protein C–protein S inhibitory pathway and

13

depletion of antithrombin and proteins C and S, whereas fibrinolysis is reduced by increases in plasma levels of plasminogen activator inhibitor 1. Thus, there may be a striking propensity toward intravascular fibrin deposition, thrombosis, and bleeding; this propensity has been most apparent in patients with intravascular endothelial infections such as meningococcemia. Evidence points to tissue factor–expressing microparticles derived from leukocytes as a potential trigger for intravascular coagulation. The contact system is activated during sepsis but contributes more to the development of hypotension than to that of disseminated intravascular coagulation (DIC).

Neutrophil extracellular traps

NETs are produced when neutrophils, stimulated by microbial agonists or IL-8, release granule proteins and chromatin to form an extracellular fibrillar matrix. NETs kill bacteria and fungi with antimicrobial granule proteins (e.g., elastase) and histones. It has been reported that NETs can form within hepatic sinusoids in animals injected with large amounts of LPS, and platelets can induce NET formation without killing neutrophils. A role played by NETs in organ hypofunction during sepsis has been proposed but not established.

Control mechanisms

Elaborate control mechanisms operate within both local sites of inflammation and the systemic compartment.

14 Local control mechanisms

Host recognition of invading microbes within subepithelial tissues typically ignites immune responses that rapidly kill the invaders and then subside to allow tissue recovery.The forces that put out the fire and clean up the battleground include molecules that neutralize or inactivate microbial signals. Among these molecules are intracellular factors (e.g., suppressor of cytokine signalling 3 and IL-1 receptor–associated kinase 3) that diminish the production of proinflammatory mediators by neutrophils and macrophages; anti-inflammatory cytokines (IL-10, IL-4);

and molecules derived from essential polyunsaturated fatty acids (lipoxins, resolvins, and protectins) that promote tissue restoration.

Enzymatic inactivation of microbial signal molecules (e.g., LPS) may be required to restore homeostasis; a leukocyte enzyme, acyloxyacyl hydrolase, has been shown to prevent prolonged inflammation in mice by inactivating LPS.

Systemic control mechanisms

The signaling apparatus that links microbial recognition to cellular responses in tissues is less active in the blood. For example, whereas LPS-binding protein plays a role in recognizing LPS, in plasma it also prevents LPS signaling by transferring LPS molecules into plasma lipoprotein particles that sequester the lipid A moiety so that it cannot interact with cells. At the high concentrations found in blood, LPS-

15

binding protein also inhibits monocyte responses to LPS, and the soluble (circulating) form of CD14 strips off LPS that has bound to monocyte surfaces.

Systemic responses to infection also diminish cellular responses to microbial molecules. Circulating levels of cortisol and anti- inflammatorycytokines (e.g., IL-6 and IL-10) increase even in patients with minor infections. Glucocorticoids inhibit cytokine synthesis by monocytes in vitro; the increase in blood cortisol levels that occurs early in the systemic response presumably plays a similarly inhibitory role.

Epinephrine inhibits the TNF-α response to endotoxin infusion in humans while augmenting and accelerating the release of IL-10; prostaglandin E2 has a similar “reprogramming” effect on the responses of circulating monocytes to LPS and other bacterial agonists. Cortisol, epinephrine, IL- 10, and C-reactive protein reduce the ability of neutrophils to attach to vascular endothelium, favoring their demargination and thus contributing to leukocytosis while preventing neutrophilendothelial adhesion in uninflamed organs. Studies in rodents have found that macrophage cytokine synthesis is inhibited by acetylcholine that is produced by choline acetyltransferase–secreting CD4+ T cells in response to stimulation by norepinephrine, whereas acetylcholineproducing B cells reduce neutrophil infiltration into tissues. Several lines of evidence thus suggest that the body’s neuroendocrine responses to injury and infection

16

normally prevent inflammation within organs distant from a site of infection. There is also evidence that these responses may be immunosuppressive.

IL-6 plays important roles in the systemic compartment. Released by many different cell types, IL-6 is an important stimulus to the hypothalamic-pituitary-adrenal axis, is the major procoagulant cytokine, and is a principal inducer of the acute-phase response, which increases the blood concentrations of numerous molecules that have anti-infective, procoagulant, or anti-inflammatory actions. Blood levels of IL-1 receptor antagonist often greatly exceed those of circulating IL-1β, for example, and this excess may inhibit the binding of IL-1β to its receptors. High levels of soluble TNF receptors neutralize TNF-α that enters the circulation. Other acute-phase proteins are protease inhibitors or antioxidants; these may neutralize potentially harmful molecules from neutrophils and other inflammatory cells. Increased hepatic production of hepcidin (stimulated largely by IL-6) promotes the sequestration of iron in hepatocytes, intestinal epithelial cells, and erythrocytes; this effect reduces iron acquisition by invading microbes while contributing to the normocytic, normochromic anemia associated with inflammation.

It may thus be said that both local and systemic responses to infectious agents benefit the host in important ways. Most of these responses and the molecules responsible for them have been highly

17

conserved during animal evolution and therefore may be adaptive.Elucidating how they become maladaptive and contribute to lethality remains a major challenge for sepsis research.

Organ Dysfunction and Shock

As the body’s responses to infection intensify, the mixture of circulating cytokines and other molecules becomes very complex:

elevated blood levels of more than 60 molecules have been found in patients with septic shock. Although high concentrations of both pro- and anti-inflammatory molecules are found, the net mediator balance in the plasma of these extremely sick patients seems to be anti-inflammatory.

For example, blood leukocytes from patients with severe sepsis are often hyporesponsive to agonists such as LPS. In patients with severe sepsis, persistence of leukocyte hyporesponsiveness has been associated with an increased risk of dying; at this time, the most predictive biomarker is a decrease in the expression of HLA-DR (class II) molecules on the surfaces of circulating monocytes, a response that seems to be induced by cortisol and/or IL-10. Apoptotic death of B cells, follicular dendritic cells, and CD4+ T lymphocytes also may contribute significantly to the immunosuppressive state.

Endothelial injury

Given the vascular endothelium’s important roles in regulating vascular tone, vascular permeability, and coagulation, many investigators

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have favored widespread vascular endothelial injury as the major mechanism for multiorgan dysfunction. In keeping with this idea, one study found high numbers of vascular endothelial cells in the peripheral blood of septic patients. Leukocyte-derived mediators and platelet- leukocyte-fibrin thrombi may contribute to vascular injury, but the vascular endothelium also seems to play an active role. Stimuli such as TNF-α induce vascular endothelial cells to produce and release cytokines, procoagulant molecules, plateletactivating factor, nitric oxide, and other mediators. In addition, regulate cell-adhesion molecules promote the adherence of neutrophils to endothelial cells. Although these responses can attract phagocytes to infected sites and activate their antimicrobial arsenals, endothelial cell activation can also promote increased vascular permeability, microvascular thrombosis, DIC, and hypotension.

Tissue oxygenation may decrease as the number of functional capillaries is reduced by luminal obstruction due to swollen endothelial cells, decreased deformability of circulating erythrocytes, leukocyte platelet- fibrin thrombi, or compression by edema fluid. On the other hand, studies using orthogonal polarization spectral imaging of the microcirculation in the tongue found that sepsis-associated derangements in capillary flow could be reversed by applying acetylcholine to the surface of the tongue or by giving nitroprusside intravenously these observations suggest a neuroendocrine basis for the loss of capillary

19

filling. Oxygen utilization by tissues may also be impaired by changes (possibly induced by nitric oxide) that decrease oxidative phosphorylation and ATP production while increasing glycolysis. The local accumulation of lactic acid, a consequence of increased glycolysis, may decrease extracellular pH and contribute to the slowdown in cellular metabolism that occurs within affected tissues.

Remarkably, poorly functioning “septic” organs usually appear normal at autopsy. There is typically very little necrosis or thrombosis, and apoptosis is largely confined to lymphoid organs and the gastrointestinal tract. Moreover, organ function usually returns to normal if patients recover. These points suggest that organ dysfunction during severe sepsis has a basis that is principally biochemical, not structural^. Septic shock

The hallmark of septic shock is a decrease in peripheral vascular resistance that occurs despite increased levels of vasopressor catecholamines. Before this vasodilatory phase, many patients experience a period during which oxygen delivery to tissues is compromised by myocardial depression, hypovolemia, and other factors. During this

“hypodynamic” period, the blood lactate concentration is elevated and central venous oxygen saturation is low. Fluid administration is usually followed by the hyperdynamic vasodilatory phase, during which cardiac output is normal (or even high) and oxygen consumption

20

declines despite adequate oxygen delivery. The blood lactate level may be normal or increased, and normalization of central venous oxygen saturation may reflect improved oxygen delivery, decreased oxygen uptake by tissues, or left-to-right shunting.

Select mechanisms implicated in the pathogenesis of sepsis- induced organ and cellular dysfunction. The host response to sepsis involves multiple mechanisms that lead to decreased oxygen delivery (DO2) at the tissue level. The duration, extent, and direction of these interactions are modified by the organ under threat, host factors (e.g., age, genetic characteristics, medications), and pathogen factors (e.g., microbial load and virulence). The inflammatory response is typically initiated by an interaction between pathogen-associated molecular patterns (PAMPs) expressed by pathogens and pattern recognition

21

receptors expressed by innate immune cells on the cell surface (Toll-like receptors [TLRs] and C-type lectin receptors [CLRs]), in the endosome (TLRs), or in the cytoplasm (retinoic acid inducible gene 1–like receptors.

Prominent hypotensive molecules include nitric oxide, β- endorphin, bradykinin, platelet-activating factor, and prostacyclin. Agents that inhibit the synthesis or action of each of these mediators can prevent or reverse endotoxic shock in animals. However, in clinical trials, neither a platelet-activating factor receptor antagonist nor a bradykinin antagonist improved survival rates among patients with septic shock, and a nitric oxide synthase inhibitor, L-NG-methylarginine HCl actually increased the mortality rate.

Severe Sepsis: A Single Pathogenesis?

In some cases, circulating bacteria and their products almost certainly elicit multiorgan dysfunction and hypotension by directly stimulating inflammatory responses within the vasculature. In patients with fulminant meningococcemia, for example, mortality rates have correlated directly with blood levels of endotoxin and bacterial DNA and with the occurrence of DIC. In most patients infected with other gram- negative bacteria, in contrast, circulating bacteria or bacterial molecules may reflect uncontrolled infection at a local tissue site and have little or no direct impact on distant organs; in these patients, inflammatory

22

mediators or neural signals arising from the local site seem to be the key triggers for severe sepsis and septic shock. In a large series of patients with positive blood cultures, the risk of developing severe sepsis was strongly related to the site of primary infection: bacteremia arising from a pulmonary or abdominal source was eightfold more likely to be associated with severe sepsis than was bacteremic urinary tract infection, even after the investigators controlled for age, the kind of bacteria isolated from the blood, and other factors. A third pathogenesis may be represented by severe sepsis due to superantigen-producing S. aureus or Streptococcus pyogenes; the T cell activation induced by these toxins produces a cytokine profile that differs substantially from that elicited by gramnegative bacterial infection. Further evidence for different pathogenetic pathways has come from observations that the pattern of mRNA expression in peripheral-blood leukocytes from children with sepsis is different for gram-positive, gram-negative, and viral pathogens.

The pathogenesis of severe sepsis thus may differ according to the infecting microbe, the ability of the host’s innate defense mechanisms to sense and respond to it, the site of the primary infection, the presence or absence of immune defects, and the prior physiologic status of the host.

Genetic factors are probably important as well, yet despite much study very few allelic polymorphisms have been associated with sepsis severity in more than one or two analyses. Further studies in this area are needed.

23 CLINICAL MANIFESTATIONS

The manifestations of the septic response are superimposed on the symptoms and signs of the patient’s underlying illness and primary infection. The rate at which severe sepsis develops may differ from patient to patient, and there are striking individual variations in presentation. For example, some patients with sepsis are normo- or hypothermic; the absence of fever is most common in neonates, in elderly patients, and in persons with uremia or alcoholism.

Hyperventilation, producing respiratory alkalosis, is often an early sign of the septic response. Disorientation, confusion, and other manifestations of encephalopathy may also develop early on, particularly in the elderly and in individuals with preexisting neurologic impairment.

Focal neurologic signs are uncommon, although preexisting focal deficits may become more prominent.

Hypotension and DIC predispose to acrocyanosis and ischemic necrosis of peripheral tissues, most commonly the digits. Cellulitis, pustules, bullae, or hemorrhagic lesions may develop when hematogenous bacteria or fungi seed the skin or underlying soft tissue.

Bacterial toxins may also be distributed hematogenously and elicit diffuse cutaneous reactions. On occasion, skin lesions may suggest specific pathogens. When sepsis is accompanied by cutaneous petechiae or purpura, infection with N. meningitidis (or, less commonly, H. influenzae)

24

should be suspected ; in a patient who has been bitten by a tick while in an endemic area, petechial lesions also suggest Rocky Mountain spotted fever. A cutaneous lesion seen almost exclusively in neutropenic patients is ecthyma gangrenosum, often caused by P. aeruginosa. This bullous lesion surrounded by edema undergoes central hemorrhage and necrosis.

Histopathologic examination shows bacteria in and around the wall of a small vessel, with little or no neutrophilic response. Hemorrhagic or bullous lesions in a septic patient who has recently eaten raw oysters suggest V. vulnificus bacteremia, whereas such lesions in a patient who has recently sustained a dog bite may indicate bloodstream infection due to Capnocytophaga canimorsus or Capnocytophaga cynodegmi.

Generalized erythroderma in a septic patient suggests the toxic shock syndrome due to S. aureus or S. pyogenes.

Gastrointestinal manifestations such as nausea, vomiting, diarrhea, and ileus may suggest acute gastroenteritis. Stress ulceration can lead to upper gastrointestinal bleeding. Cholestatic jaundice, with elevated levels of serum bilirubin (mostly conjugated) and alkaline phosphatase, may precede other signs of sepsis. Hepatocellular or canalicular dysfunction appears to underlie most cases, and the results of hepatic function tests return to normal with resolution of the infection. Prolonged or severe hypotension may induce acute hepatic injury or ischemic bowel necrosis.

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Many tissues may be unable to extract oxygen normally from the blood, so that anaerobic metabolism occurs despite near-normal mixed venous oxygen saturation. Blood lactate levels rise early because of increased glycolysis as well as impaired clearance of the resulting lactate and pyruvate by the liver and kidneys. The blood glucose concentration often increases, particularly in patients with diabetes, although impaired gluconeogenesis and excessive insulin release on occasion produce hypoglycemia. The cytokine-driven acute-phase response inhibits the synthesis of transthyretin while enhancing the production of C-reactive protein, fibrinogen, and complement components. Protein catabolism is often markedly accelerated. Serum albumin levels decline as a result of decreased hepatic synthesis and the movement of albumin into interstitial spaces.

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Distribution of SIRS and SOFA variables among infected patients at risk for sepsis, as documented in the electronic health record. Dark green bars represent the proportion of such patients with abnormal findings; light green bars, the proportion with normal findings; and white bars, the proportion with missing data.

27 MAJOR COMPLICATIONS

Cardiopulmonary Complications

Ventilation-perfusion mismatching produces a fall in arterial Po2 early in the course. Increasing alveolar epithelial injury and capillary permeability result in increased pulmonary water content, which decreases pulmonary compliance and interferes with oxygen exchange. In the absence of pneumonia or heart failure, progressive diffuse pulmonary infiltrates and arterial hypoxemia occurring within 1 week of a known insult indicate the development of mild acute respiratory distress syndrome (ARDS) (200 mmHg < Pao2/Fio2 ≤ 300 mmHg), moderate ARDS (100 mmHg < Pao2/Fio2 ≤ 200 mmHg), or severe ARDS (Pao2/Fio2 ≤100 mmHg). Acute lung injury or ARDS develops in ~50%

of patients with severe sepsis or septic shock. Respiratory muscle fatigue can exacerbate hypoxemia and hypercapnia. An elevated pulmonary capillary wedge pressure (>18 mmHg) suggests fluid volume overload or cardiac failure rather than ARDS. Pneumonia caused by viruses or by Pneumocystis may be clinically indistinguishable from ARDS.

Sepsis-induced hypotension usually results initially from a generalized maldistribution of blood flow and blood volume and from hypovolemia that is due, at least in part, to diffuse capillary leakage of intravascular fluid. Other factors that may decrease effective intravascular volume include dehydration from antecedent disease or insensible fluid

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losses, vomiting or diarrhea, and polyuria. During early septic shock, systemic vascular resistance is usually elevated and cardiac output may be low. After fluid repletion, in contrast, cardiac output typically increases and systemic vascular resistance falls. Indeed, normal or increased cardiac output and decreased systemic vascular resistance distinguish septic shock from cardiogenic, extracardiac obstructive, and hypovolemic shock; other processes that can produce this combination include anaphylaxis, beriberi, cirrhosis, and overdoses of nitroprusside or narcotics.

Depression of myocardial function, manifested as increased enddiastolic and systolic ventricular volumes with a decreased ejection fraction, develops within 24 h in most patients with severe sepsis. Cardiac output is maintained despite the low ejection fraction because ventricular dilation permits a normal stroke volume. In survivors, myocardial function returns to normal over several days. Although myocardial dysfunction may contribute to hypotension, refractory hypotension is usually due to low systemic vascular resistance, and death most often results from refractory shock or the failure of multiple organs rather than from cardiac dysfunction per se.

Adrenal Insufficiency

The diagnosis of adrenal insufficiency may be very difficult in critically ill patients. Whereas a plasma cortisol level of ≤15 μg/mL (≤10

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μg/mL if the serum albumin concentration is <2.5 mg/dL) indicates adrenal insufficiency (inadequate production of cortisol), many experts now feel that the adrenocorticotropic hormone (CoSyntropinR) stimulation test is not useful for detecting less profound degrees of corticosteroid deficiency in patients who are critically ill. The concept of critical illness–related corticosteroid insufficiency (CIRCI) was proposed to encompass the different mechanisms that may produce corticosteroid activity that is inadequate for the severity of a patient’s illness. Although CIRCI may result from structural damage to the adrenal gland, it is more commonly due to reversible dysfunction of the hypothalamic-pituitary axis or to tissue corticosteroid resistance resulting from abnormalities of the glucocorticoid receptor or increased conversion of cortisol to cortisone. The major clinical manifestation of CIRCI is hypotension that is refractory to fluid replacement and requires pressor therapy. Some classic features of adrenal insufficiency, such as hyponatremia and hyperkalemia, are usually absent; others, such as eosinophilia and modest hypoglycemia, may sometimes be found. Specific etiologies include fulminant N. meningitidis bacteremia, disseminated tuberculosis, AIDS (with cytomegalovirus, Mycobacterium avium-intracellulare, or Histoplasma capsulatum disease), or the prior use of drugs that diminish glucocorticoid production, such as glucocorticoids, megestrol, etomidate, or ketoconazole.

30 Renal Complications

Oliguria, azotemia, proteinuria, and nonspecific urinary casts are frequently found. Many patients are inappropriately polyuric;

hyperglycemia may exacerbate this tendency. Most renal failure is due to acute tubular necrosis induced by hypovolemia, arterial hypotension, or toxic drugs, although some patients also have glomerulonephritis, renal cortical necrosis, or interstitial nephritis. Drug-induced renal damage may greatly complicate therapy, particularly when hypotensive patients are given aminoglycoside antibiotics.

Nosocomial sepsis following acute renal injury is associated with a high mortality rate.

Coagulopathy

Although thrombocytopenia occurs in 10–30% of patients, the underlying mechanisms are not understood. Platelet counts are usually very low (<50,000/μL) in patients with DIC; these low counts may reflect diffuse endothelial injury or microvascular thrombosis, yet thrombi have only infrequently been found on biopsy of septic organs.

Neurologic Complications

Delirium (acute encephalopathy) is often an early manifestation of sepsis. Depending on the diagnostic criteria used, it occurs in 10–70% of septic patients at some point during the hospital course. When the septic illness lasts for weeks or months, “critical illness” polyneuropathy may

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prevent weaning from ventilator support and produce distal motor weakness. Electrophysiologic studies are diagnostic. Guillain-Barre syndrome, metabolic disturbances, and toxin activity must be ruled out.

Recent studies have documented long-term cognitive loss in survivors of severe sepsis.

Immunosuppression

Patients with severe sepsis often become profoundly immunosuppressed. Manifestations include loss of delayedtype hypersensitivity reactions to common antigens, failure to control the primary infection, and increased risk for secondary infections (e.g., by opportunists such as Stenotrophomonas maltophilia, Acinetobacter calcoaceticus-baumannii, and Candida albicans). Approximately onethird of patients experience reactivation of herpes simplex virus, varicellazoster virus, or cytomegalovirus infections; the latter are thought to contribute to adverse outcomes in some instances.

LABORATORY FINDINGS

Abnormalities that occur early in the septic response may include leucocytosis with a left shift, thrombocytopenia, hyperbilirubinemia, and proteinuria. Leukopenia may develop. The neutrophils may contain toxic granulations, Dohle bodies, or cytoplasmic vacuoles. As the septic response becomes more severe, thrombocytopenia worsens (often with prolonged thrombin time, decreased fibrinogen, and the presence of d-

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dimers, suggesting DIC), azotemia and hyperbilirubinemia become more prominent, and levels of aminotransferases rise. Active hemolysis suggests clostridial bacteremia, malaria, a drug reaction, or DIC; in the case of DIC, microangiopathic changes may be seen on a blood smear.

During early sepsis, hyperventilation induces respiratory alkalosis.

With respiratory muscle fatigue and the accumulation of lactate, metabolic acidosis (with increased anion gap) typically supervenes.

Evaluation of arterial blood gases reveals hypoxemia that is initially correctable with supplemental oxygen but whose later refractoriness to 100% oxygen inhalation indicates right-to-left shunting. The chest radiograph may be normal or may show evidence of underlying pneumonia, volume overload, or the diffuse infiltrates of ARDS. The electrocardiogram may show only sinus tachycardia or nonspecific ST–T wave abnormalities. Most diabetic patients with sepsis develop hyperglycemia. Severe infection may precipitate diabetic ketoacidosis that may exacerbate hypotension. Hypoglycemia occurs rarely and may indicate adrenal insufficiency. The serum albumin level declines as sepsis continues. Hypocalcemia is rare.

DIAGNOSIS

There is no specific diagnostic test for sepsis. Diagnostically sensitive findings in a patient with suspected or proven infection include fever or hypothermia, tachypnea, tachycardia, and leukocytosis or

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leukopenia; acutely altered mental status, thrombocytopenia, an elevated blood lactate level, respiratory alkalosis, or hypotension also should suggest the diagnosis. The systemic response can be quite variable, however. In one study, 36% of patients with severe sepsis had a normal temperature, 40% had a normal respiratory rate, 10% had a normal pulse rate, and 33% had normal white blood cell counts.

Moreover, the systemic responses of uninfected patients with other conditions may be similar to those characteristic of sepsis. Examples include pancreatitis, burns, trauma, adrenal insufficiency, pulmonary embolism, dissecting or ruptured aortic aneurysm, myocardial infarction, occult hemorrhage, cardiac tamponade, postcardiopulmonary bypass syndrome, anaphylaxis, tumor-associated lactic acidosis, and drug overdose.

Definitive etiologic diagnosis requires identification of the causative microorganism from blood or a local site of infection. At least two blood samples should be obtained (from two different venepuncture sites) for culture; in a patient with an indwelling catheter, one sample should be collected from each lumen of the catheter and another via venipuncture. In many cases, blood cultures are negative; this result can reflect prior antibiotic administration, the presence of slow-growing or fastidious organisms, or the absence of microbial invasion of the bloodstream. In these cases, Gram’s staining and culture of material from

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the primary site of infection or from infected cutaneous lesions may help establish the microbial etiology. Identification of microbial DNA in peripheral blood or tissue samples by polymerase chain reaction may also be definitive. The skin and mucosae should be examined carefully and repeatedly for lesions that might yield diagnostic information. With overwhelming bacteremia (e.g., pneumococcal sepsis in splenectomized individuals; fulminant meningococcemia; or infection with V. vulnificus, B. pseudomallei, or Y. pestis), microorganisms are sometimes visible on buffy coat smears of peripheral blood.

TREATMENT

Patients in whom sepsis is suspected must be managed expeditiously.This task is best accomplished by personnel who are experienced in the care of the critically ill. Successful management requires urgent measures to treat the infection, to provide hemodynamic and respiratory support, and to remove or drain infected tissues. These measures should be initiated within 1 h of the patient’s presentation with severe sepsis or septic shock. Rapid assessment and diagnosis are therefore essential.

ANTIMICROBIAL AGENTS

Antimicrobial chemotherapy should be started as soon as samples of blood and other relevant sites have been obtained for culture. A large retrospective review of patients who developed septic shock found that

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the interval between the onset of hypotension and the administration of appropriate antimicrobial chemotherapy was the major determinant of outcome; a delay of as little as 1 h was associated with lower survival rates. Use of “inappropriate” antibiotics, defined on the basis of local microbial susceptibilities and published guidelines for empirical therapy, was associated with fivefold lower survival rates, even among patients with negative cultures. It is therefore very important to promptly initiate empirical antimicrobial therapy that is effective against both gram- positive and gram-negative bacteria. Maximal recommended doses of antimicrobial drugs should be given intravenously, with adjustment for impaired renal function when necessary. Available information about patterns of antimicrobial susceptibility among bacterial isolates from the community, the hospital, and the patient should be taken into account.

When culture results become available, the regimen can often be simplified because a single antimicrobial agent is usually adequate for the treatment of a known pathogen. Meta-analyses have concluded that, with one exception, combination antimicrobial therapy is not superior to monotherapy for treating gram-negative bacteremia; the exception is that aminoglycoside monotherapy for P. aeruginosa bacteremia is less effective than the combination of an aminoglycoside with an antipseudomonal β-lactam agent. Empirical antifungal therapy should be strongly considered if the septic patient is already receiving

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broadspectrum antibiotics or parenteral nutrition, has been neutropenic for ≥5 days, has had a long-term central venous catheter in place, or has been hospitalized in an ICU for a prolonged period. The chosen antimicrobial regimen should be reconsidered daily in order to provide maximal efficacy with minimal resistance, toxicity, and cost.

Most patients require antimicrobial therapy for at least 1 week. The duration of treatment is typically influenced by factors such as the site of tissue infection, the adequacy of surgical drainage, the patient’s underlying disease, and the antimicrobial susceptibility of the microbial isolate(s). The absence of an identified microbial pathogen is not necessarily an indication for discontinuing antimicrobial therapy because

“appropriate” antimicrobial regimens seem to be beneficial in both culture-negative and culture-positive cases.

REMOVAL OF THE SOURCE OF INFECTION

Removal or drainage of a focal source of infection is essential. In one series, a focus of ongoing infection was found in ~80% of surgical ICU patients who died of severe sepsis or septic shock. Sites of occult infection should be sought carefully, particularly in the lungs, abdomen, and urinary tract. Indwelling IV or arterial catheters should be removed and the tip rolled over a blood agar plate for quantitative culture; after antibiotic therapy has been initiated, a new catheter should be inserted at a different site. Foley and drainage catheters should be replaced. The

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possibility of paranasal sinusitis (often caused by gram-negative bacteria) should be considered if the patient has undergone nasal intubation or has an indwelling nasogastric or feeding tube. Even in patients without abnormalities on chest radiographs, computed tomography (CT) of the chest may identify unsuspected parenchymal, mediastinal, or pleural disease. In the neutropenic patient, cutaneous sites of tenderness and erythema, particularly in the perianal region, must be carefully sought. In patients with sacral or ischial decubitus ulcers, it is important to exclude pelvic or other soft tissue pus collections with CT or magnetic resonance imaging (MRI). In patients with severe sepsis arising from the urinary tract, sonography or CT should be used to rule out ureteral obstruction, perinephric abscess, and renal abscess. Sonographic or CT imaging of the upper abdomen may disclose evidence of cholecystitis, bile duct dilation, and pus collections in the liver, subphrenic space, or spleen.

HEMODYNAMIC, RESPIRATORY, AND METABOLIC SUPPORT

The primary goals are to restore adequate oxygen and substrate delivery to the tissues as quickly as possible and to improve tissue oxygen utilization and cellular metabolism. Adequate organ perfusion is thus essential. Circulatory adequacy is assessed by measurement of arterial blood pressure and monitoring of parameters such as mentation, urine output, and skin perfusion. Indirect indices of oxygen delivery and

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consumption, such as central venous oxygen saturation, may also be useful. Initial management of hypotension should include the administration of IV fluids, typically beginning with 1–2 L of normal saline over 1–2 h. To avoid pulmonary edema, the central venous pressure should be maintained at 8–12 cmH2O. The urine output rate should be kept at >0.5 mL/kg per hour by continuing fluid administration;

a diuretic such as furosemide may be used if needed. In about one-third of patients, hypotension and organ hypoperfusion respond to fluid resuscitation; a reasonable goal is to maintain a mean arterial blood pressure of >65 mmHg (systolic pressure >90 mmHg). If these guidelines cannot be met by volume infusion, vasopressor therapy is indicated.

Titrated doses of norepinephrine should be administered through a central catheter. If myocardial dysfunction produces elevated cardiac filling pressures and low cardiac output, inotropic therapy with dobutamine is recommended. Dopamine is rarely used.

In patients with septic shock, plasma vasopressin levels increase transiently but then decrease dramatically. Early studies found that vasopressin infusion can reverse septic shock in some patients, reducing or eliminating the need for catecholamine pressors. Although vasopressin may benefit patients who require less norepinephrine, its role in the treatment of septic shock seems to be a minor one overall.

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CIRCI should be strongly considered in patients who develop hypotension that does not respond to fluid replacement therapy.

Hydrocortisone (50 mg IV every 6 h) should be given; if clinical improvement occurs over 24–48 h, most experts would continue hydrocortisone therapy for 5–7 days before slowly tapering and discontinuing it. Meta-analyses of recent clinical trials have concluded that hydrocortisone therapy hastens recovery from sepsis-induced hypotension without increasing long-term survival.

Ventilator therapy is indicated for progressive hypoxemia, hypercapnia, neurologic deterioration, or respiratory muscle failure.

Sustained tachypnea (respiratory rate, >30 breaths/min) is frequently a harbinger of impending respiratory collapse; mechanical ventilation is often initiated to ensure adequate oxygenation, to divert blood from the muscles of respiration, to prevent aspiration of oropharyngeal contents, and to reduce the cardiac afterload. The results of recent studies favor the use of low tidal volumes (6 mL/kg of ideal body weight, or as low as 4 mL/kg if the plateau pressure exceeds 30 cmH2O). Patients undergoing mechanical ventilation require careful sedation, with daily interruptions;

elevation of the head of the bed helps to prevent nosocomial pneumonia.

Stress-ulcer prophylaxis with a histamine H2-receptor antagonist may decrease the risk of gastrointestinal hemorrhage in ventilated patients.

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Erythrocyte transfusion is generally recommended when the blood hemoglobin level decreases to ≤7 g/dL, with a target level of 9 g/dL in adults. Erythropoietin is not used to treat sepsis-related anemia.

Bicarbonate is sometimes administered for severe metabolic acidosis (arterial pH <7.2), but there is little evidence that it improves either hemodynamics or the response to vasopressor hormones. DIC, if complicated by major bleeding, should be treated with transfusion of fresh-frozen plasma and platelets. Successful treatment of the underlying infection is essential to reverse both acidosis and DIC. Patients who are hypercatabolic and have acute renal failure may benefit greatly from intermittent hemodialysis or continuous veno-venous hemofiltration.

Immunocompetent adult

The many acceptable regimens include (1) piperacillin-tazobactam(3.375 g q4–6h);

(2) imipenem-cilastatin (0.5 g q6h), ertapenem (1 g q24h), or meropenem (1 g q8h); or

(3) cefepime (2 g q12h).

If the patientis allergic to β-lactam agents, use ciprofloxacin (400 mg q12h) or

levofloxacin (500–750 mg q12h) plus clindamycin (600 mg q8h).

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Vancomycin (15 mg/kg q12h) should be added to each of the above regimens.

Neutropenia (<500 neutrophils/μL) Regimens include

1. imipenemcilastatin (0.5 g q6h) or meropenem (1 g q8h) or cefepime (2 g q8h) or

2. piperacillin-tazobactam (3.375 g q4h) plus tobramycin (5–7 mg/kg q24h).

Vancomycin (15 mg/kg q12h) should be added if the patient has an indwelling vascular catheter, has received quinolone prophylaxis, or has received intensive chemotherapy that produces mucosal damage; if staphylococci are suspected; if the institution has a high incidence of MRSA infections; or if there is a high prevalence of MRSA isolates in the community. Empirical antifungal therapy with an echinocandin (for caspofungin: a 70-mg loading dose, then 50 mg daily), voriconazole (6 mg/kg q12h for 2 doses, then 3 mg/ kg q12h), or a lipid formulation of amphotericin B should be added if the patient is hypotensive, has been receiving broad-spectrum antibacterial drugs, or remains febrile 5 days after initiation of empirical antibacterial therapy.

42 Splenectomy

Cefotaxime (2 g q6–8h) or ceftriaxone (2 g q12h) should be used.

If the local prevalence of cephalosporinresistant pneumococci is high, add vancomycin. If the patient is allergic to β-lactam drugs, vancomycin (15 mg/kg q12h) plus either moxifloxacin (400 mg q24h) or levofloxacin (750 mg q24h) should be used.

IV drug user

Vancomycin (15 mg/kg q12h) isessential.

AIDS

Cefepime alone (2 g q8h) or piperacillintazobactam (3.375 g q4h) plus tobramycin (5–7 mg/kg q24h) should be used. If the patient is allergic to β-lactam drugs, ciprofloxacin (400 mg q12h) or levofloxacin (750 mg q12h) plus vancomycin (15 mg/kg q12h) plus tobramycin should be used.

GENERAL SUPPORT

In patients with prolonged severe sepsis (i.e., that lasting more than or 3 days), nutritional supplementation may reduce the impact of protein hypercatabolism; the available evidence favors the enteral delivery route.

Prophylactic heparinization to prevent deep venous thrombosis is indicated for patients who do not have active bleeding or coagulopathy;

when heparin is contraindicated, compression stockings or an intermittent

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compression device should be used. Recovery is also assisted by prevention of skin breakdown, nosocomial infections, and stress ulcers.

The role of tight control of the blood glucose concentration in recovery from critical illness has been addressed in numerous controlled trials. Meta-analyses of these trials have concluded that use of insulin to lower blood glucose levels to 100–120 mg/dL is potentially harmful and does not improve survival rates. Most experts now recommend using insulin only if it is needed to maintain the blood glucose concentration below ~180 mg/dL. Patients receiving intravenous insulin must be monitored frequently (every 1–2 h) for hypoglycemia.

OTHER MEASURES

Despite aggressive management, many patients with severe sepsis or septic shock die. Numerous interventions have been tested for their ability to improve survival rates among patients with severe sepsis. The list includes endotoxin-neutralizing proteins, inhibitors of cyclooxygenase or nitric oxide synthase, anticoagulants, polyclonal immunoglobulins, glucocorticoids, a phospholipid emulsion, and antagonists to TNF-α, IL-1, platelet-activating factor, and bradykinin.

Unfortunately, none of these agents has improved rates of survival among patients with severe sepsis/septic shock in more than one large-scale, randomized, placebo-controlled clinical trial. Many factors have contributed to this lack of reproducibility, including (1) heterogeneity of