What are the predictors of sepsis and how is it managed?

Predictors and Management of Sepsis

The most reliable predictors of sepsis include qSOFA score (altered mentation, systolic blood pressure ≤100 mmHg, and respiratory rate ≥22/min), SOFA score parameters, and clinical signs of systemic inflammatory response with suspected infection, while management requires immediate antimicrobial therapy, aggressive fluid resuscitation, vasopressors when needed, and organ support. 1

Predictors of Sepsis

Clinical Criteria and Scoring Systems

• qSOFA (quick Sequential Organ Failure Assessment) score is a valuable bedside tool to identify patients at risk of sepsis, especially in non-ICU settings, with points assigned for:

  • Altered mental status
  • Systolic blood pressure ≤100 mmHg
  • Respiratory rate ≥22/min 2, 3

• SOFA score provides more comprehensive assessment of organ dysfunction in ICU settings, evaluating:

  • PaO2/FiO2 ratio (respiratory function)
  • Glasgow Coma Scale (neurological function)
  • Mean arterial pressure/vasopressor requirements
  • Bilirubin levels (liver function)
  • Platelet count (coagulation)
  • Creatinine levels or urine output (renal function) 1

• Clinical signs of systemic inflammatory response:

  • Heart rate >90 beats per minute
  • Temperature <36°C or >38°C
  • Respiratory rate >20 breaths per minute
  • Malaise and/or apathy 1

Laboratory and Biomarkers

• Elevated inflammatory markers:

  • C-reactive protein
  • Procalcitonin (more specific for bacterial infection)
  • Lactate levels (≥2 mmol/L indicates tissue hypoperfusion) 1

• Organ dysfunction indicators:

  • Elevated creatinine (≥0.5 mg/dL increase)
  • Hyperbilirubinemia (>4 mg/dL)
  • Coagulation abnormalities (INR >1.5, thrombocytopenia <100,000/μL)
  • Hyperlactatemia (>1 mmol/L) 1

Risk Factors

• The PIRO system assesses sepsis risk across four domains:

  • Predisposition (comorbidities, especially COPD)
  • Infection (site, pathogen)
  • Response (inflammatory markers)
  • Organ dysfunction 1

• Compensatory Reserve Measurement (CRM) using photoplethysmography has shown promise in early detection of sepsis with higher sensitivity than conventional tools 4

Management of Sepsis

Immediate Interventions (First Hour)

• Recognize sepsis as a medical emergency requiring immediate treatment 1

• Obtain appropriate microbiological cultures before starting antimicrobials (if no substantial delay) 1

• Administer broad-spectrum antimicrobials within the first hour of recognition of sepsis or septic shock 1

  • For neutropenic patients: meropenem, imipenem/cilastatin, or piperacillin/tazobactam 1

• Begin aggressive fluid resuscitation:

  • Administer at least 30 mL/kg of intravenous crystalloid fluid within the first 3 hours 1
  • Further fluid administration should be guided by frequent hemodynamic reassessment 1

Ongoing Management

• Hemodynamic support:

  • Target mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 1
  • Use dynamic variables (pulse pressure variation, passive leg raises) over static measurements to predict fluid responsiveness 1
  • Consider echocardiography for detailed assessment of hemodynamic status 1

• Respiratory support for sepsis-induced ARDS:

  • Use low tidal volume ventilation (6 mL/kg predicted body weight) 1
  • Maintain plateau pressures ≤30 cm H2O 1
  • Apply positive end-expiratory pressure (PEEP) to avoid alveolar collapse 1
  • Consider prone positioning for severe hypoxemia (PaO2/FiO2 ratio <150 mmHg) 1

• Ongoing monitoring:

  • Reassess clinical status frequently (heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output) 1
  • Consider guiding resuscitation to normalize lactate in patients with elevated levels 1
  • Monitor organ function using SOFA score 1

Special Considerations

• In resource-limited settings:

  • Focus on simple diagnostic criteria based on physical examination 1
  • Implement robust triage systems to quickly recognize critically ill patients 1
  • Early warning scores combined with abdominal signs may help screen patients needing acute care surgery 1

• For neutropenic patients:

  • Any neutropenic patient with signs of systemic inflammatory reaction without obvious non-infectious cause has high probability of sepsis 1
  • Empirical antimicrobial treatment must be started immediately 1
  • PCR-based methods may be useful for detecting specific pathogens like CMV 1

Pitfalls and Caveats

• The new definition of sepsis requiring organ dysfunction may delay diagnosis and treatment; maintain awareness of early recognition and intervention 1

• qSOFA has better predictive validity than SOFA in non-ICU settings, while SOFA performs better in ICU settings 2

• Prognostic scoring systems (APACHE II, SAPS II) should not be used exclusively for end-of-life decisions in individual patients 1

• CVP alone is no longer justified to guide fluid resuscitation due to limited ability to predict fluid responsiveness 1

• Excessive fluid administration may be harmful, particularly in patients with compensated shock and profound anemia 1