What are the symptoms and treatment of septicemia?

Symptoms and Treatment of Septicemia

Septicemia presents with fever or hypothermia, tachycardia, tachypnea, and evidence of impaired organ perfusion including altered mental status, hypoxemia, elevated lactate, or oliguria—and requires immediate broad-spectrum intravenous antimicrobials within 1 hour of recognition along with aggressive fluid resuscitation of at least 30 mL/kg crystalloids. 1, 2

Clinical Symptoms

Systemic Inflammatory Signs

• Temperature dysregulation: Fever (≥38°C/100.4°F) or hypothermia (<35°C) 1, 3
• Cardiovascular: Tachycardia, bounding pulse in early stages, hypotension (systolic BP <90 mmHg or MAP <70 mmHg) 1, 4, 3
• Respiratory: Tachypnea, rapid breathing, breathlessness, difficulty breathing 1, 3

Organ Dysfunction Indicators

• Neurologic changes: Altered mental status, confusion, slurred speech, dizziness, obtundation or coma in advanced stages 1, 5, 4, 3
• Respiratory failure: Hypoxemia (PaO2/FiO2 <300), acute lung injury 1, 3
• Renal dysfunction: Oliguria (urine output <0.5 mL/kg/hr for ≥2 hours), elevated creatinine (>0.5 mg/dL increase or >2.0 mg/dL absolute) 1
• Metabolic: Elevated plasma lactate (>1 mmol/L), lactic acidosis 1, 4, 3

Additional Warning Signs

• Musculoskeletal: Severe muscle pain, extreme shivering/rigors 1, 5
• Skin changes: Clammy/sweaty skin, nonblanching rash, mottled or discolored skin, decreased capillary refill 1
• Gastrointestinal: Nausea, vomiting, diarrhea, absent bowel sounds (ileus) 1, 5
• Subjective: Feeling very unwell, impending sense of doom 1

Critical pitfall: Altered mental status, dyspnea, gastrointestinal symptoms, and muscle weakness are particularly strong predictors of severe sepsis (odds ratios 2.24-4.29) and should trigger immediate evaluation. 5

Immediate Treatment Protocol

First Hour: Antimicrobial Therapy

• Administer broad-spectrum intravenous antimicrobials within 1 hour of recognizing septic shock or severe sepsis 1, 6
• Obtain blood cultures before antibiotics if no significant delay (<45 minutes) occurs 6
• Choose empiric coverage targeting all likely pathogens (bacterial, fungal, or viral) with adequate tissue penetration 1
• Example regimen: Ceftriaxone covers common septicemia pathogens including Staphylococcus aureus, Streptococcus pneumoniae, E. coli, Haemophilus influenzae, and Klebsiella pneumoniae 7

First 3-6 Hours: Fluid Resuscitation

• Administer at least 30 mL/kg of intravenous crystalloid fluid within the first 3-6 hours for sepsis-induced hypoperfusion 1, 2, 6
• Deliver rapidly over 5-10 minutes 2
• Use crystalloids as first-line; consider albumin only if substantial crystalloid volumes are required 2
• Avoid hetastarch formulations entirely 2
• Continue fluid challenges as long as hemodynamic improvement occurs 2

Hemodynamic Targets

• Mean arterial pressure (MAP) ≥65 mmHg 1, 2, 6
• Central venous pressure 8-12 mmHg 1
• Urine output ≥0.5 mL/kg/hr 1, 2
• Central venous oxygen saturation (ScvO2) ≥70% 1, 2

Vasopressor Support

• Initiate norepinephrine as first-choice vasopressor when MAP <65 mmHg despite adequate fluid resuscitation 1, 2
• Dose: 0.1-1.3 µg/kg/min 1
• Avoid dopamine except in highly selected circumstances due to increased cardiac adverse events 1, 2
• Vasopressin (0.01-0.04 U/min) can be added to norepinephrine but should not be used as initial vasopressor 1, 2

Inotropic Support (When Indicated)

• Do NOT routinely use inotropes 2
• Administer dobutamine only when BOTH conditions are met: (1) low cardiac output with elevated cardiac filling pressures, AND (2) ScvO2 <70% despite adequate fluid resuscitation and MAP optimization 2
• Combination of dobutamine plus norepinephrine is recommended as first-line when inotropic therapy is indicated 2

Ongoing Management

Antimicrobial Reassessment

• Reassess antimicrobial regimen daily for potential de-escalation 1
• Adjust therapy to pathogen susceptibility once culture results available 1
• Typical duration: 7-10 days (longer courses for slow clinical response, undrained foci, S. aureus bacteremia, fungal/viral infections, or immunodeficiency) 1

Glucose Control

• Commence insulin when two consecutive blood glucose levels are >180 mg/dL 1, 2
• Target upper blood glucose ≤180 mg/dL (NOT ≤110 mg/dL) 1, 2
• Monitor glucose every 1-2 hours until stable, then every 4 hours 1, 2

Supportive Care

• Deep vein thrombosis prophylaxis: Daily subcutaneous low-molecular weight heparin (or unfractionated heparin if creatinine clearance <30 mL/min) 1, 2
• Stress ulcer prophylaxis: H2 blocker or proton pump inhibitor if bleeding risk factors present 1, 2
• Renal replacement: Continuous and intermittent therapies are equivalent; use continuous therapies for hemodynamically unstable patients 1, 2
• Nutrition: Administer oral or enteral feedings as tolerated within first 48 hours; avoid mandatory full caloric feeding in first week 1

Monitoring Parameters

• Hourly urine output 2
• Lactate levels and biochemical markers of renal function 2
• ScvO2 with target ≥70% 2
• Hemoglobin target 7-9 g/dL 2

Critical pitfall: Worsening or ongoing organ dysfunction and persistence of fever for >48-72 hours following treatment initiation should prompt reassessment for inadequate antimicrobial therapy, missed infectious focus, insufficient supportive therapy, new antimicrobial resistance, hospital-acquired infection, or non-infectious disease mimicking sepsis. 1