What are the stages of sepsis (Systemic Inflammatory Response Syndrome) progression to cardiac arrest?

From the Guidelines

Sepsis progresses through several distinct stages, including infection, severe sepsis, septic shock, and ultimately cardiac arrest, if left untreated or inadequately managed, with the most recent guidelines emphasizing early recognition and intervention to prevent this progression 1. The stages of sepsis can be outlined as follows:

• Infection: characterized by fever, increased heart rate, rapid breathing, and abnormal white blood cell count
• Severe sepsis: organ dysfunction develops, with signs including decreased urine output, altered mental status, difficulty breathing, and abnormal liver or kidney function tests
• Septic shock: persistent hypotension despite fluid resuscitation, requiring vasopressors like norepinephrine to maintain mean arterial pressure ≥65 mmHg Some key points to consider in the management of sepsis include:
• Early quantitative resuscitation with crystalloid fluids, with a target of at least 30 mL/kg within the first 3 hours 1
• Use of norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg 1
• Avoidance of hetastarch formulations and dopamine, except in highly selected circumstances 1
• Consideration of dobutamine infusion in the presence of myocardial dysfunction or ongoing signs of hypoperfusion despite adequate fluid resuscitation and vasopressor therapy 1
• Hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 1 The most critical aspect of sepsis management is early recognition and intervention, with a focus on restoring adequate tissue perfusion and preventing the progression to cardiac arrest 1.

From the Research

Stages of Sepsis Progressing to Cardiac Arrest

The progression of sepsis to cardiac arrest involves several stages, including:

• Sepsis: an overwhelming immune response to an infection, leading to inflammatory damage to multiple organ systems 2
• Severe sepsis: characterized by organ dysfunction, such as cardiac dysfunction, which can lead to decreased contractility and impaired ventricular response to fluid therapy 3
• Septic shock: a severe form of sepsis with persistent hypotension despite adequate fluid resuscitation, which can lead to cardiac arrest 2
• Cardiac dysfunction: characterized by decreased contractility, impaired ventricular response to fluid therapy, and ventricular dilatation, which can progress to cardiac arrest 3
• Multiple organ dysfunction syndrome (MODS): the failure of critical organ function, including the heart, which can lead to cardiac arrest 4, 5

Pathophysiology of Sepsis-Associated Cardiac Arrest

The pathophysiology of sepsis-associated cardiac arrest is complex and involves:

• Derangements of vascular tone and intravascular volume status 6
• Myocardial dysfunction, including decreased contractility and impaired ventricular response to fluid therapy 3
• Hypoxemia, acidemia, and other metabolic derangements 6
• Pulmonary hypertension 6
• Circulating factors, such as cytokines and nitric oxide, which can have direct inhibitory actions on myocyte contractility 3

Clinical Presentation and Treatment

The clinical presentation of sepsis-associated cardiac arrest can vary, but it is often characterized by:

• Persistent hypotension despite adequate fluid resuscitation 2
• Organ dysfunction, including cardiac dysfunction 3, 2
• Metabolic derangements, such as hypoxemia and acidemia 6 Treatment for sepsis-associated cardiac arrest typically involves:
• Early recognition and treatment of sepsis with antibiotics and hemodynamic support 2, 5
• Cardiopulmonary resuscitation and post-resuscitation care 6
• Potential therapeutic interventions, such as vasopressors and inotropes, to target the underlying pathophysiology 6, 3