Introduction
Definitions - Bacteremia
Presence of bacteria in the blood, as evidenced by positive blood culture
Definitions - Septicemia
Presence of microbes or their toxins in blood
Definitions - SIRS
SIRS can occur in response to a variety of severe clinical insults & is defined by
presence of two or more of following conditions
Temperature higher than 38° C or lower than 36° C
Tachycardia – HR > 90 beats per minute
Tachypnea – RR > 20 breaths per minute or a Paco2 lower than 32 mm Hg
White blood cell count > 12,000 cells/mm3 or < 4000 cells/mm3
Definitions - Sepsis
Sepsis occurs when SIRS is caused by infection
OR
SIRS that has a proven or suspected microbial etiology
Definitions – Severe sepsis
Severe sepsis is sepsis with associated organ dysfunction, hypoperfusion, or
hypotension
OR
Sepsis with one or more signs of organ dysfunction
Inflammatory variables
Leukocytosis (WBC count >12,000 cells/mm3)
Leukopenia (WBC count 4000 cells/mm3)
Normal WBC count with > 10% immature forms
Plasma C-reactive protein > 2 SD above normal value
Plasma procalcitonin > 2 SD above normal value
Hemodynamic variables
Arterial hypotension (SBP < 90 mm Hg, MAP < 70mm hg, or an SBP decrease >
40 mm Hg in adults or < 2 SD below normal for age)
EPIDEMIOLOGY
Currently, gram-positive bacteria are predominant pathogens in severe sepsis
The incidence of sepsis due to fungal organisms has increased substantially over
last 20 years
The most common sites of infection are respiratory system,bloodstream, &
genitourinary tract
PATHOPHYSIOLOGY
Severe sepsis is the end result of complex interactions between infecting
organisms & host response
Important components of this host response in early phases of sepsis are immune
system, activation of inflammatory cascade & alterations in hemostasis
In later stages, organ failure, immunosuppression & apoptosis play important
pathophysiologic roles
Characteristics of both infecting organism & host response influence outcome of
sepsis
Virulence factors, high burden of infection & resistance to antibiotics are all
organism characteristics associated with higher risk of severe sepsis
Immune response
The immune response to infection takes place through actions of two pathways
Innate immune system
Adaptive immune system
Goal of innate immune system is to provide protection in first minutes to hours
after an infectious challenge
Although it was initially thought to be a nonspecific response, research has
demonstrated that the innate immune system recognizes pathogens by means of pattern-
recognition receptors called Toll-like receptors
These receptors bind to highly conserved structures on microorganisms, which are
not easily altered by microbes to evade detection & are present on broad groups of
organisms
Current understanding of TLRs suggests that immune cells use different TLRs to
detect several features of an organism & generate a tailored response to invading
pathogen
Immune response
Activation of TLRs by microorganisms stimulates signaling pathways that
increase production of
Proinflammatory cytokines, such as tumor necrosis factor-alpha (TNF-α),
interleukin-1β (IL-1β) & nuclear factor-κB
Anti-inflammatory cytokines, such as IL-10
Upregulation of microbial killing mechanisms, such as production of reactive
nitrogen species
Role of Inflammation
For many years, prevailing theory has been that sepsis is result of an uncontrolled
inflammatory response
Animal models of sepsis that used large doses of endotoxin or bacteria created a
“cytokine storm”
Early blockage of this cytokine storm resulted in improvements in mortality
Most human patients with sepsis, however, have a complex host response that
involves activation of both proinflammatory and anti-inflammatory cascades
The interplay among proinflammatory cytokines, anti-inflammatory cytokines, &
cytokine inhibitors is a dynamic process that influences host response to sepsis
Proinflammatory cytokines such as TNF-α & IL-1β increase early in sepsis &
have overlapping & synergistic effects in further stimulating inflammatory cascade
Proinflammatory cytokines
Activate monocytes, macrophages & neutrophils
An important role in development of clinical abnormalities such as
• Fever, hypotension, capillary leakage with decreased intravascular volume &
myocardial depression
Anti-inflammatory cytokines in sepsis is still not fully understood
Current understanding - sepsis-induced multiple organ failure & death may be
caused, in part, by a shift to an anti-inflammatory phenotype & by apoptosis of key
immune cells
This shift is driven partially by increased levels of anti-inflammatory cytokines &
results from a shift in helper T-cell populations (from Th1 to Th2)
Alterations of Hemostasis
Septic shock
PATHOGENESIS
Septic shock results when infectious microorganisms in bloodstream induce a
profound inflammatory response causing hemodynamic decompensation
Pathogenesis involves a complex response of cellular activation that triggers
release of a multitude of proinflammatory mediators
This inflammatory response causes activation of leukocytes & endothelial cells,
as well as activation of coagulation system
Excessive inflammatory response that characterizes septic shock is driven
primarily by cytokines tumor necrosis factor alpha (TNF-α) & interleukin-1 (IL-1), which
are produced by monocytes in response to an infection
Although TNF and IL-1 are central to pathophysiology of septic shock,a number
of other vital mediators are also known to play a major role including high-mobility
group box 1 (HMGB1) protein
Although systemic inflammatory response of sepsis triggers profound
macrocirculatory & microcirculatory changes that impair tissue perfusion, another
important mechanism playing a role in development of acute organ dysfunction in septic
shock is apoptosis (programmed cell death)
Accelerated apoptosis is a pivotal pathogenic event in this disease
CLINICAL PRESENTATION
Patients with septic shock will typically manifest signs of systemic inflammation
Fever
Tachycardia
Tachypnea
Elevation of the white blood cell count
Septic shock
Hypovolemia
Myocardial Dysfunction
Septic shock is associated with depression of biventricular function with a
decrease in ejection fraction
Ventricular dilation occurs as a compensatory mechanism & raises end-diastolic
volume so that stroke volume can be preserved
When myocardial dysfunction occurs, a high CO can still be achieved in many
circumstances because of biventricular dilation, tachycardia & arteriolar dilation, as long
as patient is adequately volume resuscitated & does not have a preexisting
cardiomyopathy or severe cardiac suppression
Myocardial Dysfunction
Most important inflammatory mediators that induce myocardial depression are
TNF-α, IL-1, & nitric oxide
Coronary blood flow is typically normal or increased in septic shock
Although coronary blood flow can be diminished by severe arterial hypotension
that compromises coronary perfusion pressure,myocardial ischemia does not appear to be
causative factor of depression in myocardial performance
Nearly half of patients with septic shock will have echocardiographic evidence of
depressed systolic function, even in absence of preexisting cardiac disease
However, myocardial depression is typically not judged to be predominant feature
of septic shock hemodynamic profile
For majority of patients, aggressive volume resuscitation to restore adequate
cardiac filling pressures will be enough to achieve a reasonable cardiac output
Distributive Shock
After restoration of adequate cardiac filling pressures & optimal CO in pts with
septic shock, tissue hypoxia may still occur via a number of pathogenic mechanisms
These mechanisms of tissue hypoxia in face of a normal or a supranormal CO
may be caused by either
Microcirculatory failure
Mitochondrial dysfunction
Microcirculatory Dysfunction
Mitochondrial Dysfunction
Cellular utilization of oxygen can be markedly impaired in septic shock even after
effective restoration of blood flow to tissues has been achieved, & this has been termed
cytopathic hypoxia
Proposed mechanisms that result in cytopathic hypoxia in sepsis include
Diminished delivery of pyruvate into mitochondria
Inhibition of mitochondrial enzymes
Activation of poly-adenosine phosphate-ribosyl polymerase (PARP)
Management - guidelines