History
Symptoms of sepsis are usually nonspecific and include fever, chills, and constitutional symptoms of fatigue, malaise, anxiety, or confusion. [18] These symptoms are not pathognomonic for infection and may also be observed in a wide variety of noninfectious inflammatory conditions. In addition, they may be absent in patients with serious infections, especially in elderly individuals.
Because systemic inflammatory response syndrome (SIRS), sepsis, septic shock, and multiple organ dysfunction syndrome (MODS) represent a clinical continuum (see Overview), the specific features exhibited in any given case depend on where the patient falls on that continuum.
Fever is a common feature of sepsis. Fever of infectious origin results from resetting the hypothalamus so that heat production and heat loss are balanced to maintain a higher temperature. An abrupt onset of fever usually is associated with a large infectious load.
Chills are a secondary symptom associated with fever and result from increased muscular activity in an attempt to produce heat and thereby raise the body temperature to the level required to reset the hypothalamus.
Sweating occurs when the hypothalamus returns to its normal set point and senses that the body temperature is above the desired level. Perspiration is stimulated to offload excess body heat through evaporative cooling.
Altered mental function is often observed. Mild disorientation or confusion is especially common in elderly individuals. More severe manifestations include apprehension, anxiety, and agitation, and in some cases, coma may eventually ensue. The mechanism by which mental function is altered is not known, but altered amino acid metabolism has been proposed as a cause of metabolic encephalopathy.
Hyperventilation with respiratory alkalosis is a common feature of sepsis. Stimulation of the medullary ventilatory center by endotoxins and other inflammatory mediators has been proposed as the cause of hyperventilation.
The following localizing symptoms are some of the most useful clues to the etiology of both fever and sepsis:
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Head and neck infections - Earache, sore throat, sinus pain, or swollen lymph glands
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Chest and pulmonary infections - Cough (especially if productive), pleuritic chest pain, and dyspnea
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Abdominal and gastrointestinal (GI) infections - Abdominal pain, nausea, vomiting, and diarrhea
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Pelvic and genitourinary (GU) infections - Pelvic or flank pain, vaginal or urethral discharge, urea, frequency, urgency
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Bone and soft tissue infections - Focal pain or tenderness, focal erythema, edema
Physical Examination
The physical examination focuses first on the general condition of the patient. Assess the patient’s overall hemodynamic condition to search for signs of hyperperfusion. Look for signs suggestive of a focal infection. An acutely ill, toxic appearance is a common feature in patients with serious infections.
The vital signs may suggest sepsis, even if fever is absent. As noted (see above), tachypnea is common; tachycardia with an increased pulse pressure also is common.
Measure the body temperature accurately. Because oral temperatures are often unreliable, rectal temperatures should be obtained.
Investigate signs of systemic tissue perfusion. In the early stages of sepsis, cardiac output is well maintained or even increased. Along with the effects of vasodilatory mediators, this may result in warm skin, warm extremities, and normal capillary refill. As sepsis progresses, stroke volume and cardiac output fall. Patients begin to manifest signs of poor distal perfusion, including cool skin, cool extremities, and delayed capillary refill.
The following physical signs suggest focal, usually bacterial, infection:
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Central nervous system (CNS) infection - Profound depression in mental status and meningismus
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Head and neck infections - Inflamed or swollen tympanic membranes, sinus tenderness, pharyngeal exudates, stridor, cervical lymphadenopathy
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Chest and pulmonary infections - Localized rales or evidence of consolidation
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Cardiac infections - Regurgitant valvular murmur
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Abdominal and GI infections - Focal tenderness, guarding or rebound, rectal tenderness, or swelling
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Pelvic and GU infections - Costovertebral angle tenderness, pelvic tenderness, cervical motion pain, and adnexal tenderness
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Bone and soft tissue infections - Focal erythema, edema, infusion, and tenderness
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Skin infections - Petechiae and purpura
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Stages of sepsis based on American College of Chest Physicians/Society of Critical Care Medicine Consensus Panel guidelines.
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Pathogenesis of sepsis and multiorgan failure.
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Venn diagram showing overlap of infection, bacteremia, sepsis, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction.
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Acute respiratory distress syndrome (ARDS) present in this chest x-ray (CXR) film is a common organ system affected in multiorgan failure of sepsis.
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Acute respiratory distress syndrome (ARDS) shown in this chest x-ray (CXR) film is a common complication of septic shock. Note bilateral airspace infiltration, absence of cardiomegaly, vascular redistribution, and Kerley B lines.
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Organizing phase of diffuse alveolar damage (ARDS) secondary to septic shock shows diffuse alveolar injury and infiltration with inflammatory cells.
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Organizing diffuse alveolar damage in a different location showing disorganization of pulmonary architecture.
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A high-power view of organizing diffuse alveolar damage (ARDS) shows hyperplasia of type II pneumocytes and hyaline membrane deposits.
Tables
Organ System |
Mild Criteria |
Severe Criteria |
Pulmonary |
Hypoxia or hypercarbia necessitating assisted ventilation for 3-5 days |
ARDS requiring PEEP >10 cm H2 O and FI O2< 0.5 |
Hepatic |
Bilirubin 2-3 mg/dL or other liver function tests >2 × normal, PT elevated to 2 × normal |
Jaundice with bilirubin 8-10 mg/dL |
Renal |
Oliguria (< 500 mL/day) or increasing creatinine (2-3 mg/dL) |
Dialysis |
Gastrointestinal |
Intolerance of gastric feeding for more than 5 days |
Stress ulceration with need for transfusion, acalculous cholecystitis |
Hematologic |
aPTT >125% of normal, platelets < 50-80,000 |
DIC |
Cardiovascular |
Decreased ejection fraction with persistent capillary leak |
Hyperdynamic state not responsive to pressors |
CNS |
Confusion |
Coma |
Peripheral nervous system |
Mild sensory neuropathy |
Combined motor and sensory deficit |
aPTT = activated partial thromboplastin time; ARDS = acute respiratory distress syndrome; CNS = central nervous system; DIC = disseminated intravascular coagulation; FI O2 = fraction of inspired oxygen; PEEP = positive end-expiratory pressure; PT = prothrombin time. |
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