Page 831 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

562 PART 5: Infectious Disorders

CONCLUSION CHAPTER Sepsis, Severe Sepsis, and

Over half of all intensive care patients will develop fever sometime Septic Shock
during their ICU stay and countless additional patients will present to 64
the ICU with established fever or hyperthermia. An elevated tempera- Jenny Han
ture causes great concern in health care providers and is often regarded Sushma K. Cribbs
as a marker of an unwanted complication. Near 50% of all unexplained Greg S. Martin
fevers in intensive care patients are from noninfectious causes. The
occurrence of a fever deserves a critical and systematic appraisal to
provide the best and appropriate level of response. But because it can be KEY POINTS
difficult to exclude infection using only clinical data, the initial approach
to fever often involves additional imaging, cultures, and escalation of • The definition of sepsis is two or more systemic inflammatory
antibiotics. Fever by design is often a normal adaptive response and response criteria plus a known or suspected infection.
suppressive interventions may fail to provide benefit to many patients. • Severe sepsis is sepsis with acute organ dysfunction. Acute organ
dysfunction can manifest in any organ, and frequently manifests
clinically as shock, respiratory failure, acute kidney injury, hemato-
logic or metabolic disturbances, or neurologic decline. Septic shock
KEY REFERENCES is a form of severe sepsis where the organ dysfunction involves the
• Circiumaru B, Baldock G, Cohen J. A prospective study of fever cardiovascular system.
in the intensive care unit. Intensive Care Med. July 1999;25(7): • Sepsis results in a complex set of interactions between the incit-
668-673. ing microbes and the host immune response, which triggers the
• Commichau C, Scarmeas N, Mayer SA. Risk factors for fever in the inflammatory cascade and coagulation pathway.
neurologic intensive care unit. Neurology. March 11, 2003;60(5): • Management of sepsis patients involves early infection recogni-
837-841. tion, source control, fluid therapy, antibiotics, and hemodynamic
• de la Torre SH, Mandel L, Goff BA. Evaluation of postoperative supportive care. Early goal-directed therapy is the term for current
fever: usefulness and cost-effectiveness of routine workup. Am J early fluid resuscitation strategies that target central venous or
Obstet Gynecol. 2003;188(6):1642-1647. mixed venous oxygen saturation.
• Gozzoli V, Schottker P, Suter PM, Ricou B. Is it worth treating fever • The most common parameters used in monitoring septic patients
in intensive care unit patients? Preliminary results from a random- are pulse oximetry, arterial blood pressure, central venous pressure,
ized trial of the effect of external cooling. Arch Intern Med. January central venous or mixed venous oxygen saturation, and blood lac-
8, 2001;161(1):121-123. tate. Other parameters that may guide therapy include cardiac out-
• Laupland KB. Fever in the critically ill medical patient. Crit Care put, systemic vascular resistance, and extravascular lung water. Each
Med. July 2009;37(suppl 7):S273-S278. of these parameters is complementary and may assist in both the
early and late management of sepsis, organ dysfunction, and shock.
• Laupland KB, Shahpori R, Kirkpatrick AW, Ross T, Gregson DB,
Stelfox HT. Occurrence and outcome of fever in critically ill adults. • Sepsis care bundles have become an integral part of the “Surviving
Sepsis Campaign,” which aimed to improve survival from severe
Crit Care Med. May 2008;36(5):1531-1535. sepsis. These multifaceted interventions facilitate compliance
• Mackowiak PA, LeMaistre CF. Drug fever: a critical appraisal of with evidence-based guideline recommendations by creating two
conventional concepts. An analysis of 51 episodes in two Dallas “bundles” that are sequentially completed at 6 and 24 hours.
hospitals and 97 episodes reported in the English literature. Ann
Intern Med. 1987;106(5):728-733.
• Marik PE. Fever in the ICU. Chest. March 2000;117(3):855-869. DEFINITIONS AND EPIDEMIOLOGY
• Niven DJ, Stelfox HT, Shahpori R, Laupland KB. Fever in
adult ICUs: an interrupted time series analysis. Crit Care Med. Sepsis has been a life-threatening medical condition since the first steps
2013;41(8):1863-1869. in evolution. Antimalarial compounds were prescribed for fever in
• O’Grady NP, Barie PS, Bartlett JG, et al. Guidelines for evalu- China as early as 2735 bc and Hippocrates recognized the anti-infective
properties of wine and vinegar around 400 bc. The basic premise of
ation of new fever in critically ill adult patients: 2008 update infection and immune response were recognized from the time that
from the American College of Critical Care Medicine and the Marcus Terentius Varro in 100 bc noted that “small creatures invisible
Infectious Diseases Society of America. Crit Care Med. April to the eye, fill the atmosphere, and breathed through the nose cause dan-
2008;36(4):1330-1349. gerous diseases.” These early concepts carried through the Black Death
• Rehman T, Deboisblanc BP. Persistent fever in the ICU. Chest. plague of the middle ages and Janssen’s invention of the microscope, to
2014;145(1):158-165. Louis Pasteur’s germ therapy, and on to Ignaz Semmelweis and Joseph
• Schulman CI, Namias N, Doherty J, et al. The effect of antipyretic Lister’s antisepsis practices. At the turn of the last century, William Osler
therapy upon outcomes in critically ill patients: a randomized, recognized that “the patient appears to die from the body’s response to
prospective study. [Erratum appears in Surg Infect (Larchmt). infection rather than from it.”
October 2010;11(5):495 Note: Li, Pam [corrected to Li, Pamela]; Despite clear advances in understanding infection and the immune
Alhaddad, Ahmed [corrected to Elhaddad, Ahmed]]. Surg Infect. response, sepsis was not recognized as a specific medical entity deserv-
2005;6(4):369-375. ing of recognition and focused study until the 1970s. In order to facilitate
the study of sepsis, in 1992 the American College of Chest Physicians
(ACCP) and the Society of Critical Care Medicine (SCCM) jointly
developed a set of consensus definitions for sepsis and related disorders
1
REFERENCES (Table 64-1). In so doing, the ACCP/SCCM consensus definitions
immediately created a clinically applicable definition that may be used
Complete references available online at www.mhprofessional.com/hall at the bedside and can be used equally to identify patients for clinical

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