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Sepsis is the most severe manifestation of various acute infections poses a significant challenge to the healthcare systems around the world. It is one of the leading causes of death in hospital settings and intensive care units (ICU) that is not associated with coronary heart diseases. The frequency of sepsis ranges from 250 to 350 cases per 100,000 patients in countries with advanced healthcare systems (Fleischmann 2016), such as Germany or the USA (Novosad et al. 2016). The purpose of this paper is to analyze the presented case study, give definitions and criteria for sepsis, identify signs and symptoms of septic shock, and give criteria for organ dysfunction using recent academic literature and the provided patient data.
Sepsis Definitions and Criteria
The Third International Consensus on sepsis and septic shock identifies sepsis as a life-threatening dysfunction caused by the body’s overwhelming and disproportionate response to an infection (Singer, Deutschman & Seymour 2016). For ease of clinical analysis and identification, it is recommended to use the Sequential Organ Failure Assessment table (SOFA). Should the patient receive an assessment score of two or higher, they are considered susceptible to sepsis.
Having a score or greater is associated with mortality rates greater than 10%, and ending with a score of 9 or more, which is associated with mortality rates of 95%. Typically, the criteria for the standard SOFA table include the analysis of the following parameters: respiration, coagulation, liver activity, cardiovascular activity, central nervous system responsiveness, renal activity, and urine output. However, the recently implemented screen called the qSOFA offers a different set of criteria for patient evaluation:
- Altered mental state. Slow reaction times, dizziness, forgetfulness.
- Respiratory rate of over 22 breaths per minute.
- Systolic hypotension of below 100 mm Hg.
According to the case study, the patient fits the criteria for qSOFA on day 5, with low blood pressure (SBP below 100 mm Hg), high respiratory rate (over 22 breaths per minute), and altered mental state (Glasgow Coma Scale score below 15). However, a retroactive analysis shows that the patient likely developed sepsis during day 2, which is three days prior to the completion of qSOFA (Raith, Udy & Bailey 2017).
Signs and Symptoms of Septic Shock
The Third International Consensus on sepsis and septic shock identifies septic shock as a subset of sepsis, characterized by severe circulatory, cellular, and metabolic abnormalities associated with greater risks of death when compared to regular sepsis (Singer, Deutschman & Seymour 2016). During septic shock, the blood pressure in a patient falls dangerously low, meaning that the cardiovascular system is not providing enough oxygen-enriched blood to body tissues, which often results in organ failure and ischemia (Sagy, Al-Qaqaa & Kim 2013).
Symptoms of septic shock include (Mayr, Yende & Angus 2014):
- Reduced temperature and paleness in arms and legs – explained by the lowered blood supply to the limbs.
- Increased or decreased body temperature, caused by inflammation.
- Altered mental status, which may present itself in the form of lightheadedness, dizziness, and confusion, caused by low blood pressure and decreased amounts of oxygen in the blood.
- Little to no urine – due to renal and urinal systems malfunction or failure.
- Low blood pressure.
- Motley skin, palpitations, skin rashes, discolorations.
- Shortness of breath, if septic shock affected the lungs.
The patient was earlier diagnosed with influenza type A H5N1 and yet had exhibited certain symptoms that are uncharacteristic to influenza in adults, such as low blood pressure and vomiting. Other symptoms that indicated sepsis was fever and lower tongue temperature caused by peripheral perfusion. Zach entered septic shock on day 5, with following symptoms and characteristics:
- Motley skin
- Respiratory ratio (PaO2/FiO2) deterioration from 210 to 84 as the patient entered severe ARDS
- Refractory hypotension, cannot maintain MAP.
- The patient showed signs of kidney injury and failure.
- Hepatocyte injury and ischemia caused by hypoxia, hypoperfusion, and inflammatory cytokines.
- Presence of gastrointestinal and metabolic issues.
Patient’s Organ Dysfunction at Day 2
It is hard to assess the extent of the patient’s organ dysfunction on Day 2, as he scored 3 points on the qSOFA test only during day 5. On day 2, the patient has prescribed Azithromycin against suspected bronchitis, which indicates that breathing and lungs were already suffering from dysfunction. Other dysfunctions include the levels of ScVO2 at 70% at the beginning of the treatment and then dropped due to inadequate cell utilization caused by mitochondrial dysfunction.
Urine output was poor from the beginning, below 50 milliliters per hour, while the target urine output is supposed to be over 1 ml per hour per kilogram of mass. This indicated that urinal and renal systems were likely suffering a dysfunction by day 2, which ended in renal failure by day 5. To summarize, the systems suffering dysfunction at day 2 were urinal systems, renal systems, and lungs.
Appropriateness of Resuscitation
The patient was administered 3 liters of resuscitation fluid – Albumin, over the course of 24 hours. Albumin is one of the standard solutions used for resuscitation for patients with sepsis and septic shock. It plays a critical role in regulating the volemic status, neutralizes free radicals in oxygen, and helps minimize any variations in PH level, which are often present during metabolic acidosis (Myburgh, & Mythen 2014).
So, in the patient’s case, the choice of the liquid is considered appropriate – especially considering that SAFE trials showed no statistical difference between 4% albumin solution and 0.9% NaCl solution (Caironi et al. 2014). Three liters is a decent quantity, as the majority of the patients rarely require more. However, there was an issue in how quick said fluid was provided – the patient received roughly 3 liters of fluids and measured lactate over 12 hours, which should have been done in three if followed the SS guidelines (Dellinger et al. 2012).
Some research, however, indicates that the use of fluid resuscitation in sepsis patients is used based on historical beliefs and incorrect and incomplete understanding of the pathophysiology of sepsis, which is one of the reasons for high mortality rates (Byrne & Van Haren 2017).
Sepsis is a very dangerous health complication with a high mortality rate, which can be triggered by inflammatory diseases. As demonstrated in this case study, the disease can avoid detection in earlier stages, as the current SOFA and qSOFA assessment systems require the disease to translate into later stages to be identified, which increases the risk of mortality and chances of a septic shock. In this case study, the patient developed sepsis by day 2 of hospital observation, yet the qSOFA identified it as sepsis only on day 5, and by that time the patient had already entered a state of septic shock with multiple organ dysfunction or failure, which ultimately lead to his death. Early detection of sepsis is paramount to the effectiveness of medical interventions aimed at stabilizing and treating the patient.
Byrne, L & Van Haren, F 2017, ‘Fluid resuscitation in human sepsis: time to rewrite history?’, Annals of Intensive Care, vol. 7, no. 4, pp. 1-8.
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