Basic treatment principles
The management tactics for patients with sepsis directly depend on the primary focus and the severity of the condition. The main rule is the emergency transfer of the patient to an appropriate intensive care unit (surgical, obstetric, or cardiological).
Medical treatment is based on the following measures:
- Antibacterial therapy: prescribed immediately, usually as empiric combinations. For example, in obstetric and gynecological sepsis, regimens of ceftriaxone with gentamicin or vancomycin with metronidazole are used.
- Rehydration and detoxification: intravenous administration of solutions to correct hemodynamics and relieve intoxication.
- Combating shock: upon the development of infectious-toxic shock with a sharp drop in blood pressure, glucocorticosteroids such as prednisolone are used.
- Debridement of the focus: if a purulent focus is present (furuncle, infected wound), its surgical cleansing is necessary.
Diagnostic procedures
Therapeutic success is impossible without rapid and accurate diagnosis. When sepsis is suspected, the examination algorithm includes:
- Laboratory tests: complete blood count and blood biochemistry, determination of systemic inflammation markers (procalcitonin, presepsin, CRP).
- Microbiology: blood cultures, cerebrospinal fluid, and other biological fluids on nutrient media (sugar and bile broths) to identify the pathogen, as well as PCR diagnostics.
- Instrumental methods: chest X-ray, ECG, ultrasound (including transesophageal echocardiography to search for valve vegetations when endocarditis is suspected).
- Differential diagnosis: it is important to exclude particularly dangerous infections (plague, anthrax), meningococcal infection, malaria, and other severe diseases.
Pathogenesis and systemic inflammatory response
Sepsis is considered the result of systemic inflammatory response syndrome (SIRS) triggered by an infectious agent.
The development of the condition goes through two main stages:
- Hyperinflammation: massive release of pro-inflammatory cytokines and nitric oxide. This leads to microcirculatory disorders, the development of shock, and multiple organ dysfunction syndrome (MODS).
- Compensatory response: a period of immune paralysis when anti-inflammatory mechanisms are activated, reducing the functional activity of immune cells. In some patients, this suppressive response forms right from the start.
Interestingly, specific immunity to the causative pathogen is not formed after overcoming sepsis, and the fight against microbes in sterile environments is mainly carried out through phagocytosis and innate immune factors.
Briefly: answers to topical questions
Which specific pro-inflammatory cytokines are massively released during the hyperinflammation stage?
During the systemic reaction stage, a massive release of inflammatory mediators occurs, known as a cytokine storm. The main pro-inflammatory cytokines include:
- Tumor necrosis factor-alpha — is the main mediator of the systemic inflammatory response;
- Interleukin-1 (including IL-1β) — acts together with TNFα via a positive feedback loop;
- Interleukin-6 (IL-6) — high concentrations have a direct damaging effect on the myocardium;
- Interleukin-8 (IL-8);
- Gamma-interferon (γ-interferon).
What drugs are used for vasopressor and inotropic support in septic shock, besides glucocorticosteroids?
For vasopressor and inotropic support in septic shock, sources indicate:
- Norepinephrine — used as a vasopressor in monotherapy or in combination;
- Epinephrine — can be used in combination with norepinephrine, as well as for inotropic support;
- Vasopressin — can be used in combination with norepinephrine;
- Dobutamine — a drug for inotropic support;
- Levosimendan — a drug for inotropic support.
What target mean arterial pressure (MAP) must be maintained in the treatment of septic shock?
In the treatment of septic shock, the target mean arterial pressure (MAP) must be maintained at no less than 65 mmHg. This value is achieved with adequate fluid resuscitation, and if ineffective, through vasopressor support.
Class and exam questions
What is the first aid for the development of infectious-toxic shock?
In case of a sharp drop in blood pressure and signs of infectious-toxic shock, intravenous administration of prednisolone is necessary to stabilize hemodynamics.
Does immunity develop after sepsis?
No, specific immunity to a particular pathogen does not develop after recovering from a septic process.
Which antibiotics are used before blood culture results are obtained?
Broad-spectrum empiric combinations are used, for example, ceftriaxone with gentamicin or vancomycin with metronidazole.
What else to study on this topic
- Criteria for systemic inflammatory response syndrome (SIRS)
- Clinical features of cryptogenic sepsis
- Diagnosis and treatment of infective endocarditis
- Differential diagnosis of sepsis and particularly dangerous infections
- Action algorithm in obstetric and gynecological sepsis
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