reliably exclude bacterial infection as a cause of
sepsis. 20,21
Computed tomography (CT) with oral contrast
remains the commonly used diagnostic modality
to identify abdominal and pelvic sepsis, and is
able to do so with high sensitivity and specificity
in the hands of an experienced radiologist.
However, safely moving a haemodynamically
unstable patient out of the critical care
environment into a CT scanner is never desirable
and, on some occasions, might not be possible.
The use of bedside diagnostic laparoscopy in such
instances may reduce the risk involved in
transferring unwell patients to a radiology
department and also avoid the adverse
consequences of negative laparotomy. 22,23
Specifically, mortality after a negative bedside
laparoscopy (18.3%) was also statistically lower
than the percentage of patients who died after
a negative exploratory laparotomy (38.9%) and
the mean operating time in those patients who
underwent laparotomy after bedside laparoscopy
was lower, possibly because a ‘tailored
laparotomy’ could then be undertaken. 23
Antimicrobial therapy
NICE guidelines emphasise rapid commencement
of empirical antimicrobial therapy based on data
showing a direct and strong relationship between
the timeliness of appropriate therapy and
survival. 14 While early administration of
appropriate antibiotics is, therefore paramount
in the management of sepsis, audits of clinical
practice in this area suggest there may be
considerable room for improvement. The third
patient report of the National Emergency
Laparotomy Audit 24 has examined patients with
peritonitis and reported that <25% patients
received their first dose of antibiotics within
1 hour and approximately 25% waited >6 hours
from admission respectively. The Surviving
Sepsis Campaign 8 reported that early antibiotic
administration within three hours was
independently associated with survival, but
this was achieved in only 67% of cases. 12 The
recommendation has since been changed to
delivery of antibiotics within one hour of
diagnosis of sepsis 12 but it seems even less likely
that this will be achieved unless there is a sea
change in clinical performance. NHS England
have aimed to do this by incorporating targets
for timely antibiotic treatment and review into
the CQUIN (Commissioning for Quality and
Innovation) payments framework for the care of
patients in England, leading to powerful financial
incentives for the delivery of optimum care.
In sepsis-induced hypotension, 75% of patients
survive with prompt recognition and
management but with every hour’s delay this
figure falls by >7%, implying that the mortality
typically increases by approximately 30%. 11
Longer-term studies show later death rates, one
year after a bout of septic shock to exceed 50% 18
and frequent functional impairment even in
those who survive. 19
Diagnosis
Early identification of sepsis remains a significant
challenge in critically ill patients. Research in
biomarkers of sepsis such procalcitonin,
C-reactive protein and cytokines (IL-6, IL-10) is
being undertaken to aid early identification of
sepsis and its association with various pathogens
and foci of infection.
Blood cultures are routinely performed in most
patients with sepsis and indeed, they form part of
sepsis 6/Hour-1 bundle. 16 However, false negative
results are extremely common, especially if
antibiotics have already been administered. There
is also usually a delay of 48–72 hours before
results of standard blood cultures and
microbiological sensitivities become available to
the treating clinician. Molecular assays that use
polymerase chain reaction to target the ribosomal
DNA sequences of common pathogens have been
developed for clinical application, as the ability to
detect bacterial DNA does not require the
presence of live bacteria in the blood stream.
While these techniques may allow rapid
identification of bacterial pathogens they appear
to lack adequate sensitivity to allow clinicians to
Source identification and control
Early detection and timely therapeutic
intervention can improve prognosis and overall
clinical outcome in septic patients. Patients with
severe sepsis are at greatest risk of developing
septic shock. There is no direct evidence to
confirm that delayed source control worsens
outcome but it seems obvious that it will. There
are obvious advantages to physically establishing
control of a source of infection before progression
to septic shock occurs, given the associated
5–10-fold rise in mortality which occurs as the
patient deteriorates. 25,26
Guidance on source control published in
32
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