Corticosteroids reduce mortality but increase neuromuscular weakness in sepsis and septic shock
Corticosteroids reduce mortality (by approximately 2%) but increase the risk of neuromuscular weakness in patients with sepsis or septic shock, according to an international panel that reviewed conflicting recent evidence. The panel concluded that the overall body of evidence offers weak support for the use of corticosteroids in patients with sepsis with or without shock but said a no-steroid approach remained reasonable. Patient values and preferences may help guide the decision on whether or not to use corticosteroids. Patients who would prioritize living over quality-of-life would likely choose to have corticosteroid treatment, whereas those who would place more value on avoiding functional deterioration than avoiding death may be more likely to choose a no-steroid management approach.
See Management: approachSepsis patients who receive prolonged infusion of antipseudomonal beta-lactam antibiotics are 30% less likely to die, meta-analysis finds
There has been long-running debate over whether prolonged infusion of intravenous antibiotics, including beta-lactams, is more effective than standard infusion in improving outcomes in sepsis. Now a meta-analysis has found that patients with sepsis who received their intravenous antipseudomonal beta-lactam infusion over at least 3 hours were 30% less likely to die than those who received beta-lactam either as a bolus or as a short-term infusion over 1 hour or less (RR 0.7, 95% CI 0.56 to 0.87). The meta-analysis included 22 randomized controlled trials totalling 1876 patients. The authors concluded that the weight of evidence is high for the benefits of prolonged infusion in patients with sepsis. An accompanying editorial called for the prolonged infusion of beta-lactams over at least 3 hours to become standard practice in intensive care unit settings, even though most administration guides still recommend an infusion over 15 to 60 minutes. [123]
See Management: approach See Management: treatment algorithmSummary
Definition
History and exam
Key diagnostic factors
- high (>101°F [>38°C]) or low (<96.8°F [<36°C]) temperature
- tachycardia
- tachypnea
- acutely altered mental status
- poor capillary refill, mottling of the skin, or ashen appearance
- signs associated with specific source of infection
- low oxygen saturation
- arterial hypotension
- decreased urine output
- cyanosis
Risk factors
- underlying malignancy
- age >65 years
- immunocompromise
- hemodialysis
- alcoholism
- diabetes mellitus
- recent surgery or other invasive procedures
- breached skin integrity
- indwelling lines or catheters
- intravenous drug misuse
- pregnancy
- urban residence
- lung disease
- male gender
- non-white ancestry
- winter season
Diagnostic investigations
1st investigations to order
- CBC with differential
- BUN and serum electrolytes
- serum creatinine
- LFT
- coagulation studies (INR, aPTT)
- serum glucose
- lactate levels
- CRP
- blood culture
- other cultures (e.g., of sputum, stool, urine, wounds, catheters, prosthetic implants, epidural sites, pleural or peritoneal fluid)
- arterial blood gas (ABG) or venous blood gas (VBG)
- chest x-ray
- ECG
Investigations to consider
- lumbar puncture
- echocardiogram (transthoracic or transesophageal)
- ultrasound scan
- CT chest or abdomen
- serum procalcitonin
Treatment algorithm
Contributors
Authors VIEW ALL
Chief Executive
United Kingdom Sepsis Trust
Chief Executive
Global Sepsis Alliance
Programme Director
Survive Sepsis
Consultant in Critical Care and Anaesthesia
Heart of England NHS Foundation Trust
Birmingham
UK
Disclosures
RD has received payment for consultancy on sepsis from Kimal Plc, manufacturers of vascular access devices, from the Northumbria Partnership, a patient safety collaborative, and, where annual leave or other income was compromised in fulfilling his charity duties, from the UK Sepsis Trust. RD has received sponsorship to attend and speak at one meeting from Abbott Diagnostics. He is CEO of the UK Sepsis Trust and Global Sepsis Alliance, and advises HM Government, the World Health Organisation and NHS England on sepsis. Each of these positions demands that he express opinion on strategies around the recognition and management of sepsis.
Consultant Acute Physician & Sepsis Lead
Department of Acute Medicine
Royal Hampshire County Hospital
Hampshire Hospitals NHS Foundation Trust
Winchester
UK
Disclosures
MIK is a national clinical advisor on sepsis to NHS England and a national clinical advisor on deterioration to NHS Improvement. He was reimbursed for a slide set by Relias Learning.
Specialty Registrar in Gastroenterology and General Medicine
Maidstone and Tunbridge Wells NHS Trust
UK
Disclosures
AS is the clinical fellow to the National Medical Director at NHS Improvement. AS has been sponsored on two occasions by Dr Falk Pharma UK to attend specialist gastroenterology conferences abroad; there was no contractual obligation to disseminate product information.
Consultant in Emergency Medicine
Clinical Academic
University of Plymouth
Lead Doctor
Devon Air Ambulance Trust
Derriford Hospital
Plymouth
UK
Disclosures
TN is a clinical advisor to the UK Sepsis Trust.
Specialty Registrar in Emergency Medicine
Derriford Hospital
Plymouth
UK
Disclosures
EC declares that he has no competing interests.
Dr Ron Daniels, Dr Matt Inada-Kimand, Dr Aamir Saifuddin, Dr Tim Nutbeam, and Dr Edward Berry would like to gratefully acknowledge Dr Lewys Richmond and Dr Paul Kempen, previous contributors to this topic. LR and PK declare that they have no competing interests.
Peer reviewers VIEW ALL
Professor of Medicine
Infectious Disease Division
Rhode Island Hospital
Alpert Medical School of Brown University
Providence
RI
Disclosures
SMO declares that he has no competing interests.
Associate Professor
NYU School of Medicine
Medical Director of Critical Care
Bellevue Hospital Center
New York
NY
Disclosures
LE serves as the guidelines co-chair and on the steering committee of the Surviving Sepsis Campaign.
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