Treating Sepsis – 15 top tips

You’ll occasionally see a news story where someone has sadly been affected by sepsis and died. It can strike so quickly, especially as the signs can creep up without warning and go unrecognised before it’s too late. The same problem can affect animals, and in the same way, so all cases need to be carefully evaluated and quickly treated.

Posted: 11 February 2019

Treating Sepsis – 15 top tips

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Animals suffering from septic shock can develop severe cardiovascular abnormalities, multiple organ failure, and eventually death in no time at all. Aggressive fluid therapy on its own may not be enough, and additional treatments to support the failing circulatory system may be required. You’ll also need to direct your treatment at controlling the infection and protecting vital organs. Unfortunately, despite aggressive treatments, mortality rates can be very high, with anything between 20 and 60% of animals dying.

Some key facts about sepsis

  • It’s deadly – the condition is often fatal
  • Often misdiagnosed – the condition can easily be missed as the initial presentation is usually not significant, and therefore early treatment is delayed
  • An inflammatory syndrome – there is a Systemic Inflammatory Response (SIR) as a result of either infectious (bacterial, viral or fungal) or non-infectious causes
  • Results in multiple organ failure – this follows the systemic inflammatory response

15 Tips for Successfully Treating Sepsis

1. Make an efficient early diagnosis

It cannot be stressed enough how important it is to be on your toes and identify these cases as early as possible. You’ve probably got less that 6 hours to start treatment. This is achieved from a combination of a detailed history and clinical examination. Look for any signs involving all the organ systems, especially those frequently affected with infections.

2. Recognise the early signs

In early septic shock, common clinical signs are often as a result of peripheral vasodilation. These may present with two or more of the following;

  • Altered mucous membranes – injected mucous membranes will appear as the classic “brick red” colour, but can also be pale
  • Rapid or prolonged capillary refill time - CRT often <1 second or >2 seconds
  • Tachycardia – often >120bpm (dog) or >225bpm (cat)
  • Pronounced pulse – this will often be bounding
  • Tachypnoea – look for a resting respiratory rate greater than 20bpm (dog) or >40bpm (cat)
  • Pyrexia or hypothermia – a rectal temperature a couple of degrees above or below normal (>40.0°C or <38.0°C)
  • Abnormal leukogram – a leukopenia or leucocytosis, <5000 or >16,000 WBC/μL (dog) or >19,000WBC/μL (cat)

3. Keep checking for shock

It’s really important to repeatedly examine the patient if you have any suspicion of sepsis, as changes can occur rapidly. Left untreated, the animal will soon decompensate, and will then start to show some of the following;

  • Pale mucous membranes
  • Prolonged CRT (>2 seconds)
  • Hypotension which doesn’t respond to fluids
  • Weakening peripheral pulse
  • Multi organ failure
  • Death

4. Look for a source of infection

The common systems which are frequently involved include;

  • Oral cavity – periodontal disease
  • Urogenital system – cystitis, prostatitis and pyelonephritis
  • Skin and subcutaneous tissues – pyoderma, furunculosis
  • Abdomen and peritoneal cavity – peritonitis, pyometra
  • Respiratory system – pneumonia, pyothorax
  • Gastro-intestinal tract - including liver, gall bladder, biliary tree and pancreas are common sources of sepsis

5. Identify the infectious agent

Collect all the necessary samples required to allow you to culture and perform sensitivity tests. You might, for example, collect;

  • Blood – this is especially important if the animal is pyrexic. Both aerobic and anaerobic blood cultures are important 
  • Abdominal fluid – paracentesis may be indicated using ultrasound
  • Tracheobronchial lavage - cytology and culture & susceptibility
  • Urine - look for intracellular bacteria plus perform urine culture and susceptibility
  • Synovial fluid – in cases where there is evidence of acute lameness and inflammation associated with a particular joint

6. Antibiotics – choose wisely

A significant number of bacterial organisms are resistant to some of the more commonly used veterinary antibiotics. For example, E. coli is frequently resistant to fluoroquinolones. For this reason, always take samples prior to starting treatment and perform culture with identification and sensitivity testing.

7. Give intravenous fluids

Septic shock will almost always compromise the circulatory system, resulting in persistent arterial hypotension. Regaining a normal blood pressure by giving intravenous fluids is essential and should be done aggressively. Options include;

  • Hypertonic crystalloids – such as hypertonic saline 7.2%. This is generally used for its cardiovascular benefits.
  • Isotonic crystalloids – for example lactated Ringer’s solution.

Fluid and administration rates for hypovolemic and hypotensive patients can vary. A common approach is to give ¼ to 1/3 of the calculated volume, and then reassess the patient. The aim of treatment is to gain control of the circulatory system and achieve stability.

8. Maintain core body temperature

Animals in shock will, as a result of the circulatory collapse, become hypothermic quite quickly. There are numerous ways to help keep their temperature raised, such as;

  • Blankets - cover them and provide external passive warming
  • Body warming aids – the Bair Hugger is very effective
  • Warm fluids - provide fluids at body temperature
  • Peritoneal lavage – this can be done using fluids warmed to 40°C
  • Warm enemas – another effective way to raise the core temperature

9. Antibiotics – don’t delay

For every hour that antibiotics are delayed, survival rates decrease. Some studies have shown increased mortality rates of between 7% and 20% if effective antibiotics are withheld in the first 24 hours. Gram-negative enteric organisms, such as Escherichia coli, are most commonly found in small animal patients with sepsis. Some of the more common antibiotics used include;

  • Ampicillin
  • Enrofloxacin
  • Clindamycin
  • Amoxycillin with clavulanic acid

10. Support the cardiovascular system

Most of the problems from sepsis occur as a consequence of hypotension from circulatory collapse and subsequent organ failure. Fluids are an essential part of the support required, as are;

  • Inotropic drugs – these are agents given to increase myocardial contractility. Dobutamine is widely used as a first-line agent to increase cardiac output in septic shock.
  • Vasopressors – these are administered to increase vascular tone. Norepinephrine is often used as a primary vasopressor.

11. Find the focus

If a focus of infection is suspected, it’s critical to find the site and deal with the problem. A pyometra, abscess, bladder or kidney infection needs to be located and treated.

12. Prevent hospital induced infections

MRSA is prevalent these days, and none of us should be complacent. Avoid spreading resistant infections by maintaining ultimate hygiene.

  • Hand hygiene - hand washing before, during and after patient care
  • Alcohol gel – use the automatic dispensing kind to prevent touching the button
  • No jewellery – ensure protocols to avoid watches, rings and nail polish
  • Protection – provide disposable gloves for everyone

13. Monitor the patient

Throughout the whole treatment plan, don’t become complacent. Keep on top of all the vitals by measuring and recording everything. This way all clinicians involved will be aware of even slight changes in overall health.

14. Support the gut

With septic shock, blood is moved away from vital organs, including the gastro-intestinal system. This can result in ileus, ulceration and poor perfusion. To minimise the damage, you need to consider using some of the following;

  • H2-receptor antagonists e.g. ranitidine
  • Proton pump inhibitors such as omeprazole
  • Sucralfate
  • Prokinetic agents – e.g. metoclopramide
  • Enteral nutrition – this may be given by oesophagostomy or gastrostomy tube

15. Oxygen therapy

This is indicated for any patient with evidence of hypoxemia.

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