About Medicine: Sepsis; What It Is and How to Survive

Jennifer Feighner, MD, Hospitalist
Marcus Daly Memorial Hospital
1200 Westwood Drive
Hamilton, MT 59840

The red spot appeared on her right foot on Friday afternoon. Being a diabetic, Carla checked her blood sugar, it read 130, a good range for afternoon. "I'll have to keep an eye on this spot" she told her husband, George, "I'll call my doctor's office on Monday if it's still there." She went back to folding the laundry. By next morning, she awakened feeling feverish. "What's my temperature?" "You're burning up" her husband answered. "George, look at my leg!" From the spot on the foot, all the way up to her knee, was a bright, angry fire engine looking red. It was painful and warm to touch. She checked her blood sugar, it was 230. George noticed Carla was breathing rapidly and more heavily than usual. "We'd better get you in right now, that leg looks bad. I'm not sure what's going on, but you don't look good."

Infections can start just the way Carla's did. A small problem, that can become a big problem very quickly, especially for those patients with underlying health conditions such as diabetes which makes it harder for the body to fight infections. Carla has an infection of the skin known as cellulitis, but other infections can have more subtle presentations. For example, a urinary tract infection in an older person can present with low grade fever, fatigue, confusion and weakness, rather than the classic symptoms of young people who often have increased urinary frequency and pain on urination. If a urinary infection spreads to the kidneys it can cause lower back pain as well. Other common infections include pneumonia, which cause cough, fever, chills and fatigue or weakness as well. Colitis, infection or inflammation of the colon, is also common, and usually causes lower abdominal pain and diarrhea with fever and chills. Sometimes fever can occur by itself, but no obvious cause of the fever is ultimately found.

Carla and George went to Convenient Care, where Carla was checked in while waiting to be seen by the Nurse Practitioner. Her blood pressure read 96/50, heart rate 100. Her temperature was elevated at 101.5 and she was breathing about 25 times per minute. The Medical Assistant who checked Carla in saw her red leg and brought her vital signs to the practitioner in charge, who saw Carla right away.

"Carla," she said with a concerned tone. "Your blood pressure is low, your heart rate is fast, you are breathing fast and have a fever with a large infection on your leg- you have a condition called sepsis from your leg infection, also called cellulitis, and you need to go over the Emergency Department right away." She was taken to the Emergency Department in a wheelchair, where she had blood cultures and other labs drawn, and was started on IV antibiotics and IV fluids by the Emergency Medicine physician and Emergency Department team.

Sepsis is a condition where the body has an inflammatory response to infection. There are many stages of sepsis, ranging from mild sepsis to septic shock, where the blood pressure drops and the patient requires intensive care for management. Carla had symptoms consistent with sepsis to severe sepsis: She had a high temperature, rapid heart rate, rapid rate of breathing (known as the respiratory rate), and her blood pressure was borderline low, all in the setting of cellulitis (infection on the skin of her leg). All of these are classic symptoms of severe sepsis. It is extremely important to recognize sepsis and have it treated immediately. The main treatments are IV Fluids and IV antibiotics. Sometimes, such as in shock, where the blood pressure remains low despite IV Fluids, the patient requires specialized medications known as pressors to keep the blood pressure high enough to stay within normal range.

Severe sepsis and septic shock can also result in damage to other organs such as the kidneys - patients may notice that their urine decreases or changes color. Confusion can also occur as inflammation from sepsis and low blood pressure can affect how the brain works. Heart attack, or strain on the heart, can also occur in the setting of severe sepsis or septic shock. The earlier the patient receives IV fluids and IV antibiotics, the better the outcome.

The Surviving Sepsis Campaign was created in 2002 due to the high mortality, or death rate, from sepsis. This campaign has resulted in increasing survival from sepsis by increasing the amount of IV fluids patients with sepsis receive, focusing on how quickly they get fluids such as in the ambulance if patients come in by that route, and decreasing time to IV antibiotics. Here at Marcus Daly Memorial Hospital, we have sepsis protocols both in the ED and in the ICU for improving survival and recovery time from sepsis that follow these national guidelines. These protocols nationwide have resulted in reducing mortality from severe sepsis or septic shock, saving thousands of lives through these improved protocols. Blood sugar control in patients with diabetes helps improve outcomes as well, as blood sugar can be very elevated.

You can save your life, or the life of someone you love, by knowing and recognizing the signs of sepsis from an infection: in early stages fever, rapid heart rate, increased rate of breathing, with potential for more serious and advanced symptoms such as confusion, weakness, decreased urination, dry and warm skin and low blood pressure, lethargy and poor responsiveness. Remember, the sooner sepsis is recognized and treated with fluids and antibiotics, the better the outcome. The persons/patients portrayed in this health column are fictitious, although the series of events does happen.

The weekly health column is brought to you by Marcus Daly Memorial Hospital and the Ravalli Republic. For questions regarding this week's health column please contract, Jennifer Feighner, MD Hospitalist at Marcus Daly Memorial Hospital, 1200 Westwood Drive, Hamilton, MT 59840. Working together to build a healthier community!