*2.1.1 Definition of sepsis and septic shock*

Despite significant emphasis by the Centers of Medicare and Medicaid Services (CMS) on the rapid identification and treatment of sepsis, there is no gold standard definition for the spectrum of sepsis syndromes. In actuality, sepsis is a complex and poorly understood process despite two centuries of research into its mechanisms. Sepsis is thought to result from a dysregulated and overexaggerated immune response to infection [5]. However, the complexity of sepsis and the variability in its presentation has thus far defied the creation of a gold standard definition, despite nearly three decades of attempts. The first definition of sepsis spectrum disorders was published in 1992 as a joint consensus statement between the American College of Chest Physicians (ACCP) and the Society of Critical Care Medicine (SCCM) [6]. This first consensus definition defined the presence sepsis spectrum disorders on elements of the patient's systemic inflammatory response syndrome (SIRS) (**Table 1**) [6]. This definition had poor sensitivity and specificity for sepsis spectrum disorders, and multiple guidelines have since attempted to revise these initial definitions, with variable success in increasing the sensitivity and specificity. The most recent consensus definition, Sepsis-3, was published in 2016 by SSCM and the European Society of Intensive Care Medicine (ESCIM) and defined the sepsis spectrum disorders by the presence of infection and two or more elements of the quick Sequential Organ Failure Assessment (qSOFA) [7]. The Sepsis-3 consensus definitions are outlined in **Table 2** below [7].


#### **Table 1.**

*Defining sepsis based on systemic inflammatory response syndrome (SIRS): Adapted from the 1992 ACCP/ SCCM consensus statement [6].*

**21**

*Evaluation and Treatment of Elevated Temperature in the Emergency Department*

*2.1.2 Guidelines for the management of sepsis spectrum disorders*

Systolic blood pressure < 90 mmHg Respiratory rate ≥ 22 breaths per minute

antibiotic stewardship, and improve patient outcomes [9–12].

Infections of the lower respiratory and urinary tracts comprise the majority of sepsis presentations to the ED. Community-acquired pneumonia (CAP) can be caused by a variety of bacterial and viral pathogens, with *Strepotococcus pneumoniae* being the most common bacterial etiology in those requiring hospitalization [13]. Other commonly implicated organisms include *Haemophilus influenzae, Mycoplasma pneumoniae,* and respiratory viruses. In patients requiring admission to a critical care unit, *S. pneumoniae* is still the most common etiologic organism but *Legionella pneumophila, Staphylococcus aureus,* gram-negative bacilli and influenza virus are more common [14]. Risk factors for drug resistance in CAP include age > 65, alcoholism, medical comorbidities, immunocompromise, immunosuppressive medication use, and use of beta-lactam, macrolide, or fluorquinolone antibiotics in the last 3–6 months [15]. Patients with hospitalization within three months have increased risk for hospital-acquired pneumonia with nosocomial organisms and their antibiotic regimens should include adequate coverage for *Staphylococcus aureus* and *Psuedomonas auerginosa,* which are more common in this population [15].

Infections of the urinary tract account for 40% of cases of nosocomial sepsis and the risk of infection is greatest in patients with structural or functional genitourinary abnormalities [16]. Sepsis from urinary source is more common in females [17].

**2.2 Common sources: respiratory and urinary tract**

The Surviving Sepsis Campaign (SSC) guidelines offer recommendations for the resuscitation of patients with suspected sepsis spectrum disorders [8]. However, while these guidelines can provide an overview for the care of these patients, treatment should always be primarily guided by repeated clinical assessment and reassessment of these patients. Current guidelines recommend the continuous administration of crystalloid fluids as long as hemodynamic factors continue to improve [8] If 30 ml/kg ideal body weight (IBW) balanced crystalloid fluids does not achieve a MAP ≥65 mm Hg, a vasoactive agent should be started [8]. Norepinephrine is currently the vasopressor of choice patients with septic shock [8]. The cornerstone of management of sepsis spectrum disorders is prompt source control through administration of antimicrobials or, if necessary, surgical intervention [8]. Cultures should be collected before the first dose of antimicrobial medications; culture collection should not delay source control interventions [8]. In the emergency department, early broad-spectrum antimicrobial therapy should be initiated based on the pathogen profile of the suspected site of infection, the patient's prior culture results and susceptibilities, and local pathogen prevalence and resistance patterns. The spectrum of the antimicrobial agents can be narrowed as culture results become available or the patient presentation changes. Input from clinical pharmacists in the ED can assist in optimizing the initial antimicrobial choice and has been shown to decrease time to antibiotic administration, improve

*Quick sequential organ failure assessment criteria (qSOFA) [7]: sepsis-3 defines sepsis as infection with two or* 

*DOI: http://dx.doi.org/10.5772/intechopen.94899*

**qSOFA** Altered mental status

*more of the components listed below.*

**Table 2.**


#### **Table 2.**

*Trauma and Emergency Surgery - The Role of Damage Control Surgery*

Fever results from a pyrogen-mediated alteration in the set point of the thermoregulatory system in the anterior hypothalamus [1]. The interaction of endogenous and exogenous pyrogens with the hypothalamus results in increased production of prostaglandins, which act on temperature-sensitive neurons and lead to increased core temperature [1] Infection is the most common cause of fever, accounting for 74% of fevers in hospitalized patients [3]. Other processes that produce endogenous pyrogens, such as malignancy and ischemia, account for the majority of the remaining sources of fever in hospitalized medical

Despite significant emphasis by the Centers of Medicare and Medicaid Services (CMS) on the rapid identification and treatment of sepsis, there is no gold standard definition for the spectrum of sepsis syndromes. In actuality, sepsis is a complex and poorly understood process despite two centuries of research into its mechanisms. Sepsis is thought to result from a dysregulated and overexaggerated immune response to infection [5]. However, the complexity of sepsis and the variability in its presentation has thus far defied the creation of a gold standard definition, despite nearly three decades of attempts. The first definition of sepsis spectrum disorders was published in 1992 as a joint consensus statement between the American College of Chest Physicians (ACCP) and the Society of Critical Care Medicine (SCCM) [6]. This first consensus definition defined the presence sepsis spectrum disorders on elements of the patient's systemic inflammatory response syndrome (SIRS) (**Table 1**) [6]. This definition had poor sensitivity and specificity for sepsis spectrum disorders, and multiple guidelines have since attempted to revise these initial definitions, with variable success in increasing the sensitivity and specificity. The most recent consensus definition, Sepsis-3, was published in 2016 by SSCM and the European Society of Intensive Care Medicine (ESCIM) and defined the sepsis spectrum disorders by the presence of infection and two or more elements of the quick Sequential Organ Failure Assessment (qSOFA) [7]. The Sepsis-3 consensus definitions are outlined in

**2. Fever**

patients [4].

**Table 2** below [7].

**Severe sepsis**

**Septic shock**

*SCCM consensus statement [6].*

**Table 1.**

**SIRS** Two or more of the following:

blood pressure

Temperature > 38°C or < 36°C Heart rate > 90 beats per minute

Sepsis and end-organ dysfunction

Respiratory rate > 20 breaths per minute or PaCO2 < 32 mmHg White blood cell count >12,000 cu/mm, <4000 cu/mm, >10% bands

*Defining sepsis based on systemic inflammatory response syndrome (SIRS): Adapted from the 1992 ACCP/*

Sepsis with a systolic blood pressure < 90 mmHg or > 40 mmHg decrease in baseline systolic

**Sepsis** Two SIRS criteria in the setting of known or suspected infection.

*2.1.1 Definition of sepsis and septic shock*

**2.1 Sepsis**

**20**

*Quick sequential organ failure assessment criteria (qSOFA) [7]: sepsis-3 defines sepsis as infection with two or more of the components listed below.*
