reliably exclude bacterial infection as a cause of
20 , 21
sepsis .
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
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consequences of negative laparotomy . 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
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
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 .
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
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patient deteriorates . Guidance on source control published in
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