Monitoring the patient's progress

Failure to improve or deterioration at any stage should prompt thorough reassessment of the patient (ABC, history, examination etc). Consider whether the original diagnosis is correct, a new diagnosis has evolved, the current treatment is appropriate and correctly instigated, or whether a complication has developed. Signs of deterioration may include:

• Persistent or worsening tachycardia
• Persistently elevated or swinging temperature
• Rising white cell count, C-reactive protein
• Fall in blood pressure, or increased requirement for vasopressor drugs to maintain the same blood pressure
• Deteriorating renal output
• Deterioration in conscious level
• Deterioration in respiratory function 

Preventing complications

Patients with SIRS may suffer depression of immune function and many of the procedures performed on intensive care units breach the body's natural defences (e.g. orotracheal intubation, peripheral cannulae and central venous cannulae) and leave the patient prone to secondary infections. These and other complications are listed below.

Prevention of Infection

Medical staff have been implicated in the spread of infectious agents between patients. All staff must wash their hands before and after attending to a patient. Equipment (such as thermometers, stethoscopes, bed pans) should not be shared between patients if possible, but where this is necessary the equipment should be thoroughly cleaned between patients. Staff should protect themselves and their clothes from becoming contaminated with biological material by wearing (ideally disposable) aprons and gloves. Visitors should be discouraged from moving between patients. Patients should be washed daily and never be left in soiled bed linen. Wounds, including drain sites and intravenous cannulae sites, should be inspected, cleaned and dressed at regular intervals. Intravenous cannulae and central lines should be removed as soon as practical. Some units have strict protocols governing the replacement of in-dwelling cannulae after a set number of days, other units replace the cannula when clinically indicated.

Immobility and Severe Illness

Patients immobilised by sedation or severe illness are vulnerable to complications that can be prevented by good nursing care. Pressure damage can be prevented by re-positioning the patient every two to four hours, and by replacing wet linen. Particular attention should be paid to the skin over bony prominences, such as the heels and elbows, by padding these areas with cotton-wool, lint or even sheep's wool. Eye damage can be prevented by taping the eyes shut or application of protective gel. Joint stiffness and peripheral oedema may both benefit from passive movement of both the legs and arms. If there is a severe shortage of nursing staff all of these activities can be carried out by the patient's relatives if they are given the appropriate training and encouragement. In longer stay patients physiotherapy is essential to minimise muscle wasting and maintain good active and passive range of movement. Critical illness neuropathy and myopathy are common complications of SIRS. 

Ethical issues and resource allocation

There is no predictive scoring system which gives accurate predictions of outcome for individual patients. Survival from an episode of severe SIRS/sepsis is dependent the patient's age, previous health and the time delay before the onset of medical intervention, as well as the appropriateness and quality of medical care. Few countries have limitless resources, and so difficult decisions face all intensive care doctors when deciding between the potential benefits for one critically ill patient and need for provision of healthcare to several less critically ill patients. 

Appendix

Anaesthesia for the Septic Patient

The surgical drainage of abscess cavities, laparotomies, debridement of infected wounds or amputation of gangrenous limbs may be central to the successful treatment of a patient with severe sepsis. Surgery and anaesthesia is often required, even in patients in poor clinical condition.

Pre-operative Preparation

The time taken to improve a patient's condition before surgery must be balanced against the urgency to surgically treat the underlying problem. Recent studies have shown that the outcome from surgery in these high risk patients is improved if the patient's condition is 'optimised' preoperatively. When surgery can be delayed (even for a few hours), attempts should be made to resuscitate the patient to ensure adequate oxygen delivery, cardiac output and blood pressure. This is often easiest done in theatre, recovery or ICU. In a few patients immediate surgery is lifesaving and should be carried out as soon as practical (eg necrotising fasciitis). In these patients preparation time is limited but initial resuscitation (airway, breathing and circulation) should be completed and continuing resuscitation carried out during anaesthesia. Common problems in the perioperative period include anaemia, hypotension, coagulation disturbance, electrolyte disturbance (particularly hyper or hypokalaemia) and acidosis.

Regional or General Anaesthesia?

Physiological stability during anaesthesia is compromised by the combined effects of sepsis, anaesthesia, blood loss and surgical stress. Close monitoring is required because rapid changes in physiological parameters may occur.

When inducing anaesthesia in a septic patient the same considerations which are described in the airway / breathing section of resuscitation apply. Supplementary analgesia may be needed and intravenous or inhalational agents can be used to maintain anaesthesia. Use smaller doses of cardiovascularly active drugs to assess the patient's response. Ketamine anaesthesia is widely used in these high risk patients, although in this situation it may be cardiovascularly depressant and does not protect the airway as effectively as an endotracheal tube. Following induction of anaesthesia there is a reduction in sympathetic tone that often results in hypotension which may need treating by i/v infusion of fluids and a vasopressor.

Neuraxial blockade (spinal and extradural anaesthesia) should only be considered if recent blood tests have shown the clotting to be normal. The haemodynamic effects of a these techniques in the setting of cardiovascular compromise may be devastating and hard to reverse. A further concern is the risk of epidural abscess complicating an epidural haematoma formation. The evidence is not clear but the risk is likely to be increased in patients who are frankly septic. Peripheral nerve blocks or regional infiltration may be used and are very effective at minimising the sympathetic response to a painful stimulus, whilst avoiding the systemic effects of opioids. 

Further reading

1. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Critical Care Medicine 1992;20:864-74.
2. Oxford Textbook of Critical Care. Editors: Webb AR, Shapiro MJ, Singer M and Suter PM. Oxford University Press 1999. Oxford, New York, Tokyo.
3. Alderson P, Schierhout G, Roberts I, Bunn F. Colloid versus crystalloid for fluid resuscitation in critically ill patients. Cochrane Database Systemic Review. 2000;(2):CD000567.
4. Meduri GU. Levels of evidence for the pharmacological effectiveness of prolonged methylprednisolone treatment in unresolving ARDS. Chest1999; 116:S116-118.
5. Amato MB et al. Effect of protective-ventilation strategy on mortality in the acute respiratory distress syndrome. New England Journal of Medicine 1998;338:347-54.
6. Cook D. Ventilator-associated pneumonia: perspectives on the burden of illness. Intensive Care Medicine 2000;26:S31-7.
7. Hebert PC et al. A multicenter, randomised controlled clinical trial of transfusion requirements in critical care. New England Journal of Medicine 1999;340:409-17.
8. Nathens AB and Marshall JC. Selective decontamination of the digestive tract in surgical patients: a systematic review of the evidence. Archives of Surgery 1999:134:170-6. 

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