Sepsis: Current Concepts and Perioperative Management

Abstract

The syndrome sepsis embodies success and failure in modern medical care. Advances such as the development of antibiotics and organ support prevent immediate deaths from infection and organ dysfunction. However, patients with sepsis go on to develop critical illness and multiorgan system failure. Many still die. The result is that the population of patients with sepsis is sicker today than it was 50, or even 10, years ago. Mortality is effectively unchanged, whereas resource utilization increases. Each advance in therapy results in prolonged states of morbidity and unchanged mortalities. In 2005, an elderly patient with chronic obstructive pulmonary disease presenting to an intensive care unit with pneumonia and sepsis would have received a pneumococcal vaccine, an insulin infusion with the goal of ‘‘tight’’ glycemic control (i.e., serum glucose values between 80 and 110 mg/dL), and drotrecogin a (recombinant activated protein C), to disrupt a destructive inflammatory and coagulation cycle and improve end-organ perfusion. Just 7 years later, there is ample evidence to suggest that none of these therapies is helpful, and they may be harmful. Sepsis research has uncovered a complicated process of immune response to illness with broad systemic effects. We know more about the mechanisms that contribute to the syndrome, but efforts to block the response have been largely unsuccessful. Much of what we thought we knew about sepsis turned out to be wrong. With the exceptions of the control of the source of sepsis, timely antibiotics, and resuscitation, little has been discovered to improve outcomes in sepsis (Supplemental Digital Content 1, http://links.lww.com/ ASA/A321). Even these measures are subject to debate. The septic patient remains a therapeutic challenge. As professionals in perioperative medicine, anesthesia providers must be prepared to manage patients with sepsis syndrome. Timely and effective care is essential to the management of the septic patient and demands skills in resuscitation, monitoring, and operative management. For anyone practicing in the field of anesthesia and critical care, understanding sepsis is essential (Supplemental Digital Content 2,