“When I use a word,’ Humpty Dumpty said in rather a scornful tone, ‘it means just what I choose it to mean — neither more nor less.”

“The question is,” said Alice, “whether you can make words mean so many different things.”

“The question is,” said Humpty Dumpty, “which is to be master— that’s all” (1).

==================================

Although in Lewis Carroll’s novel Through the Looking-Glass, Humpty can make any word mean what he wants it to mean, that is not so in our reality-based world (unless you were an official in the GW Bush administration) (2). Thus, when attempting to discuss “sepsis”, especially when the query poses living with it for weeks or months, we must ensure of what we are discussing.

While the word “sepsis” has been used for millennia, it is only in the past, roughly, 30 years that its use has become significant. This significance relates to our ability to resuscitate and treat the very sick humans who present with this syndrome. Over this 30 year period, there has been some development and alteration of the definition of sepsis. Presently, sepsis is defined as “life threatening organ system dysfunction caused by a deregulated host response to infection”. A severe subset of sepsis, septic shock, is defined as sepsis in which “underlying circulatory and metabolic abnormalities are severe enough to substantially increase mortality” (3).

In practical terms, these two definitions help with thinking about sepsis, but aren’t too helpful in diagnosing it at the bedside. This matters greatly as missing the diagnosis of sepsis increases the risk of death; to optimize outcome, we want to initiate treatment within 1 hour of the diagnosis being seriously considered.

The clinical criteria used to identify sepsis at a patient’s bedside are the presence of suspected or confirmed infection along with an assessment of organ failure; a scoring system is used for this, the Sequential Organ Failure Assessment (SOFA). Septic shock is a more severe subset of sepsis, diagnosed when drugs are needed to keep blood pressure in an acceptable range and when blood lactic acid levels – indicating, among other things, inadequate organ perfusion – is elevated.

Early recognition of sepsis and following the clinical guidelines – the Sepsis Bundle – for treatment all impact outcome. The most recent (2018) iteration of the Sepsis Bundle demands that within 1 hour of identifying potential sepsis: a. Serum lactate is measured; b. blood cultures are obtained; c. broad-spectrum antibiotics are begun; d. fluids are administered for low blood pressure or elevated Lactate; e. drugs are initiated for persistently low blood pressure after fluid has been given.

When these guidelines are followed, mortality has been shown to decrease – although there are multiple studies with somewhat varying numbers – from some 18% – 35% to as low as 10%.

There are tens of thousands of words that can be written on the identification and diagnosis, workup and treatment of sepsis. You will not be subject to that here. Simply I will note that one does not live for “…weeks, months, and even years…” with this syndrome.

References:

1. Through the Looking-Glass last accessed 17 January, 2020
2. Bush’s War on the Press  “…As an unnamed Bush official told reporter Ron Suskind, “We’re an empire now, and when we act, we create our own reality. And while you’re studying that reality–judiciously, as you will–we’ll act again, creating other new realities, which you can study too, and that’s how things will sort out. We’re history’s actors…and you, all of you, will be left to just study what we do…” Alterman E. Bush’s War on the Press. The Nation. 21 April, 2005.

   last accessed 17 January, 2020

3. Leisman DE, Deutschman CS. What is Sepsis? What is Septic Shock? What are MODS and Persistant Critical Illness? In: Deutschman CS, Neligan PJ (Editors). Evidence-Based Practice of Critical Care. 3rd Ed. Chapter 30. Elsevier, Philadelphia, 2020.