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Sepsis

Sepsis is a potentially life-threatening, systemic complication of an infection resulting from the spread of bacteria or their toxic products from a focus of infection. Pneumonia is the most common cause, followed by intraabdominal and urinary tract infections. No source is found in about one third of cases. The clinical presentation of sepsis is highly variable depending on the etiology.


Presentation

The clinical features of septicemia intensify over time from mild to severe.

The cardinal symptoms of sepsis include:

These features may be preceded by lethargy, headache and minor changes in consciousness.

In the elderly and immunocompromised patients, the clinical features may be quite subtle.

Tachypnea
  • The infant was managed with respiratory support and gradually infant improved and diagnosis of transient tachypnea of newborn was made.[ncbi.nlm.nih.gov]
  • Sepsis is the systemic response to infection manifested as hyperthermia or hypothermia, tachycardia, tachypnea, and shock. This condition represents a major life-threatening factor in all age groups, particularly in neonatal period.[ncbi.nlm.nih.gov]
  • Tachycardia and tachypnea are extremely common in mild pediatric illness; these are not as useful in selecting for septic patients. Therefore either a temperature or leukocyte abnormality must be present to meet pediatric SIRS criteria.[mdcalc.com]
  • Local inflammation is recognized as rubor (redness), tumor (swelling), calor (heat) and dolor (pain), and when a systemic response is elicited, it is called SIRS (Systemic Inflammatory Response Syndrome), which consists of tachypnea, tachycardia, hyperpyrexia[blogs.biomedcentral.com]
  • Components of SIRS include tachycardia, tachypnea, hyperthermia or hypothermia, and elevated white blood count.[medpagetoday.com]
Respiratory Distress
  • A healthy 3-year-old girl admitted to the Pediatric Emergency Department presented a sepsis-associated purpura with neurological and respiratory distress. An empiric antibiotherapy (anti-meningococcal) was prescribed.[ncbi.nlm.nih.gov]
  • An 86-year-old previously healthy Sundanese man was admitted to the intensive care unit at our institution with septic shock, acute kidney injury, and respiratory distress.[ncbi.nlm.nih.gov]
  • A late preterm male infant, Indian race was admitted to the neonatal intensive care unit for respiratory distress developing soon after birth.[ncbi.nlm.nih.gov]
  • His research interests include septic shock, acute lung injury, acute respiratory distress syndrome and ventilator-associated pneumonia. To view Dr. Robert A. Balk ' s publications, visit PubMed[mdcalc.com]
Fever
  • A 32-year-old female presented with fever and generalised malaise to a rural hospital in Ghana. The patient had previously been diagnosed as having enteric fever from a neighbouring health facility.[ncbi.nlm.nih.gov]
  • Basic observations and investigations suggested sepsis: tachypnoea, sinus tachycardia, fever and a raised white cell count and C reactive protein level.[ncbi.nlm.nih.gov]
  • The symptoms and fever resolved in 2 days. She was continuously treated with chloramphenicol for another 10 days before discharge.[ncbi.nlm.nih.gov]
  • All patients had a short history of illness ( 2 weeks) and presented uniformly with prolonged fever, bi or trilineage cytopenia and multiorgan dysfunction syndrome (MODS) at admission or developed MODS during the course of their illness.[ncbi.nlm.nih.gov]
  • He was eventually diagnosed with Rocky Mountain spotted fever. Aggressive treatment of sepsis and timely administration of empiric antibiotics were lifesaving in this situation.[ncbi.nlm.nih.gov]
Chills
  • A 55-year-old woman underwent surgery for lumbar spinal stenosis and developed high fever (39.5 C) after surgery, accompanied by chills and fatigue.[ncbi.nlm.nih.gov]
  • Chills are subjective—a patient feels chills but it cannot be observed by a health-care provider,” Dr. Dellinger says.[rd.com]
  • Patients with nonspecific symptoms are usually acutely ill with fever, with or without shaking chills. Mental status may be impaired in the setting of fever or hypoperfusion.[emedicine.medscape.com]
  • People with weakened immune systems Infants and children The elderly People with chronic illnesses, such as diabetes, AIDS, cancer, and kidney or liver disease People suffering from a severe burn or physical trauma Common symptoms of sepsis are fever, chills[nlm.nih.gov]
Weakness
  • When the values related to sepsis were examined, a strong relationship was determined between sepsis and SOFA score, PRC values, and Lac values in the preseptic period and a weak relationship with NLR.[ncbi.nlm.nih.gov]
  • Sepsis: Bacteremia or another infection triggers a serious bodywide response ( sepsis ), which typically includes fever, weakness, a rapid heart rate, a rapid breathing rate, and an increased number of white blood cells.[merckmanuals.com]
  • At first, people have a high (or sometimes low) body temperature, sometimes with shaking chills and weakness. As sepsis worsens, the heart beats rapidly, breathing becomes rapid, people become confused, and blood pressure drops.[msdmanuals.com]
  • […] feeding not drinking for more than 8 hours (when awake) bile-stained (green), bloody or black vomit/sick Activity and body soft spot on a baby's head is bulging eyes look "sunken" child cannot be encouraged to show interest in anything baby is floppy weak[nhs.uk]
Hypothermia
  • Sepsis is the systemic response to infection manifested as hyperthermia or hypothermia, tachycardia, tachypnea, and shock. This condition represents a major life-threatening factor in all age groups, particularly in neonatal period.[ncbi.nlm.nih.gov]
  • This response includes an abnormally high temperature ( fever ) or low temperature ( hypothermia ) plus one or more of the following: Rapid heart rate Rapid breathing rate Although many infections cause such symptoms throughout the body, in sepsis organs[msdmanuals.com]
  • The most prominent are: Decreased urine output Fast heart rate Fever Hypothermia (very low body temperature) Shaking Chills Warm skin or a skin rash Confusion or delirium Hyperventilation (rapid breathing) Cleveland Clinic News & More Cleveland Clinic[my.clevelandclinic.org]
High Fever
  • A 55-year-old woman underwent surgery for lumbar spinal stenosis and developed high fever (39.5 C) after surgery, accompanied by chills and fatigue.[ncbi.nlm.nih.gov]
  • For instance, when certain criteria are present, such as high fever and increased respiratory rate, CRP values can be used to diagnose an inflammatory condition or infection, which could develop into sepsis.[radiometer.com]
  • Overview: Crew arrives to find a 56-year-old female with sudden onset of high fever, general malaise and a non-productive cough. She woke this morning feeling normal. Her symptoms began suddenly right after lunch and worsened rapidly.[ems1.com]
Vomiting
  • We report a case of Escherichia coli SICM in a 63-year-old woman presented with sudden onset of dyspnoea on exertion and orthopnoea following nausea, vomiting and diarrhoea after consuming Chinese foods.[ncbi.nlm.nih.gov]
  • Two weeks after his discharge, he presented with severe abdominal pain, fever, and vomiting. Radiologic assessment showed pneumoperitoneum. Urgent exploratory laparotomy revealed significant amount of gas and no bowel perforation.[ncbi.nlm.nih.gov]
  • The first symptoms of meningitis are often fever, vomiting, headache and feeling unwell. Septic shock In some cases, symptoms of more severe sepsis or septic shock (when your blood pressure drops to a dangerously low level) develop soon after.[nhs.uk]
  • Sam appeared to have tiny threads of blood in his vomit. We realised he wasn’t urinating. Hours passed as we waited for a call back from a doctor.[theguardian.com]
  • If the body’s blood pressure drops to a dangerous level, a person will also feel dizzy, confused, experience diarrhoea and or vomiting and nausea. Their skin will also become cold, pale and clammy and they may slur their words.[independent.co.uk]
Nausea
  • We report a case of Escherichia coli SICM in a 63-year-old woman presented with sudden onset of dyspnoea on exertion and orthopnoea following nausea, vomiting and diarrhoea after consuming Chinese foods.[ncbi.nlm.nih.gov]
  • People with suspected sepsis can show: · low blood pressure · high temperature (fever) or low temperature · fast heartbeat · breathlessness · feeling weak or loss of consciousness · being confused or disorientated · loss of appetite · diarrhoea, nausea[nice.org.uk]
  • If the body’s blood pressure drops to a dangerous level, a person will also feel dizzy, confused, experience diarrhoea and or vomiting and nausea. Their skin will also become cold, pale and clammy and they may slur their words.[independent.co.uk]
  • Other common warning signs include: Fever and chills Very low body temperature Peeing less than normal Rapid pulse Rapid breathing Nausea and vomiting Diarrhea Continued Sepsis Treatment If your doctor believes you might have sepsis, he’ll do an exam[webmd.com]
Abdominal Pain
  • Two weeks after his discharge, he presented with severe abdominal pain, fever, and vomiting. Radiologic assessment showed pneumoperitoneum. Urgent exploratory laparotomy revealed significant amount of gas and no bowel perforation.[ncbi.nlm.nih.gov]
  • Diffuse abdominal pain may suggest pancreatitis (not sepsis) or generalized peritonitis, whereas right upper abdominal quadrant (RUQ) tenderness may suggest a gallbladder etiology (eg, cholecystitis, cholangitis ), and tenderness in the right lower abdominal[emedicine.medscape.com]
  • Narrow your results Refine your results RSS feed Highlighted Cochrane Review Pharmacological interventions for recurrent abdominal pain in childhood Alice E Martin, Tamsin V Newlove‐Delgado, Rebecca A Abbott, Alison Bethel, Joanna Thompson‐Coon, Rebecca[cochranelibrary.com]
  • pain – Diffuse pain (suggesting pancreatitis or generalized peritonitis), right upper quadrant (RUQ) tenderness (gallbladder etiology), right lower quadrant (RLQ) tenderness (appendicitis or Crohn disease), or discrete left lower quadrant (LLQ) tenderness[emedicine.medscape.com]
Diarrhea
  • Congenital tufting enteropathy (CTE) is characterized by the early-onset of chronic diarrhea and the inability to develop. It is a rare congenital disease with a low prevalence of 1:50,000 - 100,000 live births p.a.[ncbi.nlm.nih.gov]
  • Other common warning signs include: Fever and chills Very low body temperature Peeing less than normal Rapid pulse Rapid breathing Nausea and vomiting Diarrhea Continued Sepsis Treatment If your doctor believes you might have sepsis, he’ll do an exam[webmd.com]
  • Sepsis symptom: nausea, vomiting, and diarrhea iStock/monkeybusinessimages Unfortunately, GI symptoms are what threw off Rory Staunton’s doctors—they thought he just had a stomach virus.[rd.com]
Hypotension
  • Septic shock is defined as hypotension with a mean arterial pressure less than 65 mm Hg, requiring vasopressors despite adequate fluid resuscitation and/or lactic acid levels above 2 mmol/L.[ncbi.nlm.nih.gov]
  • In severe sepsis, resuscitation is performed during the first six hours to enhance the heart function in order to correct hypoxia, hypotension and hypoperfusion.[symptoma.com]
  • Severe sepsis (sepsis that has progressed to cellular dysfunction and organ damage or evidence of hypoperfusion) and septic shock (sepsis with persistent hypotension despite adequate fluid resuscitation) are still associated with high mortality rates[ncbi.nlm.nih.gov]
  • Administration of 30 ml/kg IV crystalloid for hypotension or lactate 4 mmol/L.[cdemcurriculum.com]
  • In the first international consensus definitions, which date from 1991, severe sepsis was defined as sepsis associated with organ dysfunction, hypoperfusion, or hypotension; septic shock was defined as sepsis with hypotension despite adequate fluid replacement[bestpractice.bmj.com]
Tachycardia
  • A 63-year-old woman presented with fever, tachycardia and tachypnoea, with right sided chest and hypochondrial pain. Chest radiograph showed right basal consolidation and she was treated for community acquired pneumonia with intravenous antibiotics.[ncbi.nlm.nih.gov]
  • We report the case of a 12-year-old boy with relapsed and refractory pre-B-cell acute lymphoblastic leukemia who presented in distress with tachycardia, history of fever, and diffuse abdominal tenderness.[ncbi.nlm.nih.gov]
  • Basic observations and investigations suggested sepsis: tachypnoea, sinus tachycardia, fever and a raised white cell count and C reactive protein level.[ncbi.nlm.nih.gov]
  • Sepsis is the systemic response to infection manifested as hyperthermia or hypothermia, tachycardia, tachypnea, and shock. This condition represents a major life-threatening factor in all age groups, particularly in neonatal period.[ncbi.nlm.nih.gov]
  • Tachycardia and tachypnea are extremely common in mild pediatric illness; these are not as useful in selecting for septic patients. Therefore either a temperature or leukocyte abnormality must be present to meet pediatric SIRS criteria.[mdcalc.com]
Warm Skin
  • The most prominent are: Decreased urine output Fast heart rate Fever Hypothermia (very low body temperature) Shaking Chills Warm skin or a skin rash Confusion or delirium Hyperventilation (rapid breathing) Cleveland Clinic News & More Cleveland Clinic[my.clevelandclinic.org]
  • In general, symptoms of sepsis can include: Chills Confusion or delirium Fever or low body temperature ( hypothermia ) Lightheadedness due to low blood pressure Rapid heartbeat Skin rash or mottled skin Warm skin A person with sepsis will be admitted[nlm.nih.gov]
Eruptions
  • And then it escalates, quickly erupting into widespread infection and inflammation that can cause organ failure and death if not treated fast enough.[statnews.com]
Oliguria
  • The cardinal symptoms of sepsis include: Fever, chills or hypothermia Hypotension and oliguria Hyperventilation Mental status changes Skin manifestations These features may be preceded by lethargy, headache and minor changes in consciousness.[symptoma.com]
  • […] of the body, most readily seen in the fingers/arms, toes/legs Sepsis is diagnosed when there is an infection somewhere in the body AND one of the following: Organ dysfunction (organ failure) Hypoxemia (inability to circulate oxygen to your tissues) Oliguria[christopherreeve.org]
  • The many signs and symptoms of sepsis include abnormalities in the individual’s body temperature, heart rate, respiratory rate and white blood cell count, in addition with hypoxaemia , oliguria, lactic acidosis, elevated liver enzymes and altered cerebral[ausmed.com]
Confusion
  • […] children The elderly People with chronic illnesses, such as diabetes, AIDS, cancer, and kidney or liver disease People suffering from a severe burn or physical trauma Common symptoms of sepsis are fever, chills, rapid breathing and heart rate, rash, confusion[nlm.nih.gov]
  • Common symptoms of sepsis are fever, chills, rapid breathing and heart rate, rash, confusion and disorientation.[cottagehealth.org]
  • As sepsis worsens, the heart beats rapidly, breathing becomes rapid, people become confused, and blood pressure drops.[msdmanuals.com]
  • […] of the following symptoms may be present: Infection Elevated temperature, greater than 38.30C or 101.30F Fast heart rate, greater than 90 beats per minute Fast respiratory rate, greater than 20 breaths per minute Other symptoms that may be present: Confusion[christopherreeve.org]
Lethargy
  • A term male infant presented on day 4 of post-natal life with the complaint of decreased appetite, fast respiration and lethargy. The clinical examination showed features of sepsis and shock with chest radiogram showing pneumonia.[ncbi.nlm.nih.gov]
  • Poor feeding (39.21%) and lethargy (35.29%) were the most common clinical symptoms and previous history of hospital stay (40.19%) and surgery (21.56%) the most common risk factors for neonatal sepsis development.[ncbi.nlm.nih.gov]
  • The cardinal symptoms of sepsis include: Fever, chills or hypothermia Hypotension and oliguria Hyperventilation Mental status changes Skin manifestations These features may be preceded by lethargy, headache and minor changes in consciousness.[symptoma.com]
  • […] potential infections Prevent infections that can lead to sepsis by: Cleaning scrapes and wounds and practicing good hygiene by washing hands and bathing regularly If you have an infection, look for signs like: Fever and chills Extreme weakness, dizziness, lethargy[cottagehealth.org]
  • If a child younger than 2 months of age has fever, lethargy, poor feeding, a change in normal behavior, or an unusual rash, call the doctor and proceed to the hospital.[emedicinehealth.com]
Altered Mental Status
  • Severe sepsis is diagnosed when the septic patient has organ dysfunction (for example, low or no urine flow, altered mental status).[medicinenet.com]
  • mental status; leukocytosis (WBC count 12 10⁹/L [12,000/microlitre]); leukopenia (WBC count 10% immature forms. [2] Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.[bestpractice.bmj.com]
  • Classic Presentation The classic presentation is that of an elderly patient with multiple comorbidities who presents to the ED with fever, tachycardia, tachypnea, and/or hypotension with altered mental status coming in from a nursing home.[cdemcurriculum.com]
Headache
  • Infection and sepsis has been reported as a possible cause for this disorder.We present a 19-year-old immunocompetent Caucasian man with known type 1 diabetes mellitus who presented to the emergency department with acute onset of bilateral visual loss, headaches[ncbi.nlm.nih.gov]
  • The authors present the case of a 19-year old man presenting to the emergency department with a 2-day history of left eye pain and ptosis, facial pain around the maxillae, coryza, headaches and fevers.[ncbi.nlm.nih.gov]
  • The cardinal symptoms of sepsis include: Fever, chills or hypothermia Hypotension and oliguria Hyperventilation Mental status changes Skin manifestations These features may be preceded by lethargy, headache and minor changes in consciousness.[symptoma.com]
  • The first symptoms of meningitis are often fever, vomiting, headache and feeling unwell. Septic shock In some cases, symptoms of more severe sepsis or septic shock (when your blood pressure drops to a dangerously low level) develop soon after.[nhs.uk]

Workup

Early diagnosis and treatment of sepsis is the basic key in preventing the morbidity and mortality resulting from the sepsis.
Cardiac monitoring, blood pressure monitoring and pulse oxymetry are indicated in patients with septic shock. Once the patient is stabilized, the clinicians can move forward to the diagnostic workup. This involves the use of the following investigation to determine the cause and site of infection:

  • Blood CP
  • Blood culture
  • Chest radiography
  • Ultrasound abdomen and pelvis
  • Urea & creatinine levels
  • Liver function tests
  • Sputum culture
  • Urine culture
  • Arterial blood gases
  • Coagulation profile
Pneumoperitoneum
  • Radiologic assessment showed pneumoperitoneum. Urgent exploratory laparotomy revealed significant amount of gas and no bowel perforation. However, right retroperitoneal gas collection was noted and drained.[ncbi.nlm.nih.gov]
Liver Biopsy
  • Liver biopsy revealed grade IV siderosis with micronodular cirrhosis. Haemochromatosis is a common, inherited disorder leading to iron overload that can produce end-organ damage from excess iron deposition.[ncbi.nlm.nih.gov]

Treatment

The following goals should be kept in mind while treating the patients with septic shock:

  • Adequate antibiotic therapy should be started as early as possible (within one hour of making the diagnosis in severe sepsis) [8].
  • In severe sepsis, resuscitation is performed during the first six hours to enhance the heart function in order to correct hypoxia, hypotension and hypoperfusion [9]. This is known as early goal directed therapy and effectively reduces mortality in these patients [10].
  • The source of infection should be identified identify and should be managed with anti-microbial therapy, surgery or both.
  • Adequate organ system function should be maintained.

Prognosis

The mortality resulting from sepsis is usually quoted to be in the range of 20-50% [7]. However, with the advances in the clinical trials in the past ten years, the mortality rate has been limited to 24 to 41%. The mortality greatly depends on the severity of illness.

The severity of the illness and the prognosis depend on the causative organism, site of infection, the strength of the patient’s immune system, the presence of any underlying disease and the developmet of septic shock.

Etiology

There are number of causes which lead to the development of sepsis. Most of these causes are bacterial in nature but viruses and fungi can also cause sepsis.

The common gram positive organisms that cause sepsis include Staphylocossus, Streptocossus and Enterococcus; whereas Proteus, Pseudomonas and Klebsiella are the common gram negative organisms.

In previously healthy adults, the most common sources of infection are intraabdominal infections, urinary tract infections and pneumonia. In many cases of septicemia, the focus of infection may not be apparent.

Few other rare causes include parasites, fungi, viruses and mycobacteria.

The common predisposing conditions for gram negative bacteremia include diabetes mellitus, lymphoproliferative disorders, cirrhosis of liver, burns, invasive procedures and neutropenia.

In contrast, intravenous drug abuse, vascular catheterization, the presence of indwelling mechanical devices and burns are the predisposing conditions for gram positive bacteremia.

Immunosuppression and broad-spectrum antimicrobial therapy predispose the patient to fungemia.

Epidemiology

In the United States, the per annum episodes of sepsis are 400,000 to 750,000. Sepsis is more common in the extremes of ages such as infancy or old age. Statistical data shows that the male gender more commonly develops sepsis; the sex ratio being 1.5:1.

The development of sepsis is favored by poor hygienic conditions and overcrowding. 5-10% of gram positive bacteremias and 50-60% of gram negative bacteremias are complicated by sepsis.

Sex distribution
Age distribution

Pathophysiology

The septic response results from the microbial signals or toxins coupled with the body response in the form of formation of cytokines, prostaglandins and the activation of complement C5a.

Microbial factors

Bacterial signals initiate the release of inflammaory mediators from leukocytes and endothelial cells. Exotoxins (such as peptoglycan and lipoteichoic acid produced by gram positive organisms) and endotoxins (such as lipopolysacchardie produced by gram negative organisms) are the important microbial factors in this regard.

Body response

There is convincing evidence to support the belief that sepsis develops from exaggerated systemic inflammatory response which is induced by infecting organisms. Some of the inflammatory mediators include TNF (tumor necrosis factor), cytokines, leukotrienes, interleukins, eicosanoids, interferon gamma, selectins and complement C5a [3][4][5].

The interaction of these mediators leads to an inflammatory cascade of reactions that causes widespread endothelial damage, hypotension, refractory shock and multiorgan failure.

Abnormalities of coagulation and fibrinolysis

As a result of endothelial damage, clotting factors and the extrinsic clotting cascade are activated. This leads to disseminated intra-vascular coagulation (DIC) and microvascular thrombosis which ultimately results in organ dysfunction and death [6].

Circulatory abnormalities

Distributive shock is characterized by the pathological vasodilatation and shunting of blood from vital to non-vital tissues and organs. Septic shock falls under this category. Disturbances in blood flow, micro-circulation and peripheral shunting of oxygen result in the deficiency of oxygen and accumulation of lactic acid.

Organ dysfunction and failure

As a result of the abnormalities in circulation, coagulation, peripheral shunting and chemical mediators, the main systems and organs of the body fail to function properly. The improper oxygenation that develops ultimately leads to organ failure and death.

Prevention

Promotion of the hygienic conditions and prevention of overcrowding greatly prevents sepsis. High risk individuals must be identified beforehand to ensure early diagnosis.

Summary

Sepsis can be defined as the systemic inflammatory response to microbial invasion. It is characterized by the presence of two or more of the following  four conditions [1].

  • Oral temperature greater than 38°C or less than 36°C
  • Heart rate more than 90 beats/minutes
  • Respiratory rate more than 20 breaths/minute; or less than 32 torr partial pressure of carbon dioxide.
  • Leukocyte count of more than 12,000 cells/mm3 or less than 4000 cells/mm3 or greater than 10% band forms

Dysfunction of major organs occurs in severe sepsis and may lead to septic shock. Septic shock can be defined as sepsis with hypotension that is unresponsive to fluid resuscitation with signs of organ dysfunction and perfusion abnormalities such as metabolic acidosis, acute alteration in mental status, oliguria or adult respiratory distress syndrome.

Early sepsis is usually reversible whereas patients with septic shock often die even if aggressive therapy is provided. For this reason, it is necessary to detect the cause of sepsis and treat it as early as possible. Sepsis causes millions of death each year [2].

Patient Information

Sepsis is a condition in which in which microorganisms or their toxins are present in the blood. It is characterized by fever, fast breathing and heart rate and an increase in white blood cell count. Individuals at the extremes of ages (old age or infancy) or those who have poor health, or unhygienic living conditions are more prone to the development of sepsis. Sepsis can be fatal if not diagnosed and managed promptly.

References

Article

  1. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Critical care medicine. Apr 2003;31(4):1250-1256.
  2. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Critical care medicine. Jan 2008;36(1):296-327.
  3. Salles MJ, Sprovieri SR, Bedrikow R, et al. [Systemic inflammatory response syndrome/sepsis--review and terminology and physiopathology study]. Revista da Associacao Medica Brasileira. Jan-Mar 1999;45(1):86-92.
  4. Avdeeva MG, Shubich MG. [Pathogenetic mechanisms of the initiation of systemic inflammatory response syndrome (a literature review)].
  5. Klinicheskaia laboratornaia diagnostika. Jun 2003(6):3-10.
    Jaffer U, Wade RG, Gourlay T. Cytokines in the systemic inflammatory response syndrome: a review. HSR proceedings in intensive care & cardiovascular anesthesia. 2010;2(3):161-175.
  6. Nimah M, Brilli RJ. Coagulation dysfunction in sepsis and multiple organ system failure. Critical care clinics. Jul 2003;19(3):441-458.
  7. Russel JA. The current management of septic shock. Minerva medica. Oct 2008;99(5):431-458.
  8. Soong J, Soni N. Sepsis: recognition and treatment. Clinical medicine. Jun 2012;12(3):276-280.
  9. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. The New England journal of medicine. Nov 8 2001;345(19):1368-1377.
  10. Jones AE, Brown MD, Trzeciak S, et al. The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: a meta-analysis. Critical care medicine. Oct 2008;36(10):2734-2739.

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Last updated: 2017-08-09 18:21