Sepsis. Tim Nutbeam Specialist Trainee in Emergency Medicine, West Midlands School of Emergency Medicine, Birmingham, UK EDITED BY

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1 Sepsis EDITED BY Ron Daniels Chair, Surviving Sepsis Campaign United Kingdom, Consultant in Anaesthesia and Critical Care, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK; Fellow, NHS Improvement Faculty Tim Nutbeam Specialist Trainee in Emergency Medicine, West Midlands School of Emergency Medicine, Birmingham, UK A John Wiley & Sons, Ltd., Publication

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3 Sepsis

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5 Sepsis EDITED BY Ron Daniels Chair, Surviving Sepsis Campaign United Kingdom, Consultant in Anaesthesia and Critical Care, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK; Fellow, NHS Improvement Faculty Tim Nutbeam Specialist Trainee in Emergency Medicine, West Midlands School of Emergency Medicine, Birmingham, UK A John Wiley & Sons, Ltd., Publication

6 This edition first published 2010, 2010 by Blackwell Publishing Ltd BMJ Books is an imprint of BMJ Publishing Group Limited, used under licence by Blackwell Publishing which was acquired by John Wiley & Sons in February Blackwell s publishing programme has been merged with Wiley s global Scientific, Technical and Medical business to form Wiley-Blackwell. Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ , USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should notbe relied upon as recommending or promoting aspecific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging-in-Publication Data ABC of sepsis / edited by Ron Daniels, Tim Nutbeam. p. ; cm. Includes bibliographical references and index. ISBN: Septicemia. I. Daniels, Ron, MD. II. Nutbeam. Tim. [DNLM: 1. Sepsis. WC 240 A ] RC182.S4A dc A catalogue record for this book is available from the British Library Set in 9.25/12 Minion by Laserwords Private Limited, Chennai, India PrintedandboundinSingapore

7 Contents Contributors, vii Preface, ix 1 Introduction, 1 Mitchell M. Levy 2 Defining the Spectrum of Disease, 5 Ron Daniels 3 Identifying the Patient with Sepsis, 10 Ron Daniels 4 Serious Complications of Sepsis, 15 Hentie Cilliers, Tony Whitehouse and Bill Tunnicliffe 5 The Pathophysiology of Sepsis, 20 Edwin Mitchell and Tony Whitehouse 6 Initial Resuscitation, 25 Tim Nutbeam 7 Microbiology and Antibiotic Therapy, 29 Partha De and Ron Daniels 8 Infection Prevention and Control, 36 Fiona Lawrence, Georgina McNamara and Clare Galvin 9 The Role of Imaging in Sepsis, 42 Morgan Cleasby 10 Presentations in MedicalPatients, 48 Nandan Gautam 11 Presentations in Surgical Patients, 57 Jonathan Stewart and Sian Abbott 12 Special Cases: The Immunocompromised Patient, 62 Manos Nikolousis 13 The Role of Critical Care, 68 Julian Hull 14 Monitoring the Septic Patient, 73 David Stanley 15 Novel Therapies in Sepsis, 78 Gavin D. Perkins and David R. Thickett 16 Approaches to Achieve Change, 83 Julian F. Bion and Gordon D. Rubenfield Index, 87 v

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9 Contributors Sian Abbott Specialist Registrar in Colorectal Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK Julian F. Bion Chair, European Board of Intensive Care Medicine, Professor of Intensive Care Medicine, University of Birmingham, Honorary Consultant in Intensive Care Medicine, University Hospitals Birmingham, Birmingham, UK Hentie Cilliers Specialist Registrar in Anaesthesia, West Midlands Deanery, Birmingham, UK Morgan Cleasby Consultant Radiologist, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK Ron Daniels Chair, Surviving Sepsis Campaign United Kingdom, Consultant in Anaesthesia and Critical Care, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK; Fellow, NHS Improvement Faculty Partha De Consultant Microbiologist, Royal Surrey County Hospital NHS Trust, Guildford, UK Clare Galvin Sepsis Nurse Practitioner, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK Nandan Gautam Consultant in Acute Medicine and Critical Care, University Hospitals Birmingham, Birmingham, UK Julian Hull Consultant in Anaesthesia and Critical Care, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK Fiona Lawrence Professional Development Sister for Critical Care, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK Mitchell M. Levy Professor of Medicine, The Warren Alpert Medical School of Brown University, Director, Critical Care Services, Rhode Island Hospital, Medical Director, MICU, Rhode Island Hospital, Providence, RI, USA Georgina McNamara Sepsis Nurse Practitioner, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK Edwin Mitchell Specialist Registrar in Anaesthesia and Advanced Intensive Care Medicine Trainee, West Midlands Deanery, Birmingham, UK Manos Nikoulousis Specialist Registrar in Haematology, Heart ofenglandnhsfoundation Trust, Birmingham, UK Tim Nutbeam Specialist Trainee in Emergency Medicine, West Midlands School of Emergency Medicine, University Hospitals Birmingham, Birmingham,UK Gavin D. Perkins Honorary Consultant in Critical Care Medicine, Heart of England NHS Foundation Trust, Co-Director of Research, Intensive Care Society, Associate Clinical Professor in Critical Care and Resuscitation, Warwick University Medical School, Coventry, UK Gordon D. Rubenfield Chief, Program in Trauma, Emergency, and Critical Care, Sunnybrook Health Sciences Centre, Professor of Medicine, University of Toronto, Canada David Stanley Consultant in Anaesthesia and Intensive Care Medicine, Dudley Group of Hospitals, West Midlands, UK vii

10 viii Contributors Jonathan Stewart Consultant in Colorectal Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK David R. Thickett Wellcome Senior Lecturer in Medical Science, University of Birmingham, Honorary Consultant in Respiratory Medicine and Critical Care, University Hospitals Birmingham and Heart of England NHS Foundation Trust, Birmingham, UK Bill Tunnicliffe Consultant in Critical Care, University Hospitals Birmingham, Birmingham, UK Tony Whitehouse Consultant in Critical Care and Anaesthesia, University Hospitals Birmingham, Birmingham, UK

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