Perioperative Management of the Septic Patient

Anesthesia providers provide patients with medications in a variety of contexts, ranging from critical care to cardiothoracic surgery to obstetrics.¹ Across these settings, patients may present with preexisting morbidities, such as neurologic diseases² or hypertension³ that make anesthesia provision more complicated. One such preexisting issue is sepsis, which is a potentially life-threatening condition caused by infection. Anesthesia providers should be knowledgeable about the biology and symptomology of sepsis, as well as perioperative and anesthetic implications. 

Sepsis is a syndrome caused by the body’s dysregulated immune response to an infection.⁴ Normally, the body releases chemicals into the bloodstream to fight infection.⁵ Sepsis occurs when these chemicals, which have pro- and anti-inflammatory effects, are out of balance.⁶ The stages of sepsis include sepsis, marked by a system inflammatory immune response to an infection;⁷ severe sepsis, which occurs when organs begin to fail; and septic shock, which is marked by a sustained drop in blood pressure that impairs blood flow to the tissues.⁸ Diagnosing sepsis is difficult and remains unstandardized.⁷ However, common clinical manifestations include fever, mental status changes, elevated respiration and heart rate, low blood pressure, increased white blood cell count and blood coagulation abnormalities.⁷ Severe sepsis is characterized by multiple organ dysfunction syndrome (MODS).⁹ Septic shock includes all of the signs of sepsis and severe sepsis, along with severe hypotension.¹⁰ Any infection from bacteria, fungi or viruses can result in sepsis.⁴ Sepsis is considered the final step before patients with severe infections die,⁴ and the overall sepsis-related mortality rate ranges from 18 to 25 percent.¹¹ Sepsis is common among intensive care unit (ICU) patients, with prevalence ranging from 8.2 to 35.3 percent of all ICU patients.¹¹ It is also one of the most frequent cause of death among hospitalized patients⁴ and among humans in general,⁶ making it a significant public health problem.¹² 

The anesthesia provider plays a central role in managing patients with severe sepsis, including the initial deterioration in the ward, transfer to the diagnostic imaging area, intraoperative care for emergency surgery and even resuscitation during sepsis-induced cardiac arrest.^13,14 Before surgery, the anesthesia provider is responsible for administering antimicrobial medications, fluids, vasopressors (medications that cause constriction of blood vessels) and positive inotropes (medications that cause an increased force of cardiac contraction).¹⁴ During surgery, the anesthesia provider will carefully induce and maintain anesthesia, avoid lung injury during mechanical ventilation and keep blood volumes at an optimal level.¹⁴ Because patients with severe sepsis have significant respiratory and cardiovascular issues,¹⁵ anesthesia providers must be especially vigilant during intraoperative monitoring of vital signs such as oxygenation, blood pressure, kidney indices and electrolyte levels.¹⁴ Though general anesthesia is usually indicated during surgery for sepsis, the majority of anesthetics have cardiovascular depressant effects and can potentiate hemodynamic instability.¹⁵ A paper by Yoon suggests using drugs such as ketamine or etomidate, which avoid the cardiovascular depression of propofol, thiopental and midazolam, along with vasopressors and inotropes.¹⁶ Overall, it is crucial that the anesthesia provider use antibiotics and stabilizing medications, avoid lung injury during ventilation, closely monitor vital signs and provide adequate resuscitation for septic patients.¹⁷ 

Anesthesiology practitioners must be prepared for patients who present with a variety of preexisting conditions. Sepsis, which is a leading cause of death worldwide, is caused by dysfunction in the body’s response to infection and may lead to organ failure and shock. The anesthesia provider is vital to the multidisciplinary management of a patient with sepsis undergoing surgery, from the time the patient shows septic symptoms to the surgery itself. Anesthesiologists must administer several medications including general anesthesia, provide safe ventilation, diligently monitor vital signs and resuscitate patients intraoperatively. Future research should investigate the possibility of using alternative forms of anesthesia for sepsis, which may have fewer cardiovascular and respiratory side effects.¹⁸ 

1.American Society of Anesthesiologists. ​Guide to a Career in Anesthesiology. ASA Medical Student Component 2020; https://www.asahq.org/education-and-career/asa-medical-student-component/guide-to-a-career-in-anesthesiology. 

2.McSwain JR, Doty JW, Wilson SH. Regional anesthesia in patients with pre-existing neurologic disease. Current Opinion in Anaesthesiology. 2014;27(5):538–543. 

3.Chung F, Mezei G, Tong D. Pre-existing medical conditions as predictors of adverse events in day-case surgery. British Journal of Anaesthesia. 1999;83(2):262–270. 

4.Van Der Poll T, Wiersinga WJ. Sepsis. In: Cohen J, Powderly WG, Opal SM, eds. Infectious Diseases (Fourth Edition): Elsevier; 2017:415–426.e411. 

5.Clinic M. Sepsis. Diseases & Conditions November 16, 2018; https://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/syc-20351214. 

6.Nedeva C, Menassa J, Puthalakath H. Sepsis: Inflammation Is a Necessary Evil. Frontiers in Cell and Developmental Biology. 2019;7(108). 

7.Balk RA. Systemic inflammatory response syndrome (SIRS): Where did it come from and is it still relevant today? Virulence. 2014;5(1):20–26. 

8.León AL, Hoyos NA, Barrera LI, et al. Clinical course of sepsis, severe sepsis, and septic shock in a cohort of infected patients from ten Colombian hospitals. BMC Infectious Diseases. 2013;13:345. 

9.Gavins FNE. Sepsis. In: Gavins FNE, Stokes KY, eds. Vascular Responses to Pathogens. Boston: Academic Press; 2016:1–9. 

10.Norrby-Teglund A, Treutiger C-J. Sepsis. In: Finch RG, Greenwood D, Norrby SR, Whitley RJ, eds. Antibiotic and Chemotherapy (Ninth Edition). London: W.B. Saunders; 2010:472–482. 

11.Rosner MH. Sepsis. In: Lerma EV, Sparks MA, M. Topf J, eds. Nephrology Secrets (Fourth Edition): Elsevier; 2019:84–88. 

12.Lewis AJ, Billiar TR, Rosengart MR. Biology and Metabolism of Sepsis: Innate Immunity, Bioenergetics, and Autophagy. Surgical Infections. 2016;17(3):286–293. 

13.Ben-Jacob TK, Sreedharan R, Nunnally ME, Chang BPM. Perioperative Management of the Septic Patient. ASA Newsletter. 2017;81(11):18–20. 

14.Eissa D, Carton EG, Buggy DJ. Anaesthetic management of patients with severe sepsis. BJA: British Journal of Anaesthesia. 2010;105(6):734–743. 

15.Yuki K, Murakami N. Sepsis pathophysiology and anesthetic consideration. Cardiovascular & Hematological Disorders—Drug Targets. 2015;15(1):57–69. 

16.Yoon SH. Concerns of the anesthesiologist: Anesthetic induction in severe sepsis or septic shock patients. Korean Journal of Anesthesiology. 2012;63(1):3–10. 

17.Nunnally ME. Sepsis for the anaesthetist. British Journal of Anaesthesia. 2016;117(Suppl 3):iii44–iii51. 

18.Mutz C, Vagts DA. Thoracic epidural anesthesia in sepsis – Is it harmful or protective? Critical Care. 2009;13(5):182.