Sepsis and septic shock impact millions of patients worldwide (Evans et al., 2021). Sepsis is defined as life threatening end-organ dysfunction caused by a dysregulated host response to infection. Sepsis is the leading cause of death in critically ill patients; early identification and appropriate management markedly improves morbidity and mortality. Management includes prompt recognition, timely administration of appropriate antibiotics, fluid resuscitation, hemodynamic support, and control of the source of infection (Forrester, 2021).
Source control is defined as surgical and non-surgical interventions used to treat an infection (Marshall, 2010). Rapid identification and establishment of source control is an essential component in the workup and treatment of sepsis. It involves investigation with history and physical examination, laboratory studies, and appropriate imaging (Marshall, 2010).
On initial presentation, the process to identify the source of infection can be difficult as the source may not be readily apparent. While a chest radiograph, urinalysis and blood cultures are standard orders in the identification of potential sources of infection, many times further investigation and computed tomography (CT) imaging is warranted to rule out a surgical source of the underlying infection (Kim & Park, 2019).
Four Components of Source Control
The core elements of source control consist of four components: drainage, debridement, device removal, and definitive measures (Lagunes et al., 2016; Marshall, 2010).
1. Drainage refers to the evacuation of infected fluid through the opening of an infected abscess. This is performed through incision and drainage or by in the insertion of a drain. The process of drainage converts a closed, infected abscess into a controlled sinus or fistula to promote drainage (Marshall, 2010). Examples include incision and drainage of an infected Bartholin cyst with insertion of packing, or insertion of a percutaneous cholecystectomy tube in the case of cholecystitis.
2. Debridement involves the removal of necrotic or devitalized or infected tissue through surgical or non-surgical interventions. Local wound care is an example of non-surgical debridement. Surgical debridement involves the excision of gangrenous soft tissue such as necrotizing fasciitis, or debridement of infected intestine.
3. Device removal involves removal of a prosthetic device that has become colonized by organisms. This could include the removal of a central line or urinary catheter, excision of an infected vascular graft, or removal of infected orthopedic hardware.
4. Definitive measures are other interventions, usually surgical, that are performed to remove a focus of infection and restore optimal function and quality of life. This can include surgical excision of diverticular disease and restoration of intestinal continuity, decortication of lung following the drainage of an empyema, or repair of an abnormal wall hernia following treatment of peritonitis.
Sepsis and septic shock carry high mortality rates. Early identification, resuscitation, initiation of antibiotics and prompt identification and management of the underlying source and cause of sepsis is imperative in improving patient outcomes.
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., Belley-Cote, E., … Levy, M. (2021). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 47(11), 1181–1247. https://doi.org/10.1007/s00134-021-06506-y
Forrester, J. (2021, September). Sepsis and septic shock. Merck manual: professional version. https://www.merckmanuals.com/professional/critical-care-medicine/sepsis-and-septic-shock/sepsis-and-septic-shock
Kim, H. & Park, S. (2019). Sepsis: Early Recognition and Optimized Treatment. Tuberculosis and respiratory diseases, 82(1), 6–14. https://doi.org/10.4046/trd.2018.0041
Lagunes, L., Encina, B., & Ramirez-Estrada, S. (2016). Current understanding in source control management in septic shock patients: a review. Annals of translational medicine, 4(17), 330. https://doi.org/10.21037/atm.2016.09.02
Marshall J. C. (2010). Principles of source control in the early management of sepsis. Current infectious disease reports, 12(5), 345–353. https://doi.org/10.1007/s11908-010-0126-z