Principles of source control in the management of sepsis

Abstract

This brief overview of the role of source control in sepsis emphasizes the underlying principles rather than the empiric evidence from well-performed clinical studies. The reasons for this are several. First there is a paucity of high-level published evidence, with few rigorous large clinical series, and even fewer clinical trials. Second, the decision-making process in the individual patient is complex, and often not amenable to study using the design of a randomized controlled trial, for decisions involve consideration not only of the underlying disease but of the stability of the patient, the presence of comorbidities, and the prior surgical history, all factors that can heavily influence the decision to choose one therapeutic option rather than another. The scope of the topic is large, and the space limited. Interested readers are referred to more detailed discussions such as that found in the background to the recommendations on source control in the guidelines of the Surviving Sepsis Campaign.(1) Source control is a core treatment modality in the management of the patient with severe sepsis or septic shock. Its optimal use assumes a comprehensive knowledge of biologic principles, the complexities of the septic response, and the range of surgical and nonsurgical options, and a combination of therapeutic aggressiveness and judicious caution in the clinician charged with making the decision. As every intensivist learns, appropriate source-control intervention can rapidly alter the course of sepsis to a more favorable direction, and suboptimal decision-making can change a difficult clinical challenge into a nightmare.