“I’ll take Unrecognized Life-Threatening Emergencies for $62 billion in hospital costs, Alex.”

“This condition is diagnosed 1.7 million times a year in the US, and it causes one out of every three hospital deaths. About 2.5 million people are survivors, and they have a lifelong increased risk for serious complications.”

“What is sepsis?”

“That is correct!”

For such a common situation, sepsis is surprisingly poorly understood by many, and frequently escapes early detection until the patient is very ill. This is why sepsis is a leading cause of hospital deaths and the main cause of hospital readmissions.

What is Sepsis?

Hippocrates used the term sepsis in the 4th century BCE to denote decomposition of tissues. In modern usage, the word implies infection; its antonym, antisepsis, of course refers to actions taken to prevent infection.

Until recently, the terms sepsis, septicemia, and blood poisoning were used more or less interchangeably. Then in 2016, a group of experts gathered to clarify some of the nomenclature around sepsis and related disorders. Along with these classifications, they also proposed some diagnostic criteria and screening tools based on various tests that are outside our scope of practice. Together, these labels and criteria have helped health-care providers improve outcomes for patients with sepsis. (See Sepsis Nomenclature sidebar.)

Pathophysiology of Sepsis

At one time it was assumed that sepsis was the result of uncontrolled spread of pathogens throughout the body. Then, as we became more knowledgeable about the inflammatory process and immune system activity, we came to understand that infection is only one aspect of sepsis, and that it is more accurate to describe this situation as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.”¹

In other words, sepsis is not a synonym for infection. Rather, it is the result of infection, immune system activity, and inflammation that together lead to organ damage, organ failure, and death. (Interestingly, this is the same triad of features that makes COVID-19 so dangerous to some patients.)

It is worthwhile to point out that organ failure related to immune system activity and inflammation can also happen without infection. This situation is called systemic inflammatory response syndrome (SIRS). SIRS can be triggered by sepsis, but it can also be the result of pancreatitis, severe trauma, allergic reactions, cancer, or other causes. Close study of the inflammatory and immune system activities in both sepsis and SIRS has confirmed that these processes are similar; the main difference is the presence or absence of a pathologic trigger like a bacterial or viral infection.

Both sepsis and SIRS can lead to pathologic clotting in the blood vessels that supply the limbs and organs, which can cause tissue death and gangrene. This accounts for about 10 percent of all amputations that happen in the US each year.

Sepsis Signs and Symptoms

One of the truly scary things about sepsis is how quickly a person can go from feeling fine or only mildly “off” to being in end-stage organ failure or at risk for losing a limb. In the video that accompanies this article, I describe sepsis experiences shared with me by two massage therapists. The stories are very different, but the thing they share is the suddenness with which the extreme and dangerous consequences of sepsis hit.

Because sepsis is not directly linked to the presence of pathogens or white blood cells in the bloodstream, it can be difficult to identify early, especially outside a hospital. Some specific diagnostic criteria have been created, but they require tests and screens that are available only in emergency health-care settings.

General signs and symptoms can (but don’t always) include fever, impaired mental status, increased respiration, warm or cold skin, and low blood pressure. However, a handful of other serious situations can mimic sepsis, including dehydration, gastrointestinal bleeding, diabetic ketoacidosis, pancreatitis, pulmonary embolism, and others.

Some patients’ blood pressure dips very low, causing septic shock: a situation in which organs can fail because of lack of blood supply. Septic shock is very serious, and it has a higher risk of mortality than sepsis without hypotension.

A mnemonic for sepsis symptoms (“TIME”) is promoted by an organization called the Sepsis Alliance (see It’s About TIME graphic, page 41). This protocol can help get people at risk to emergency services where they can be evaluated for the risk of sepsis.

Treatment

Sepsis is treated with antibiotics, rehydration, and medications to stabilize blood pressure. Other treatments depend on the initial cause of the sepsis, but just getting stabilized can take enormous time and resources. It is not unusual for patients who survive sepsis to stay in the hospital for a week or more.

Post-Sepsis Syndrome

Sepsis is a life-threatening situation with subtle early signs and a risk of permanent organ damage, amputation, and death. For those who survive, their struggle may not be over.

Many people who survive sepsis go on to develop post-sepsis syndrome (PSS). PSS can involve long-term physical, psychological, and mental disabilities. Patients report problems with memory, learning, and decision-making. PSS is associated with fatigue, pain, muscle weakness and wasting, posttraumatic stress disorder (PTSD) symptoms, chest pain, shortness of breath, insomnia, depression, anxiety, and more. (Does this sound familiar? The same symptoms are associated with chronic fatigue syndrome and long COVID—two other post-infection situations.)

And PSS is common. Improved early recognition of sepsis and more effective treatment options means the number of sepsis survivors is increasing. This is good news, of course, but it also means that the number of people with PSS is increasing, and there are no established effective medical treatment protocols for this population.

Implications for Massage Therapy

Massage therapists are unlikely to see clients with acute sepsis, but it’s not impossible. And the signs and symptoms of this condition are variable, unpredictable, and often not immediately indicative of a system-wide, life-threatening infection an inflammatory reaction.

If fever is present, that is an obvious reason to cancel an appointment and refer the client to a primary health-care provider. But not all people with active sepsis have a fever, and other symptoms can be scarily vague.

It is far more likely that we might see a client who is recovering from sepsis rather than dealing with an acute infection. Some patients recover fully without long-term consequences, but as we have seen, the number of people with post-sepsis syndrome is increasing as survival rates for sepsis improve.

Can massage therapy offer anything for a client with PSS? As always, the answer is, “It depends.”

Let’s put this through a critical-thinking process to see where we land. Let’s say we have a client with PSS, and their main complaints are about muscle weakness in their legs, severe low-back and neck pain, and milder joint and muscle achiness everywhere else. They want to see if massage therapy might help.

Analyze the question. The client’s goals are clear. What kind of massage therapy might improve symptoms of weakness and muscle and joint pain for this client with PSS?

Identify relevant variables. Relevant variables in this situation include issues like whether they still have an active infection (delay massage until treatment is completed); what medications they use and the side effects of those medications; what their activities of daily living are—which gives us some ideas about their general energy levels and resilience; and finally, what their goals are and how to track whether they make progress. Other variables are more specifically related to their experience of PSS. Some of this will be revealed as you learn more about the client’s experience. Articles like this one and others listed in the resources section will help fill in your knowledge about this condition.

Challenge assumptions. What assumptions have we made so far? At this point, it would be useful to ensure we have a clear and accurate understanding of our client’s priorities and a full grasp of any safety issues as we begin to envision treatment options. For instance, a client’s low-back pain might be due to musculoskeletal factors—or it might be a referral from their damaged kidneys. For this reason, it is wise (with permission) to consult with the client’s health-care provider about your plans and goals to be sure they’re in alignment. (Note: The phrase “consult with” is not the same as asking permission. A consultation will allow you to get the fullest possible picture of the client’s needs.)

Consider alternatives. Before we map out a session plan, we should look for any information about what other practitioners have done for patients with PSS. I can save you some time here: My dive into what the research says about PSS suggests that there is no specific treatment protocol using massage or other interventions. So while there are infinite choices for how to proceed, none of them have been documented to be better than others.

Plan and conduct your first session. You’ve gathered information about PSS, and you have a clear idea about your client’s goals. You have a sense of their resilience, so you can provide a session that does not overchallenge their allostatic capacity—their ability to maintain homeostasis with ease.

Take a moment now to visualize that session: What is your plan? How long will the session be? How will you position your client on the table? What kind of pressure and speed will you use? Where on the body will you focus? What other accommodations will you make for this client?

Reflect on results. Congratulations. That was a lot of work just to get ready for one session. But how will you know if your work is effective? When a client has some specific goals for massage (like having less muscle and joint pain, and feeling stronger), it’s important to plan how to track progress. That way, if you do make progress, you can celebrate. But if you don’t make the progress that you’re looking for, you can adjust your strategies.

Post-sepsis syndrome is common and becoming more so. Many people with PSS experience pain, weakness, depression, anxiety, fatigue, insomnia, and other situations for which massage therapy has demonstrated benefits. As long as you are working in conjunction with the rest of your client’s health-care team, it seems reasonable to suggest massage therapy might be a great choice for people who live with this chronic, common, poorly understood condition.

Sepsis Nomenclature

• Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection.

• Systemic inflammatory response syndrome (SIRS) is similar to sepsis, except that it can be caused by noninfectious problems.

• Multiple organ dysfunction syndrome (MODS) is the result of sepsis. It can affect several body systems.

• Septic shock is a subset of sepsis, with dangerously low blood pressure and several other abnormalities. Septic shock poses a greater risk of death than sepsis alone.

• Bacteremia refers to a bacterial infection of the bloodstream that could lead to organ damage. (Note: Viruses and fungi may also infect the bloodstream.)

• Pseudosepsis involves fever, hypotension, and other signs that are easily mistaken for sepsis, but are not the result of infection.

Resources

Al-Khafaji, Ali H. “Multiple Organ Dysfunction Syndrome in Sepsis: Background, Pathophysiology, Epidemiology.” Medscape (updated January 27, 2020). https://emedicine.medscape.com/article/169640-overview.

Al-Khafaji, Ali H. “How are Sepsis and Systemic Inflammatory Response Syndrome (SIRS) Differentiated?” Medscape (updated January 27, 2020). www.medscape.com/answers/169640-99167/how-are-sepsis-and-systemic-inflammatory-response-syndrome-sirs-differentiated.

Bokhari, Amber Mahmood. “Bacterial Sepsis: Practice Essentials, Background, Etiology.” Medscape (February 5, 2019). https://emedicine.medscape.com/article/234587-overview.

Faix, James D. “Biomarkers of Sepsis.” Critical Reviews in Clinical Laboratory Sciences 50, no. 1 (March 2013): 23–36. https://doi.org/10.3109/10408363.2013.764490.

Farkas, Joshua David. “The Complete Blood Count to Diagnose Septic Shock.” Journal of Thoracic Disease 12, suppl. 1 (February 2020): S16–S21. https://doi.org/10.21037/jtd.2019.12.63.

Gritte, Raquel Bragante et al. “Why Septic Patients Remain Sick After Hospital Discharge?” Frontiers in Immunology 11, 605666 (February 2021). https://doi.org/10.3389/fimmu.2020.605666.

Huang, Min, Shaoli Cai, and Jingqian Su. “The Pathogenesis of Sepsis and Potential Therapeutic Targets.” International Journal of Molecular Sciences 20, no. 21 (October 2019 ): 5376. https://doi.org/10.3390/ijms20215376.

Mostel, Zachary et al. “Post-Sepsis Syndrome—An Evolving Entity that Afflicts Survivors of Sepsis.” Molecular Medicine 26, no. 6 (December 2019). https://doi.org/10.1186/s10020-019-0132-z.

Nursing Times. “Post-Sepsis Syndrome: Overview of a Relatively New Diagnosis.” (July 8, 2019).   www.nursingtimes.net/roles/hospital-nurses/post-sepsis-syndrome-overview-of-a-relatively-new-diagnosis-08-07-2019.

Sepsis Alliance. “Losing Limbs to Sepsis: Limb Loss Awareness Month.” April 1, 2019. www.sepsis.org/news/losing-limbs-to-sepsis-limb-loss-awareness-month.

Sepsis Alliance. “Post-Sepsis Syndrome.” Updated January 21, 2021. www.sepsis.org/sepsis-basics/post-sepsis-syndrome.

Torrey, Trisha. “Sepsis and Septicemia Are Not the Same.” Verywell Health. www.verywellhealth.com/sepsis-and-septicemia-2615130.

Note

1. Singer, Mervyn et al., “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3),” JAMA 315, no. 8 (February 2016): 801–10, https://doi.org/10.1001/jama.2016.0287.