Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Sepsis


Related Terms

  • Bacteremia
  • Septic Shock
  • Septicemia

Differential Diagnosis

Specialists

  • Cardiologist, Cardiovascular Physician
  • Emergency Medicine Physician
  • Gastroenterologist
  • Infectious Disease Internist
  • Internal Medicine Physician
  • Nephrologist
  • Neurologist
  • Pulmonologist
  • Urologist

Comorbid Conditions

Factors Influencing Duration

The cause and severity of sepsis, timeliness of treatment, age and health status of the individual, and the response to treatment will influence the length of disability. The development of septic shock or organ failure or the presence of drug-resistant organisms will greatly extend the length of disability.

Medical Codes

ICD-9-CM:
995.91 - Systemic Inflammatory Response Syndrome Due to Infectious Process without Organ Dysfunction; Sepsis
995.92 - Systemic Inflammatory Response Syndrome Due to Infectious Process with Organ Dysfunction; Severe Sepsis

Overview

Sepsis refers to a whole body inflammatory response to serious infection (systemic inflammatory response syndrome [SIRS]). It is a complex and sometimes rapid process that results when disease-causing organisms (pathogens), usually bacteria and the chemicals they produce (bacterial toxins), are introduced into the bloodstream (bacteremia) either directly or from another source of infection. This triggers the body's release of pro-inflammatory mediators (i.e., cytokines or endotoxins such as tumor necrosis factor [TNF] and interleukin-1 [IL-1]) and anti-inflammatory mediators (i.e., leukotrienes, histamine, and serotonin) to control this overwhelming systemic infection. In rare cases, fungi and viruses also can cause sepsis. The widespread presence of the causative organisms and the pro- and anti-inflammatory mediators released by the body to fight them results in a septic inflammatory state (septicemia), that includes blood vessel dilation, leakage of fluid into tissues, coagulation abnormalities, and, initially an increase in cardiac output, followed by an eventual decline in cardiac output. Blood pressure may then drop severely (septic shock), and tissue throughout the body is deprived of blood and oxygen, resulting in ischemia, cell damage, and multiple organ failure, including failure of the heart, liver, lungs, brain, and kidneys. Failure of any of these organs can be fatal. Even with modern therapeutic measures, septic shock is fatal in 10% to 80% (average 40%) of all cases (Weil).

The most common pathogens responsible for sepsis and septic shock are gram-negative bacteria and gram-positive cocci (staphylococci and meningococci). Sepsis may result when pathogens enter the bloodstream from puncture wounds, deep cuts, burns, infected surgical incisions, gangrene of bowel or any tissue, acute pancreatitis, major trauma, or the use of intravenous lines and invasive devices such as indwelling vascular or urinary catheters, endotracheal tubes, post-operative drainage tubes, ostomy devices and tubing and extended use of corticosteroid drugs or antibiotics. In most cases, the infection is hospital-acquired. Sepsis is potentially fatal, especially in the elderly whose already compromised systems are more susceptible to septic shock.

Incidence and Prevalence: The incidence of sepsis has been increasing for the past 30 years because of the increased use of intravascular catheters and other invasive devices, widespread use of immunosuppressive drugs, an increase in HIV infection/AIDS, and the emergence of antibiotic-resistant organisms. Medical has increasingly prolonged the life of individuals with cancer, diabetes, and AIDS, thus increasing the incidence of infection, which also increases the incidence of sepsis.

The incidence of sepsis, severe sepsis, and septic shock in the US is recorded separately: sepsis is diagnosed in 400,000 individuals annually, resulting in about 60,000 deaths; severe sepsis with organ failure affects 300,000 individuals annually, resulting in another 60,000 deaths; and septic shock (severe sepsis with significant hypotension) occurs in 200,000 individuals, resulting in 90,000 deaths annually (Weil). One large study prior to 2003 estimated that in the US, there are more than 750,000 cases of sepsis annually (Cohen 614). More recent estimates indicate about 900,000 cases are diagnosed annually, of which about one-third progress to organ failure and septic shock (Weil).

Source: Medical Disability Advisor



Causation and Known Risk Factors

People most at risk for sepsis are those whose immune system is weakened. They include people with diseases such as HIV infection/AIDS, multiple sclerosis, diabetes, and lymphoma, transplant patients taking immunosuppressant drugs, and people receiving chemotherapy. Other people at risk are those who have had recent surgery, who have invasive devices such as urinary catheters or intravenous (IV) lines, who have been burned over a large part of their body, or who have experienced recent acute trauma. Neonates, pregnant women, and individuals over age 85 who have other serious medical conditions are at particularly high risk of developing septic shock (Weil). Elderly men are at increased risk because of urinary tract obstruction and urosepsis resulting from an enlarged prostate (prostatic hypertrophy) (Cunha). Risk is independent of sex or race but increases with age; septic shock occurs most frequently in individuals over age 35 (Weil).

Source: Medical Disability Advisor



Diagnosis

History: The individual usually will complain of fever and chills. The individual may complain of shortness of breath (dyspnea), rapid heart rate (tachycardia), and a feeling of apprehension or confusion. There may be specific symptoms suggesting the original site of infection (e.g., abdominal pain if gangrene of the intestine is present), but such localized symptoms often are absent. There may be a history of recent surgery, lung infections (e.g., pneumonia) or other severe known infections, recent acute trauma, puncture wounds, deep cuts, or burns. The individual may report having an invasive device (e.g., indwelling catheter). The individual may have a history of receiving immunosuppressive therapy, chemotherapy, antibiotic therapy, or corticosteroids, and / or may have a history of an underlying chronic illness such as diabetes or chronic obstructive pulmonary disease (COPD), or other debilitating disease such as AIDS, cirrhosis, or cancer.

Physical exam: On physical exam, the individual usually will have a fever; although some individuals may be have a subnormal temperature (hypothermic). Examination, symptoms, and history may suggest the source of the infection; possible sources can be gastrointestinal, genitourinary, respiratory, intravascular, or cardiovascular. If the individual has an invasive device, the entry site may show signs of infection; however only 50% of patients with infection within an IV line also have an infected insertion site (Cunha). Other common signs of sepsis may include rapid, shallow breathing; flushed skin and sweating; weak pulse; dehydration and decreased urine output; sudden high fever with chills; cold hands and feet with a bluish tinge to the skin (cyanosis); tachycardia (> 90 beats per minute); extreme exhaustion (prostration); and changes in mental status (e.g., confusion, agitation, disorientation, coma), especially among the elderly. Some individuals develop a red, pinpoint rash (petechiae) caused by capillary hemorrhages beneath the skin. A rectal examination in men may reveal tenderness suggesting prostatic abscess or signs of prostatic hypertrophy. Signs of organ failure may include a drop in blood pressure or an arrhythmia in cardiovascular failure; reduced respiratory rate and low blood oxygen levels (hypoxemia) in respiratory failure; and decreased urinary output in kidney failure. In patients with known or suspected infection, sepsis is a likely diagnosis if systemic signs of inflammation are present. However, confirmatory diagnostic testing is essential.

Tests: Normally tests begin with a complete blood count (CBC). A white blood cell (WBC) count and peripheral smear may show nonspecific signs of infection. The platelet count may decrease markedly early in sepsis. Blood chemistries are done to monitor electrolytes as an indication of fluid balance and renal functioning. Cardiac enzymes will help evaluate heart function, and lactate levels may be increased as shock develops. Erythrocyte sedimentation rate (ESR), procalcitonin, and C-reactive protein are measured to identify possible inflammatory processes. Coagulation tests may be done. Liver and kidney function tests also may be performed. Adrenal function may be evaluated by measuring serum cortisol levels. A blood gas analysis may show hypoxemia. Blood samples or samples of sputum (mucus) or spinal fluid may be cultured to identify the infective organism. Urinalysis and urine culture will be done, especially in individuals who have had indwelling urinary catheters in place. An electrocardiogram (ECG) may show abnormalities in heart rhythm. A chest x-ray may be done to look for evidence of pneumonia or pancreatitis. Ultrasound imaging may help detect abdominal abscesses or rule out biliary tract obstruction, and a computed tomography (CT) scan may be done if non-biliary infection in the abdomen is suspected or to investigate kidney pathology. Monitoring is an ongoing process as sepsis is treated, and these tests will be repeated as the individual's condition changes.

Source: Medical Disability Advisor



Treatment

The goal of treatment is to eliminate the underlying infection and avoid organ damage and a progression to septic shock. Sepsis generally is treated in a hospital intensive care unit (ICU) with intravenous antibiotics directed at the infective organism and intravenous fluids to restore fluid and electrolyte balance and to maintain the volume of blood for proper circulation. Mechanical respiration may be required to provide adequate oxygen supply to the tissues.

If the source of sepsis is an abscess or dead (necrotic) tissue, surgery is required to drain the abscess (incision and drainage) or to remove the dead tissue (débridement). Less commonly, sepsis is caused by a fungal infection and can be treated with antifungal drugs. Because immunosuppressant drugs inhibit the body's defense against infection, these drugs are discontinued whenever possible and resumed only when there is complete recovery from the infection.

Blood, urine, and other fluid cultures will be repeated regularly to monitor for continuing infection. Heart function and blood oxygen levels may be monitored.

Source: Medical Disability Advisor



Prognosis

The predicted outcome for sepsis is variable. If infection is detected early and the individual is otherwise in good health, sepsis is treatable and the prognosis is good. Poor outcomes occur when aggressive treatment is not begun within 6 hours of suspected sepsis. When a specific infectious site is identified and can be accessed, a good outcome is dependent upon a thorough incision and drainage procedure of the infected area, as well as thorough débridement of all necrotic and infected tissue. If metabolic acidosis, severe sepsis with organ failure, or septic shock develop, the prognosis is poor, especially for neonates, pregnant women, and the elderly, for whom the death rate can reach 80% (Weil). Septic shock is the most common cause of death in intensive care units and the thirteenth most common cause of death in the US (Cohen 614). The death rate from septic shock is about 40% (Weil).

Source: Medical Disability Advisor



Complications

Generalized clotting of the blood (disseminated intravascular coagulation [DIC]) is a serious complication that leads to hemorrhage. Organ failure associated with septic shock is a common complication. Multiple organ failure (heart, lungs, kidneys, liver) usually is fatal.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

If sepsis resolves without complications, no work restrictions or accommodations are necessary. Septic shock requires hospitalization with intensive treatment followed by a period of convalescence, necessitating prolonged leave of absence. Any permanent damage to organs caused by septic shock may require specific restrictions or accommodations. For example, heart damage may reduce the number of hours an individual can work and limit work to light or sedentary duties. Kidney damage may require the individual to work reduced hours to allow time for dialysis treatment. Damage to liver or lungs may force individuals to avoid exposure to certain chemicals or fumes.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual have fever and chills? Dyspnea? Tachycardia? A feeling of apprehension, confusion, or disorientation?
  • Has individual recently had surgery?
  • Has individual been taking immunosuppressant drug, chemotherapy, antibiotic therapy, or corticosteroids for an extended time?
  • Does individual have a chronic illness or debilitating disease such as cancer, AIDS, or cirrhosis?
  • Has individual recently had pneumonia or other severe infection?
  • Has individual had a puncture wound, deep cut, or burn recently?
  • Does individual have an indwelling catheter, IV catheter, or other invasive device?
  • On exam, was individual hypotensive?
  • Was there high fever? Cold hands and feet? Cyanosis? Weak pulse? Flushed skin?
  • Was individual's mental status altered?
  • Was blood culture done? Were infective organisms present in the blood? Spinal fluid?
  • Were urinalysis and urine culture done? CBC? Blood chemistries? Blood gas analysis?
  • Did chest x-ray revealed pneumonia?
  • Was CT scan done?
  • Has the site of infection been determined? Infective organism identified?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Was individual hospitalized at the time of diagnosis? After diagnosis? Treated promptly with IV antibiotics?
  • Was the causative organism cultured for antibiotic resistance? Was the infective organism sensitive to a specific antibiotic?
  • Was the cause of the sepsis an abscess? Was it drained?
  • Was the cause of the sepsis necrotic tissue? Was it removed?
  • Was sepsis caused by a fungal infection? Was it treated with antifungal drugs?
  • Have catheters and other devices suspected as causing or aggravating the infection been changed or removed?
  • Is individual being treated with immunosuppressant drugs? Is it possible to discontinue immunosuppressant therapy until individual has recovered?

Regarding prognosis:

  • Is individual's employer able to accommodate any necessary restrictions?
  • Is individual pregnant? Age 65 or older?
  • Does individual have any underlying chronic or otherwise debilitating disease conditions that may affect the ability to recover?
  • Has individual developed the complication of DIC?
  • Did sepsis progress to organ failure? Which organ(s)?

Source: Medical Disability Advisor



References

Cited

Cohen, Jonathan, and William Powderly, eds. Infectious Diseases. 2nd ed. St. Louis: Mosby, Inc., 2003. MD Consult. Elsevier, Inc. 26 Sep. 2009 <http://mdconsult.com>.

Cunha, Burke A. "Sepsis, Bacterial." eMedicine. Eds. Pranatharthi Haran Chandrasekar, et al. 1 Aug. 2008. Medscape. 16 Sep. 2009 <http:emedicine.medscape.com/article/234587-overview>.

Weil, Max Harry. "Sepsis and Septic Shock." The Merck Manual of Diagnosis and Therapy. Eds. Robert S. Porter, et al. 18th ed. Whitehouse Station, NJ: Merck and Company, Inc., 2008.

Source: Medical Disability Advisor






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