5/6 Sepsis (Ch 27)

Question 1

Sepsis = SIRS + ??

What is SIRS?

Answer 1

Sepsis = SIRS + infection

**SIRS = serious systemic inflammation!! **

(defined as 2 or more disturbances in Temp, HR, RR or WBCs)

Question 2

what is septic shock?

Answer 2

Sepsis + bad hypotension (Systolic < 60)

(so….. septic shock = SIRS + infection + hypotension)

Question 3

what is the most freq cause of SIRS?

what else can cause it?

Answer 3

Most frequent: infection

Also: autoimmune dz, drug reactions, anaphylaxis, trauma…

Question 4

why bother diagnosing sepsis rather than just attending to the underlying cause (infection, drug rxn, anaphylaxis etc)?

Answer 4

at a certain point, sepsis takes on a life of its own

also, identifying sepsis opens the door to some treatments we might not use for the original insult.

Question 5

what is mortality rate from sepsis?

Answer 5

10-30% depending on who is septic:

if pt is immunodeficient, old, has chronic medical issue -> grim.

Question 6

what is the main cause of sepsis today?

Answer 6

bacterial infection

Also, yeast, fungi, viruses (in decreasing order)

Question 7

main cause of sepsis today is bacterial infection: specifically, what kinds of bacterial infections/what locations?

Answer 7

-pneumonia (#1!)

• bacteremia (likely endocarditis)
• intra-abdominal/GI
• Urinary tract
• skin/soft tissue infections

(the causes move anatomically down the body, starting with the lungs…..)

Question 8

pathogenesis of sepsis?

what starts it off - how do things progress from there?

Answer 8

From his notes:

-infectious trigger

• inflammatory freakout
• self-perpetuating inflammatory freakout
• secondary hemodynamic insults from blood vessel dilation, leakiness, shunting
• maladaptive intravascular coagulation
• superimposed tissue injury
• inflammatory freakout

Question 9

what is the physiological purpose of blood vessel dilation during infection, and what is the unintended consequence that may be maladaptive?

Answer 9

Blood vessel dilation:

Purpose: improve tissue circulation

Bad consequence: Low BP

Question 10

what is the physiological purpose of leaky blood vessels during infection, and what is the unintended consequence that may be maladaptive?

Answer 10

leaky blood vessels:

Purpose: improve immune cell diapedesis

Bad outcome: Low BP

Question 11

what is the physiological purpose of the cytokine response during infection, and what is the unintended consequence that may be maladaptive?

Answer 11

cytokine response:

purpose: recruit immune help to sites of inflammation

bad outcome: runaway immune responses

Question 12

what is the physiological purpose of the sympathetic storm during infection, and what is the unintended consequence that may be maladaptive?

Answer 12

sympathetic storm:

purpose: epinephrine response to stress and hypotension; routes blood to most critical organs (brain, kidneys)

bad outcome: tissue ischemia to neglected areas (GI, digits)

Question 13

what is the possible spectrum of presentations of sepsis?

Answer 13

may only affect a single organ (renal failure, a few toes turning purple);

may become multi-organ failure (poor prognostic sign)

Question 14

treatment of sepsis: what is the first thing to do?

Answer 14

find the source of the infection, fast. (may be obvious, but if not, go hunting. MRI, CT, CSF….)

then treat it. (until you know what it is, give broad spectrum abx like Vanco. do it fast).

if there’s pus, drain it.

Question 15

While you are giving broad-spectrum abx (vanco) and trying to find the source of the infection, what else do you want to be doing? how?

Answer 15

support tissue perfusion

• aggressive IV fluid (saline generally fine)
• vasopressors (norepinephrine, vasopressin)

Question 16

major strengths of ICU care? (it was bolded….)

Answer 16

• excellent nursing care
• intensive monitoring
• tight glucose control
• mechanical support for respiratory and renal failure

Question 17

in a septic patient, what do we need to prevent from happening?

Answer 17

try to do no harm:

want to prevent hyperglycemia, line infections, DVTs, psychosis, muscle contractures….

Question 18

a very nice summary of sepsis:

Answer 18

Sepsis is bad, esp if you’re frail. Sepsis often results from pneumonia or infections in the abdomen, and stems from immune responses designed to be protective, but which go haywire, leading to decreased sytemic vascular resistance, leaky capillaries, and abnormal coagulation. The end result is multiple organ failure, and, in 30%, death.

Proper treatment involves targeted antibiotics, draining pus, IV fluids +/- pressors, adjunctive ICU care. The avoidance of harmful ICU care is also critically important.