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Semester 2 - Infection > 5. Acute sepsis > Flashcards

5. Acute sepsis Flashcards

1
Q

What is sepsis?

A

Characterised by a life threatening organ dysfunction due to a dysregulated host response to infection; characterised by inflammation
Can lead to organ failure if not treated immediately, but with early diagnosis can be treated with antibiotics

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2
Q

What is septic shock?

A

Septic shock is a type of sepsis where you have significant circulatory, cellular and metabolic abnormalities that seriously increases the risk of mortality.

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3
Q

Give the 4 things that happen in a local infection

A
  1. Rubor- redness
  2. Tumour- swelling
  3. Calor- heat
  4. Dolor- pain
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4
Q

Give the 3 things that happen during sepsis that cause inflammation

A
  1. Vasodilation
    Vasodilation of the vessels occurs, this is necessary to allow WBCs, platelets and fibrin to reach the affected areas.
    There’s increased blood flow to the site of infection.
    This gives the redness (rubor) and warmth (calor) in an infection.
  2. Capillary leakage
    Vessels will get leaky to get the compounds out to the tissue where they’re needed.
    This causes the swelling seen (tumour).
  3. Amplification
    upregulation of cytokines
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5
Q

What are the effects of sepsis on the airways?

A

No specific effect unless infection arises from throat or neck.
However, decreased consciousness may be at risk of airway problems.

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6
Q

What are the effects of sepsis on breathing?

A

Raised respiratory rate (tachypnoea) —> faster, shallower breaths
Fluids and proteins leaking into interstitial tissues lead to lung oedema and decreased lung compliance
Need ventilation to increase oxygen saturation

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7
Q

What are the effects of sepsis on circulation?

A

Hypovolaemia due to vasodilation and capillary leakage leading to hypotension
Blood pressure = cardiac output x systemic vascular resistance
Tachycardia to increase blood flow
End organ damage if not enough blood flows to organs

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8
Q

What are the effects of sepsis on disability?

A
  • reduced blood flow to brain —> confusion, drowsiness, slurred speech, agitation, anxiety, decreased level of consciousness
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9
Q

What are the effects of sepsis on exposure?

A 
High temp due to hypothalamic response to infection
Beware hypothermia (temp less than 36 degrees) especially in the elderly
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10
Q

Who is especially at risk of developing sepsis?

A

Anyone can develop sepsis however there’s a high risk in certain groups:
• Very young (< 1 year old).
• Elderly (>75 years) or very frail.
• Pregnant, post partum (within last 6 weeks).
• Patients with impaired immune system due to illness or drugs e.g patients with HIV, patients undergoing chemotherapy or patients with poorly controlled diabetes

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11
Q

How is sepsis diagnosed?

A

There are certain situations that should immediately make a clinician think sepsis:

  • early warning scores (NEWS2) —> of 5 or more
  • red flag sepsis
  • physical appearance of illness
  • signs of infection
  • sepsis screening tools
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12
Q

What is a national early warning score (NEWS2).

A

It’s a single system used to identify sepsis and its endorsed by NHS England. It’s used to identify and respond to patients at risk of clinical deterioration.
It can be used in non pregnant adults, in acute and ambulance settings.
Scores are allocated to six difference physiological measurements:
1. respiration rate
2. oxygen saturation
3. systolic blood pressure
4. pulse rate
5. level of consciousness or new confusion*
6. temperature.

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13
Q

What role does the NEWS 2 score have in diagnosis and give the importance of clinical judgement when using this score

A
  • An elevated NEWS 2 score doesn’t provide a diagnosis it just helps to identify the patients who need an urgent clinical review.
  • However in terms of the score it’s important of the medical professional to use their clinical judgement as some patients may score high but constant review is not appropriate e.g. in end of life situations.
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14
Q

What is the acronym for sepsis to the public

A 
Slurred speech/confusion
Extreme shivering or muscle pain
Passing no urine
Sever breathlessness
It feel like death
Skin mottled or discoloured
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15
Q

What is red flag sepsis?

A
  • It’s a set of criteria that used to make an informal diagnosis of sepsis.
  • It uses measurements already done or easily obtainable bedside tests to identify patients with a high likelihood of a degree of organ dysfunction.
  • This is because these patients at a high risk of deterioration.
  • However it’s important to understand that different sepsis tools are used for under 5s, ages 5-11 and pregnant patients.
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16
Q

What is the red flag criteria

A
  • AVPU - alert/ responding to voice/ responding to pain/ unconscious
  • Acute confusion
  • Resp rate higher than 25 per min
  • Need o2 to keep stats above 92%
  • Heart rate more than 130bpm
  • No passed urine in 18hours
  • Nonblanching rash or motteled
  • Recent chemo
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17
Q

How is sepsis managed?

A

The sepsis 6 are a set of 6 tasks that are used to manage sepsis

  1. Give oxygen
  2. Take blood cultures
  3. Give antibiotics
  4. Consider fluids
  5. Take Hb and lactate
  6. Monitor urine output

These set of tasks have been shown to increase the patient’s chance of survival if delivered within the first hour following recognition of sepsis.

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18
Q

As part of sepsis 6, why is oxygen, fluids and antibiotics given?

A
  1. Give oxygen
    To improve the oxygen content of the blood, and therefore it’s delivery to the tissues.
  2. Give antibiotics
    To control the underlying infection, this removes the trigger for immune overreaction.
  3. Consider fluids
    This is to improve the preload in the heart by correcting hypovolaemia this therefore improves cardiac output
19
Q

As part of sepsis 6, why is blood and sputum cultures, lactate and HB, urine taken?

A
  1. Take blood and sputum cultures
    To help identify pathogens, to determine the likely source of infection and guide antimicrobial therapy.
  2. Take blood sample and lactate levels
    High lactate indicates hypoperfusion, therefore the response of lactate helps to guide resuscitation.
  3. Monitor urine output
    Urine output fails if the patient is hypovolaemic it also provides an indicator of adequate cardiac output.
20
Q

What is renal hypoperfusion?

A

This occurs when the renal auto regukation process is impaired which leads to a fall in the mean arterial pressure to below 80 mmHg.
This can act as a important sign of sepsis.

21
Q

List supportive and specific investigations used in suspected sepsis cases

A 
Supportive investigations:
Full blood count,
Urea and Electrolytes
Blood sugar
Liver Function Tests
C-Reactive protein (CRP)
Coagulation (clotting) studies
Blood gases

Specific investigations:
Cerebrospinal Fluid
Throat swab
EDTA bottle for PCR

22
Q

How is the Cerebrospinal fluid obtained?

A

CSF is obtained by lumbar puncture.

23
Q

What is the lifespan of CSF?

A

It deterorates very quickly, as soon as you extract it.

24
Q

What are the Types of tests carried out on CSF?

A
  • Glucose and protein estimation tests are carried out using biochemistry, microscopy and culture in microbiology.
  • Use of microscopy to identify any WBCs or RBCs present.
  • Gram staining to identify the bacterium
25
Q

How is the meningococcus bacterium spread?

A

It’s spread by aerosols and nasopharyngeal secretions

26
Q

3 stages of action for the meningococcus bacterium

A

The bacterium can either be cleared by the body, it can stay in the body with no effect so the individual becomes a carrier or in action occurs and the body shows symptoms of meningitis

27
Q

Give the 4 main types of the meningococcus bacterium

A

A, B, C, W-135

28
Q

How does the meningococcus bacterium evade degradation

A

This bacterium possesses polysaccharide
capsular antigens which help to evade the immune response bypreventing phagocytosis.
Its outer membrane acts as an endotoxin.

29
Q

Give the causes of meningitis

A 
BACTERIAFUNGI
• Neisseria meningitidis
• Streptococcus pneumoniae
• Haemophilus influenzae
VIRUSES 
Enteroviruses:
• Echoviruses
• Coxsackie viruses A and B
• poliovirus
Herpes viruses:
• Herpes simplex virus 1 and 2
FUNGI
• Cryptococcus
• neoformans (occurs in HIV/AIDS)
30
Q

What are key signs of meningitis

A 
Raised temp and pulse
High resp rate
Widespread non blanching rash
Neck stiffness
Photophobia
31
Q

What will CSF look like in meningitis

A

Turbidy and creamy

It should be like water

32
Q

How can you treat and prevent meningitis?

A
  1. Antibiotics- however the antibiotics used must be able to cross the blood brain barrier. Unfortunately most drugs can’t the antibiotic most often used is ceftriaxone.
  2. Vaccination- Men B, Men C, Men ACWY
  3. Prophylaxis- this is a preventative treatment used to reduce the chances of meningitis in individuals who have been in close contact with the meningitis patient
33
Q

Give the colour of air, fat, water and soft tissue and bone on an x-ray scan

A
  • air looks black
  • fat (as in subcutaneous tissue) looks dark grey
  • water and soft tissue looks light grey (e.g. solid organs)
  • bone looks off-white
34
Q

How is the immune system activated in sepsis?

A
  • innate immune system is activated by bacterial cell wall products, such as lipopolysaccharide (endotoxin) binding to host receptors, including Toll-like receptors found on monocytes, macrophages and some epithelial cells. These receptors have specificity for different bacterial, fungal or viral products
  • activation releases pro-inflammatory cytokines such as tumour necrosis factor and interleukins 1 and 6 which in turn activate immune cells
  • the complement system is activated and mediates activation of leukocytes, attracting them to the infection site to directly attack the organism
35
Q

What happens to the endothelium and coagulation system in sepsis?

A
  • the vascular endothelium becomes activated which allows the adhesion and migration of stimulated immune cells and also becomes porous to large molecules such as proteins, resulting in tissue oedema
  • procoagulant factors can increase, such as plasminogen activator inhibitor type 1 and tissue factor, and there can be a reduction in circulating levels of natural anticoagulants. Seen as clotting in small vessels and a tendency to bleed at other sites
36
Q

How does inflammation and organ dysfunction occur in sepsis?

A
  • vasodilation (causing reduced systemic vascular resistance) and increased capillary permeability (causes extravasation of plasma) results in relative and absolute reductions in circulating volume
  • this hypovolemia is compounded by reduced LV contractility to produce hypotension. Initially, through an increase HR, CO increases to compensate but as this compensatory mechanism becomes exhausted, hypoperfusion and shock may result
  • impaired tissue oxygen delivery is exacerbated by pericapillary oedema so oxygen must diffuse a greater distance to reach target cells. There’s a reduction of capillary diameter due to mural oedema and the pro-coagulant state results in capillary microthrombus formation
37
Q

Why is sepsis difficult to diagnose?

A

Can initially look like flu, gastroenteritis, chest infection or viral infection

There is no one sign, and symptoms can present differently between adults and children

38
Q

How do you spot sepsis in children? (Campaign)

A
  • fast breathing
  • fits/ convulsions
  • looks mottled/ blueish/ pale
  • has a rash that doesn’t fade when pressed
  • very lethargic/ difficult to wake
  • abnormally cold to touch
39
Q

How do you spot sepsis in children under 5? (Campaign)

A
  • not feeding
  • repeatedly vomiting
  • not passed urine for 12 hours
40
Q

What is the peritoneal cavity?

A
  • a space space between the parietal and visceral peritoneum
  • contains thin film of peritoneal fluid which consists of water, electrolytes, leukocytes and Abs
  • fluid acts as a lubricant, enabling free movement of the abdominal viscera and the Abs help fight infection
  • of capillary thinness
  • referred to as a potential space as excess fluid can accumulate to cause ascites
41
Q

What causes peritonitis and what is a sign?

A
  • bacteria gets into peritoneal cavity from bowel
  • can be caused by tumour in large bowel which causes perforation so bacteria can spread from bowel e.g. E Coli
  • air under diaphragm is usually seen in x-rays from the air released by the bacteria
42
Q

Explain how sepsis leads to a reduction in blood pressure?

A
  • Endotoxins of bacteria cause WBCs in the blood to increase
  • WBCs release cytokines to attract more WBCs (immune response)
  • Cytokines cause vasodilation which decreases bp
43
Q

What is a limitation of NEWS2?

A

Only for non pregnant adults.

Semester 2 - Infection (19 decks)

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