Acute and emergency Flashcards
Define, diagnose, and manage sepsis effectively
Definition of sepsis.
Life threatening organ dysfunction caused by a dysregulated host response to infection.
It occurs when the body’s immune system overreacts to infection. The body’s immune system goes into overdrive, setting off a series of reactions that can lead to widespread inflammation (swelling) and blood clotting.
Cytokine storm due to overwhelming infection → systemic inflammatory response syndrome (SIRS) → vasodilation, increased vascular permeability, and hypotension.
Diagnosis of sepsis.
When there is a confirmed diagnosis of an infection and a SIRS (≥2 in temperature changes, increased HR, respiratory changes, WBC changes)
Based on:
* History and presentation — GP, ED, ward
* Clinical signs
* NEWS2
* Further investigations – FBC, blood cultures, lactate levels, organ function tests
https://www.mdcalc.com/calc/1096/sirs-sepsis-septic-shock-criteria#next-steps
What are some clinical signs that may indicate severe sepsis?
With identified/suspected source of infection
- Mottled skin
- Pallor and cyanosis (skin, lips, tongue)
- Prolonged capillary refill time
- Non-blanching petechial or purpuric rash
In addition to vital signs derangement e.g. tachycardia, tachypnoea, fever, confusion, hypotension
What is the immediate management of sepsis? (Sepsis 6)
Used within 1 hour of diagnosis of sepsis
- Ensure Oxygen 94-98%
- Blood cultures
- IV broad-spectrum antibiotics — may depend on risk and clinical judgement to avoid related harms
- Fluid resuscitation (500 mL of crystalloid, with sodium in the range 130 to 154 mmol/L (130 to 154 mEq/L), over less than 15 minutes, if either lactate is over 2 mmol/L or systolic blood pressure is less than 90 mmHg)
- Lactate levels monitoring
- Urine output monitoring
What are the major life-threatening complications of sepsis?
Think 3 categories
Septic shock,
DIC, and
organ dysfunction e.g. ARDS, AKI, type 2 MI, and multiple organ dysfunction syndrome (MODS)
Pathophysiology of organ failure in sepsis.
Generally, organ failure (secondary to tissue damage) is caused by septic shock, inflammatory processes, widespread bleeding/clotting i.e. DIC and causes hypotension, which results in shock — inadequate supply (O2, nutrients, remove waste) and end-organ damage.
What factors in sepsis impair oxygen uptake?
List 4
- Pulmonary oedema/Acute Respiratory Distress Syndrome (ARDS): Septic shock and widespread inflammation causes increased permeability of the alveolar-capillary membrane and leading to fluid accumulation in the lungs.
- Pneumonia/chest infection
- Microvascular Thrombosis in pulmonary circulation.
- Hypoperfusion and Organ Dysfunction secondary to septic shock/ tissue hypoxia.
What is neutropenic sepsis? What is its differentiating diagnostic feature from ‘normal’ sepsis?
A life-threatening complication in patients with significant neutropenia (ANC < 0.5 x 10⁹/L), characterized by fever and signs of infection.
or neutrophil levels expected to fall below that in 48 hours.
The signs of SIRS are the same e.g. fever, rigours and chills, tachypnoea, GI disturbances etc.
What are common causes of neutropenic sepsis?
List 5 causes
Chemotherapy, bone marrow suppression e.g. in leukaemia patients, radiotherapy, certain medications e.g. DMARDs, steroids, and infections like HIV/AIDS.
RFs: myelosuppresive chemotherapy, elderly, poor nutritional status, comorbidities
In which cancer patients are neutropenic sepsis most comon?
Patients with haematological malignancy (bone marrow suppression)
In cancer/chemotherapy patients, what are two other fever syndromes that may occur, mimicking sepsis?
Tumour fever and drug fever
Tumour fever: Occurs in cancer patients due to cytokine release from malignancy itself (no neutropenia or infection). The patient is often clinically well between fevers and doesn’t present with hypotension.
Drug fever: Certain chemotherapy drugs may cause fever as an adverse reaction. The patient lacks signs of systemic infection, and fever resolves after stopping the drug.
What are some common antibiotic regimens that commence within 1 hour of suspected neutropenic sepsis?
What if penicillin allergic?
Piperacillin-tazobactam 4.5 g IV every 6 hours.
If penicillin allergy or risk of Gram-negative resistance, use alternatives like meropenem.
*However, check trust guidelines!!
‘Tazosin’, ‘pip-taz’
Do sepsis 6 as usual.
What is GI condition that can present with SIRS?
Pancreatitis
Apart from infectious causes, what other conditions can trigger a SIRS?
Trauma-related and auto-immune related
Trauma-related causes:
* Severe trauma,
* ischaemia e.g. MI,
* Haemorrhage,
* Surgery
Immune-mediated causes:
* Anaphylaxis: Severe allergic reactions.
* Drug Reactions: Adverse reactions to medications.
* Transfusion Reactions: Reactions to blood transfusions.
* Autoimmune Diseases: Conditions like systemic lupus erythematosus (SLE) and rheumatoid arthritis.
Pathophysiology of alcohol withdrawal.
Chronic alcohol use enhances GABAergic inhibition and inhibits glutamatergic excitatory pathways.
Adaptation: over time the brain compensates by downregulating GABA receptors and upregulating NMDA/glutamate receptors to maintain balance.
Alcohol cessation leads to sudden loss of GABAergic inhibition and unopposed glutamatergic excitaiton.
