Acute Sepsis Flashcards
What is sepsis?
Sepsis is life-threatening organ
dysfunction due to a dysregulated host
response to infection
What is septic shock?
• Septic shock is persisting hypotension
requiring treatment to maintain blood
pressure despite fluid resuscitation
What is bacteraemia?
Bacteraemia is the presence of
bacteria in the blood (+/- clinical
features)
What is septicaemia?
• Septicaemia is an outdated clinical term meaning generalised sepsis • Sepsis is a serious life-threatening response to infection i.e. the terms are not interchangeable
What are methods used which could identify sepsis?
Identifying sepsis
• Clinical assessment of patients who look sick or have raised Early Warning Score (EWS)
• Clinical features suggesting source (e.g. pneumonia, UTI, meningitis, etc)
• Check for Red Flags
What is a care bundle?
Bundle - a group on intervention that when used together is proven to have better outcomes for the patient
Better for the patient
Consistency when treating patient
Efficient in terms of training delivery - everyone doing the same thing
What is a purpuric rash?
Glass against rash - doesnt disappear
Meningococcus? Septaecaemia?
What is the sepsis screening & action tool?
See slide
What are the sepsis red flags?
If any one preset - highly suspect sepsis
- Responds only to voice or pain / unresponsive
- Acute confusional state
- Systolic B.P ≤ 90 mmHg (or drop > 40 from normal) • Heart rate > 130 per minute
- Respiratory rate ≥ 25 per minute
- Needs oxygen to keep SpO2 ≥ 92%
- Non-blanching rash, mottled / ashen / cyanotic (cyanosis - purple discolouration of skin/mucous memb due to low oxygen sat)
- Not passed urine in last 18 h / UO <0.5 ml / kg / hr
- Lactate ≥ 2 mmol / l - low Berri soon to kidneys
- Recent chemotherapy
What is the sepsis 6 bundle?
- Titrate oxygen to a saturation target of 94%
- Take blood cultures.
- Administer empiric intravenous antibiotics.
- Measure serum lactate and send full blood count.
- Start intravenous fluid resuscitation.
- Commence accurate urine output measurement.
For sepsis for every hour delay giving antibiotics,morality goes up 7%
What are urgent investigations after sepsis is confirmed?
• Full blood count, Urea and Electrolytes - electrolytes to check kidneys
• EDTA bottle for PCR – organism specific eg to meningococcus
• Blood sugar
• Liver Function Tests - baseline
• C-Reactive protein (CRP) - marker of inflammation and infection, used to check if coming down after antibiotics given
• Coagulation (clotting) studies
• Blood gases - pH an lactate of blood
• Other microbiology samples (CSF, urine,
etc)
What is a cause of meningococcal meningitis?
- Bacterial pathogen Neisseria meningitidis
- Spread by direct contact with respiratory secretions
- Most people are harmlessly colonised
- In the unlucky few - rapidly progressive (and potentially fatal) disease if not recognised and treated promptly - can cause sepsis or bacteraimia if gets into blood stream
What is the inflammatory cascade?
ENDOTOXINS BINDS TO MACROPHAGES
Local - cytokines - stimulate infmallatory response to promote wound repair and recruit RE system
Systemic -cytokines released into circulation - stimulating growth factor, macrophages and platelets
Sepsis - if infection not controlled - cytokines lead to activation of humoral cascades and RE system. Circulatory insult
How can cytokines lead to multiorgan failure?
- Cytokines initiate production of thrombin and thus promote coagulation
- Cytokines also inhibit fibrinolysis
- Coagulation cascade leads to microvascular thrombosis and hence -small clots in microvascualature leading to
- Organ ischaemia, dysfunction and failure
- Microvascular injury is the major cause of shock and multiorgan failure
What is supportive and specific treatment?
Supportive - symptom relies, physiological restoration eg raise low oxygen levels
Oxygen - raise seats (supportive)
Specific = antimicrobials, antibiotics
Is say perforated appendix - surgery - if antibiotics not enough
What is antibiotic treatment?
Antibiotic treatment
• An agent likely to be active against the pathogens that cause meningitis in this age group (different in neonates and the elderly)
• An agent that penetrates into the CSF
• Empiric choice is CEFTRIAXONE
What are life threatening complications of sepsis?
- Irreversible hypotension
- Respiratory failure
- Acute kidney injury (renal failure)
- Raised intracranial pressure
- Ischaemic necrosis of digits/hands/feet
How can a sepsis diagnosis be confirmed?
Confirming the diagnosis
• Blood culture
• PCR of blood
• Lumbar puncture (if safe)
– Microscopy & Culture of cerebrospinal fluid
(CSF) – PCR of CSF
Check before doing it. Need o make sure they don’t have raised intersmth pressure - lumbar puncture can make it fall rapidly which can be fatal
Suspicion of this - Brian ct first - you do not do it if confirmed
What is CSF examined for?
Examination of the CSF • Urgent transport of CSF to laboratory – Glucose and protein estimation in biochemistry, microscopy and culture in microbiology • Appearance – turbidity and colour (turbidity= infection likely) • Microscopy WBCs, RBCs • Gram stain - can see bacteria • Referral for PCR
What is Neisseria mengitidis?
• Neisseria meningitidis
• Gram-negative diplococcus
• Numerous serogroups (e.g. A, B, C, W-135 based on the
• Polysaccharide capsular antigen
– evades immune response by preventing phagocytosis
• Outer membrane acts as an endotoxin
Gove some facts on meningococcal disease
Meningococcal disease - can be cleared, sit in nasal cavity, or invade (active infection)
• Around 10% of the population have asymptomatic nasopharyngeal carriage
• Spread by aerosols and nasopharyngeal secretions
• Acquisition → clearance, carriage or invasion
• In England ~ 1000 cases/yr mainly Group B & W
• Fatality rate ~10%
• Elsewhere other serogroups predominate e.g. ‘meningitis belt’ across Africa
What are 2 ways to prevent meningococcal disease
Vaccination
Antibiotic prophylaxis
Describe vaccination against meningococcal disease
Prevention 1. vaccination
• Meningococcal C conjugate vaccine
– Introduced in UK in 1999 & led to dramatic decrease
• ACWY vaccine
– Originally for immunocompromised patients &
travel protection – Now replacing MenC vaccine as ↑ W cases in UK
• Serogroup B vaccine (Sep 2015 onwards)
– b capsule poorly immunogenic and similar to neural tissue – Vaccine developed after screening candidate subcapsular
antigens from genome studies. Current vaccine has 4 antigens – Given to babies at 2, 4 & 12 months and adults at increased risk
Describe antibiotic prophylaxis
- Meningitis is a notifiable disease
- Cases reported to the local Health Protection Unit of Public Health England
- Close contacts can be given antibiotic prophylaxis & considered for vaccination
Given to ppl exposed to someone who had meningococcal infaection
If meningitis diagnosed - need to inform local health protection team
In the lab if meningitis detected in bld/csf- let them know - public health will speak to patient, relative etc, ashes who they have contact are , risk assessment of i they will acquire it, these contacts are given antibiotic prophylactic and vaccination \
