INFECTIOUS DISEASES: Sepsis

Question 2

Define sepsis

Answer 2

Life threatening organ dysfunction caused by a dysregulated host response to an infection

Question 3

Define septic shock

Answer 3

Subset of sepsis with profound circulatory, cellular and metabolic abnormalities. Associated with greater risk of mortality than sepsis alone

Z2F: this is when arterial BP drops resulting in organ hypo-perfusion

Question 4

How can septic shock be measured?

Answer 4

Systolic BP less than 90 despite fluid resuscitation
HYPERlactaemia - where lactate is >4 mmol/l

Question 5

Pathophysiology of sepsis?

Answer 5

3 main parts: Cytokine - Coag - Lactate

Cytokines:

1) Pathogens recognised by macrophages, lymphocytes and mast cells
2) Cells release cytokines - cytokines activates other parts of immune system.
3) activation causes vasodilation
4) cytokines make endothelial lining of BV more permeable = so fluid leaks out —> get oedema and reduced intravascular vol.
5) oedema around BV means less O2 can reach tissues

COag:

6) Coag system is activated too!
7) fibrin deposits throughout circulation = also reducing tissue perfusion.
8) Platelets and clotting factors are used up to make clots —> causes thrombocytopenia, haemorrhages (so can’t make any other clots or stop bleeding). = DIC.

Lactate:
9) Get anaerobic resp as no O2 reaching tissues = so blood lactate rises. (as lactate is waste prod of anaerobic resp).

Question 6

SEPSIS mnemonic

Answer 6

Slurred speech or confusion
Extreme shivering or muscle pain
Passing no urine (in 24hrs)
Severe breathlessness
I feel like I’m going to die
Skin mottled or discoloured

Question 7

RF for developing sepsis?

Answer 7

V young or old - under 1, over 75
Chronic conditions e.g. COPD, DM
Immunosuppressed - chemo, immunosuppressants, steroids
Surgery, trauma, burns
Pregnancy, permpartum (just before or after birth)
Indwelling medical devices - catheter, cannula

Question 8

Presentation of sepsis?

Answer 8

Scoring on NEWS.
What is involved?:
Temp, HR, RR, O2 sats, BP, consciousness level (AVPU)

Question 9

Signs of sepsis on examination?

Answer 9

• Sources of infection - cellulitis, wound discharge, cough, dysuria
• Non blanching rash
• Mottled skin
• Cyanosis
• Arrythmia - new onset AF

Question 10

Investigations for sepsis?

Answer 10

FBC - Wcc, neutrophils
U&Es - renal function, AKI
LFTs - liver function, liver is potential source of infection
CRP - assess inflammation
Coag screen/clotting - DIC
Blood cultures - bacteraemia
Blood gas - lactate, pH, glucose

Also could do:

• Urine dip and culture
• CXR
• CT scan abdo - suspect infection or abscess
• Lumbar puncture - suspect meningism

Question 11

Management for sepsis

Answer 11

1) Assessed and treated within 1 hour of presentation
2) Perform sepsis 6:
Take blood lactate, take urine output, take blood cultures.
Give oxygen, broad spec abx, IV fluids
3) escalate - senior, HDU, ICU

Question 12

Define neutropenic sepsis

Answer 12

Sepsis in pt with low neutrophil count of less than 1 x10(9) L

Question 13

Causes of neutropenia in pts?

Answer 13

Anti- cancer chemo
Immunosupressants for RA - Hydroxychloroquine, Methotrexate, Sulfasalazine
Other immunosuppressants - Infliximab, Rituximab
Malaria treatment - Quinine
HyperThyroid treatment - Carbimazole

Question 14

Why is neutropenic sepsis so urgent to manage?

Answer 14

Pts do not have immune system to fight infection - so are at high risk of death. Need emergency admission and management

Question 15

Specific treatment for neutropenic sepsis

Answer 15

Immediate broad spec abx:
Piperacillin with tazobactam (tazocin)