Sepsis Flashcards

1
Q

Define

A

Systemic inflammatory response syndrome / SIRS = generalised inflammatory response, defined by the presence of ≥2 criteria (abnormal temperature or WCC must be one of the criteria):
* Abnormal core temperature (<36 or >38.5°C)
* Abnormal HR (>2 S.D. above normal for age, or less than 10th centile for age if child aged < 1 years)
* Raised RR (>2 S.D. above normal for age, or mechanical ventilation for acute lung disease)
* Abnormal WCC in circulating blood (above or below normal range for age, or >10% immature cells)

Red-flag Sepsis = clinically based criteria to diagnose a high-risk sepsis -> immediate sepsis 6 pathway

  1. Hypotension
  2. Blood lactate >2mmol/L
  3. Prolonged capillary refill >5 seconds
  4. Pale/mottled or non-blanching (purpuric) rash
  5. Oxygen needed to maintain saturations >92 %
  6. RR >60 min-1 or >5 below normal, or grunting
  7. AVPU = V, P or U
    * Abnormal behaviour
    * Excessively dry nappies, lack of response to social cues, significantly decreased activity, weak, high-pitched or continuous cry

Sepsis = SIRS in the presence of infection

Severe sepsis = sepsis in presence of CV dysfunction, respiratory distress syndrome, or dysfunction of ≥2 organs

Septic shock = sepsis with CV dysfunction persisting after at least 40 mL/kg of fluid resuscitation in one hour

The neonatal period is the time of highest risk in childhood for acquiring a serious invasive bacterial infection.

Categorised into: early-onset or late-onset sepsis

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2
Q

Causes

A

Common causative organisms:

GBS and Escherichia coli, L. monocytogenes -> early onset neonatal sepsis

Coagulase-negative Staphylococcus (CoNS) -> late onset neonatal sepsis
* I.E. Staphylococcus epidermidis

Other causative organisms:

  • Staphylococcus aureus (Coagulase +ve)
  • Non-pyogenic streptococci
  • Streptococcus pneumoniae
  • Neisseria meningitidis

Early-onset Infection <72h after birth

Bacteria will have either:
* Ascended from the birth canal
* Invaded the amniotic fluid: direct contact with amnoeotic fluid causing pneumonia

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3
Q

Risk factors for early onset sepsis

A
  • Risk factors for Early Onset Neonatal Sepsis
  • Mothers previously had baby with invasive GBS
  • Current GBS colonisation, bacteriuria or infection in current pregnancy
  • Prelabour rupture of membranes
  • Intrapartum temperature ≥ 38oC or suspected chorioamnionitis
  • Rupture of membranes ≥ 18 hours
  • Premature (< 37 weeks)
  • Parenteral antibiotic treatment given for confirmed or suspected invasive bacterial infection during labour or in 24 hour period before/ after birth (NOT prophylaxis)- RED FLAG
  • Suspected or confirmed infection in another baby in case of multiple pregnancy- RED FLAG
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4
Q

Symptoms and Signs

A
  • Altered behaviour or responsiveness
  • Altered muscle tone (e.g. floppiness)
  • Feeding difficulties
  • Feed intolerance- including vomiting, excessive gastric aspirates
  • Abdominal distension
  • Abnormal heart rate- bradycardia or tachycardia
  • Respiratory distress à grunting, nasal flaring, use of accessory muscles, tachypnoea

Respiratory distress for > 4 hours- RED FLAG
Seizures- RED FLAG
Signs of shock- RED FLAG

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5
Q

Investigations

A

SEPSIS SIX Protocol

  • Chest X-ray and septic screen

1.Blood cultures (x 2 if possible)
2.Urine output
3.Lactate

Bloods:
* Clotting (as DIC can feature in sepsis)
* VBG (including glucose and lactate) – quick
* metabolic acidosis is concerning (especially if base deficit ≥ 10mmol/)
* FBC - check for neutropaenia/ philia
* CRP (N.B. takes 12-24hrs to rise) - NOT useful for diagnosis, but sequential assessment to help guide management and progress (usually raised)
* U&Es and creatinine

  • LP- if concerns of meningitis as source of sepsis, <1m old; 1-3m who appear unwell; 1-3m with WCC <5 or >15 x109/L

If the blood culture is positive or there are any neurological signs, CSF must be examined and cultured
* Urine MC&S- not usually done for early onset but may be done for late onset

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6
Q

Management

A
  1. ABC (don’t ever forget glucose)
  2. GET SENIORS
    * Review by ST4 or above (<30 minutes) and then a consultant (<1 hour)
  3. Paediatric sepsis 6 within 1 hour and transfer to acute setting (+ continuous monitoring, review hourly)
  4. IV access (if failed after 2 attempts, gain IO access)
  5. IV fluid resuscitation + 20mL/kg 0.9% NaCl bolus over 5-10 minutes

Antibiotics (within 1hr) -> follow local guidelines:
IV Benzylpenicillin + Gentamicin (usually 7 days)
If Gram-negative sepsis, add another antibiotic, e.g. Cefotaxime

If meningococcal sepsis:
* IM benzylpenicillin (in the community)
* IV cefotaxime (in hospital)

Switch to appropriate antibiotics once Gram stain/ culture results come back
* Gram negative: IV Cefotaxime alone
* Gram positive: IV Amoxicillin + Cefotaxime
* GBS: Continue with IV Benzylpenicillin + Gentamicin

Late onset infection >72 hours
(most likely staph coagulase negative)
* IV Ampicillin + gentamicin/ ceftriaxone
* Flucloxacillin + gentamicin

After 36 hours, consider STOPPING antibiotics if:

Blood culture is negative
* Tends and levels of CRP are reassuring
* Clinical condition reassuring with no indicators of possible infection

Other management factors:
* Maintain adequate oxygenation
* Maintain normal fluid and electrolyte status
* Prevent or manage hypoglycaemia
* Prevent or manage metabolic acidosis

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