sepsis Flashcards
what is sepsis?
life threatening organ dysfunction caused by a dysregulated host response to an infection
what is septic shock?
- more severe form of sepsis, technically defined as ‘in which circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone
what will someone with septic shocks blood pressure and serum lactate be?
- persistent hypertension requiring vasopressors to maintain MAP >/= to 65 mmHg
- serum lactate = >2mmol/L
risk factors for sepsis?
- very young (<1 yr) or very old (>70 yrs)
- immunosuppressed (chemo, steroids, recent surgery ect)
- pregnancy (inc post part, post termination, post miscarriage)
- neonates
loss of skin integrity
what are 3 examples of pathogens that can cause sepsis?
1- neisseria meningiditis
2- streptococcus pneumonia
3- streptococcus pyogenes
4- staph aureus
symptoms of sepsis?
- fever, sweats or chills
- breathlessness
- headache
- nausea and vomitting
- diarrhoea
signs of sepsis?
- tachycardia
- hypotension
- pyrexia
- peripheral vasodilation
- hypoxia
- tachypnoea
- hypothermia
what is sepsis 6?
the six steps in the investigation of sepsis and often referred to as sepsis 6
what are the 6 parts of ‘sepsis six’?
1- take bloods
2- take blood cultures
3- administer oxygen if required
4- administer IV antibiotics
5- administer IV fluid resuscitation
6- monitor urine output
what are other investigations you should do for sepsis?
- imaging (CXR, echocardiogram, abdominal ultrasound)
- viral PCR for diagnosis of influenza
- urinalysis
what is ‘qSOFA’?
adult patients outside of ICU with suspected infection are identified as being at heightened risk of mortality if they have a quickSOFA score
- meeting >/= to 2 of the following criteria:
- resp rate of 22/min or greater
- altered mutation
- systolic blood pressure of 100mmHg or less.
what are the immune mechanisms underlying sepsis?
- Cytokine mediated hyper inflammatory phase which most patients survive
- subsequent immune suppressive phase
(Patients failure to eradicate the the invading pathogen and are susceptible to opportunistic organisms)
describe the pathophysiology of sepsis?
- system wide release of cytokines, mediators and pathogen related molecules
- activation of coagulation and complement pathways
- widespread inflammation, tissue damage and multi organ dysfunction.
what are the inflammatory mechanisms underlying sepsis?
During sepsis, systemic activation of the innate immune system by PAMPs(pathogen associated molecular pattern) and DAMPs (damage associated molecular pattern) results in a severe and persistent inflammatory response characterised by an excessive release of inflammatory cytokines such as IL-1, TNF, and IL-17, collectively known as the “cytokine storm”
what is the early response (innate immune system) to sepsis?
release of:
- IL-1
- IL-6
- IL- 8
- IL-12
- IL-18
- TNF alpha
- INF gamma
- activation of compliment, coagulation and phagocytes
what is the cellular immune response to sepsis?
activation of B cells, neutrophils and myeloid derived suppressor cells
what is the humeral immune response (adaptive immune system) to sepsis?
production of immunoglobulins
IgM
IgG
what 3 things lead to deterioration on sepsis?
1- decrease of HLA-DR expression
2- T cell exhaustion
3- apoptosis of immune cells
what 3 things fall under immunoparalysis?
1- nosocomial infection
2- viral reactivation
3- endotoxin tolerance
how many deaths per year are due to sepsis?
1/5 of all deaths globally
how many deaths in children per year?
3 millions death per year for children <5
prevention of sepsis?
- hand hygiene
- clean environment
- safe water and sanitation
- infection, prevention and control programmes
how can the evolution of sepsis be prevented?
1- early detection of sepsis signs an symptoms
2- prompts seeking of medical care
3- promo antimicrobial treatment and its reassessment
what are the 3 different types of sepsis?
1- bacterial sepsis
2- viral sepsis
3- fungal sepsis
bacterial sepsis?
excessive amounts of normal pro-inflammatory antibacterial signalling
- responds to antibiotics
- most common
viral sepsis?
- often contracted outside the hospital
- largest risk factor is age and prematurity
- least common
fungal sepsis?
- highest mortality rate
- exclusively contracted in the hospital
- severe CNS effects
what 2 things should you consider when looking at the presentation of sepsis?
1- localising symptoms or signs that point to the underlying cause
2- general symptoms or signs that reflect on the severity of sepsis (informing triage)
what are the 3 main things measured in qSOFA?
1- altered mental status <15
2- fast respiratory rate >22
3- low blood pressure <100
management of sepsis, rationale and overview?
1- resuscitation (ABC DE)
2- early antibiotic
3- triage to appropriate place of care
what blood tests should you do?
FBC
U&E
LFT
CRP
lactate
what is a high lactate a sign of?
hypo perfusion in sepsis - a high lactate Is associated with a high mortality
- if lactate is >4 repeat at 4-6hrs
blood culture?
- minimum of one set of optimally filled blood cultures ideally before antibiotics but should not delay antibiotic treatment
- consider source and source control
what antibiotics should be given?
IV amoxicillin + metronidazole + gentamicin.
if allergic to penicillin give:
IV vancomycin + metronidazole + gentamicin
what is the fluid challenge?
- give a set volume over a period of time (in doses)
- prescribe 250-500ml of fluid
what is the difference between aggressive and excessive fluids?
aggressive fluids = this will maintain perfusion requirements to vital organs and mitigate shock
excessive fluids = precipitate pulmonary oedema, respiratory failure an will complicate treatment
what is a sign of effective urine output?
0.5mls/kg/hr
if origin of sepsis is unknown what kind of antibiotics do you give?
broad spectrum
describe ‘golden hour’?
- early recognition
- early stratification
- early antibiotics
- specific goals
- triage of care
- handover (SBAR)
