sepsis

Question 1

what is sepsis

Answer 1

dysregulated host response to infection leading to life threatening end organ dysfunction

Question 2

what is septic shock

Answer 2

sepsis with evidence of cardiovascular dysfunction
hypotension is a late sign

Question 3

how to recognise sepsis

Answer 3

should be considered in a patient with suspected or proven infection and/or fever/hypothermia
plus
any sign of impaired tissue perfusion

Question 4

signs of impaired tisssue perfusion

Answer 4

tachycardia
bradycardia
cold shock: raised CRT, cool peripheries, cool or mottled skin, reduced peripheral pulses, narrow pulse pressure
warm shock: reduced CRT, boudning pulses, wide pulse pressure
altered level of consciousness
new onset end organ dysfunction
evolving petechial or purpuric rash
unexplained pain

Question 5

cold shock

Answer 5

raised CRT, cool peripheries, cool or mottled skin, reduced peripheral pulses, narrow pulse pressure

Question 6

warm shock

Answer 6

reduced CRT, boudning pulses, wide pulse pressure

Question 7

inital management of sepsis

Answer 7

call for help
apply oxygen
establish vascular access
take blood (should not delay Abs)
commence Abs
commence fluid resus
correct hypoglycaemia if present

Question 8

how to call for help

Answer 8

in ED: call consultant, move patient to resus room, consider PCC review
on ward: follow sepsis recognition escalation pathway on the observation and response chart

Question 9

what should you send the bloods for

Answer 9

blood culture, lactate (venous blood gas), FBC, ureaa, electrolytes and creatinine, LFTs, coagulation profile, and CRP

Question 10

ongoing resus

Answer 10

continue fluid resus with repeat boluses 10-20ml/kg of sodium chloride 0.9% as needed

Question 11

if circulatory failure persists following 40ml/kg saline

Answer 11

PCC review
consider peripheral ionotropes
consider further fluid bolus
prepare for intubation
arrange transfer to PCC
consider hydrocortisone for fluid refractory, catecholamine resistant shock

Question 12

high risk groups

Answer 12

infants less than 3 months of age
immunosuppression due to chemo, long term steroids, other immunosuppresssants, asplenia and other chronic medical conditions
unimmunissed/incomplete immunisation
children with central venous access devices, indwelling medical devices
recent surgery, burn or wound
rural, remote or socioeconomic issues
re-presentation

Question 13

vascular accesss

Answer 13

if IV access cannot be obtained, opt for intraosseous access
it may be appropriate to opt for intraosseous acces initially in critically unwell patient or for whom access is clearly going to be difficult

Question 14

blood tests

Answer 14

hould be taken at the time of IV access, wth priority given to venous blood gas and blood culture collection
antibiotic administration and fluid resus mut not be delayed by repeated attempts to collect blood samples

Question 15

blood lactate

Answer 15

a normal blood lactate level does not exclude sepsis
there is an association between elevated blood lactate and adverse outcomes in paediatric septic shock

Question 16

hypoglycaemia

Answer 16

all children should have blood glucose checked
correct hypoglycaemia with 2ml/kg of glucoe 10%
repeat BGL after treatment

Question 17

antibiotics

Answer 17

infants < 4 weeks: cefotaxime, immediately then amoxicillan, consider adding gentamycin or aciclovir
infant/child > 4 weeks old: ceftriaxone immidiately then gentamycin

Question 18

when should you add vanc

Answer 18

in an infant/child > 4 weeks who
- is too unwell for LP
- gram positve coccii seen on CSF
- recent treatment with penicilln, cephalosporin or carbepenam

different for healthcare associated antibiotics

Question 19

adrenaline infusion

Answer 19

add 6mg to a 1L bag of saline 0.9%

Question 20

intubation

Answer 20

in sepsis this is a high risk procedure
if GCS<8, imminent respiratory or cardiac failure, or perisstant shock or instability