Sepsis

Question 1

What is sepsis?

Answer 1

Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection.

SIRS (systemic inflammatory response syndrome criteria) + presumed/confirmed infection.  

Question 2

What is the SIRS criteria for sepsis?

Answer 2

SIRS is identified by at least two of the following symptoms:
- temperature > 38°C or < 36°C
- heart rate > 90/ min
- respiratory rate > 20/ min
- WBC > 12,000/mm³ or < 4,000/mm³

Question 3

What is the criteria for severe sepsis?

Answer 3

Severe sepsis: sepsis + evidence of organ dysfunction:
CHOM
- confusion
- hypoxia
- oliguria (low urine output)
- metabolic acidosis

Question 4

What are the different causes of sepsis?

Answer 4

• SIRS is a common inflammatory response to a wide variety of physiological insults, can be caused by infection, ischaemia, inflammation e.g. pancreatitis, trauma, burns.
• Can progress to multiple organ dysfunction syndrome (MODS) – altered organ function in an acutely ill patient so that haemostasis cannot be maintained without intervention.

Question 5

What are the risk factors for sepsis?

Answer 5

• Surgical patients, 
• Mainly patients with anastomotic leaks, abscesses and extensive superficial infections such as necrotising fasciitis 

Question 6

What are the presenting symptoms of sepsis?

Answer 6

• Cyanosis 
• Malaise 
• Nausea, vomiting 
• Diarrhoea
• Signs associated with specific source of infection 
• High early warning score (e.g., NEWS2 5 or more) 
• Tachypnoea (NEWS2) 
• High or low temperature, sometimes with rigors (NEWS2) 
• Tachycardia (NEWS2) 
• Acutely altered mental status (NEWS2) 
• Low oxygen saturation (NEWS2) 

Question 7

What signs of sepsis can be found on physical examination?

Answer 7

1. Hypotension (NEWS2) 
2. Oliguria - small volume urine.
3. Poor capillary refill, mottling of the skin, or ashen appearance

Question 8

What investigations are used to diagnose/ monitor sepsis?

Answer 8

• Blood cultures 
• Serum lactate 
• Hourly urine output 
• FBC
• U&E (including creatinine) 
• Serum glucose 
• CRP
• Serum procalcitonin 
• Clotting screen 
• Liver function tests 
• Blood gas 
• ECG 

Question 9

How is sepsis managed?

Answer 9

• SEPSIS 6 
  If any of the red flags are present the ‘sepsis six’ should be started straight away: 
  give 3
  1. Administer oxygen: Aim to keep saturations > 94% (88-92% if at risk of CO2 retention e.g. COPD) 
• ‘Critically ill’ patients, including those with sepsis, should receive high-flow oxygen irrespective of their saturations
  2. Give broad spectrum antibiotics (e.g. vancomycin) 
  3. Give intravenous fluid challenges: NICE recommend a bolus of 500ml crystalloid over less than 15 minutes (Aim for CVP 8-12 cm H2O, MAP >65mmHg) 
  take 3
  4. Take blood cultures
  5. Measure serum lactate 
  6. Measure accurate hourly urine output :
• IV antibiotic therapy
• Surgical removal of source of infection
• Critical care involvement.