Sepsis Flashcards
What tool would you use to identify organ dysfunction related to sepsis and whats included?
When using this tool, what is needed to diagnose sepsis?
SOFA score Sepsis-related organ failure assessment
Respiratory via PaO2/FiO2 for acute resp distress
Coag (platelets) for DIC
Liver (Serum bilirubin)
Cardio - MAP
CNS - GCS
Renal - Creatinine and urine output
Acute increase in SOFA score by 2 or more points diagnoses sepsis
Define Sepsis
Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection.
Gram +ve and -ve organisms almost equally cause sepsis, although if you had to pick one say positive. What !organ! infections may lead to sepsis most frequently? (4)
Lung (pneumonia)
Abdominal (gut infection) (G-ve)
Skin (cellulitis)
Renal + GU (UTI, pyelonephritis)
What is considered an altered mental status?
GCS <15
What is considered hypotension as a positive indication for sepsis?
What is considered hypotension that requires fluid resus?
What fluid would you give for resus?
What would you give for resus in a case of severe sepsis
sepsis = <100 mmHg
Hypotension = <90 mmHg or 40 below baseline
0.9% Saline at 30ml/kg
Albumin at 30ml/kg
You are asked to see a patient and see the common symptoms of sepsis. What are they? What are the common blood test findings in this case?
You notice that the patient is deteriorating quite rapidly and there is no time to complete the SOFA score. What would you use and what are the relevant cutoffs to diagnose sepsis at the bedside?
Fever Tachypnea tachycardia, altered mental state, clammy/sweaty skin
Tests: increase in lactate, WCC (>12 or <4), CRP, Procalcitonin but reduced creatinine
qSOFA = HAT
Hypotension <100
Altered mental status GCS <15
Tachypnea >22
If fluids fail to control BP, what will you do?
Contact anaesthetics/ICU for vasopressor administration
Define Septic shock
Sepsis requiring vasopressors to achieve MAP >65 + lactate >2 despite adequate fluid resus
What are your ddx for raised lactate
Sepsis/septic shock
liver failure
reduced tissue perfusion (ALI, PE, MI…)
What organ is most susceptible to septic shock?
How will you identify that organ dysfunction
Kidney
Reduced urine output
raised urea and creatinine
Just dont say GFR cuz this is an acute case
T or F: 1/3 of sepsis is of idiopathic cause
true
How does sepsis lead to DIC?
The coagulation dysfunction seen in especially in platelets and fibrinogen. Excess activation of platelets and coagulation cascade lead to thrombocytopenia and low fibrinogen seen in DIC causing microthrombi systemically leading to end organ failure
What would you use to obtain serum lactate levels at the bedside?
VBG/ABG
What is the MAP? How is it calculated?
How is it monitored?
What is the role of vasopressors?
What is the cutoff requiring vasopressors? What are the first, second, and 3rd line?
Mean arterial pressure obtained via DP +1/3 (SP - DP)
Monitored on the blood pressure monitor (it is in parenthesis like this)
Role of vasopressors = vasoconstriction
MAP<65. Norepinephrine, Vasopressin, Epinephrine
What are the 3 main pathophysiological features of sepsis?
Endothelium: Vasodilation, leukocyte adhesion => increased permeability and procoagulant state => widespread oedema
Coagulation activation: Microthrombi + DIC => DVT risk
Immune system dysfunction: Opportunistic infections + increased risk due to hospital stay
Give the RFs for sepsis
Focus on patients predisposition to infection
1) Age <1 or >75
2) Immunocompromised: Chemo/cancer, diabetes, long term steroid use, immunosuppressant tx (transplant, RA, SLE…)
3) Breach of skin integrity: Surgery, wound, IV drug use, indwelling catheters
4) Pregnancy - 6 weeks post-partum
Clinical features of sepsis are dependent on the source of the infection. e,g liver will have increased SBR and LFTs. What criteria is considered high risk according to the NICE Guidelines?
Moderate risk = between normal and high risk
History: evidence of altered mental state (moderate: collateral hx of change in behaviour)
Resp: RR>25
Cardio: HR >130
BP: <90 or 40 below normal
Urine output: Not passed in 18 hours or <0.5ml/kg/hr
Skin: Cyanosis, mottling, non-blanching rash (meningitis)
A patient with cellulitis quickly begins to deteriorate.
What investigations would you carry out?
What management would you carry out?
Inv: Take 3 + 1
Blood gas
Blood culture
Bloods (FBC, U and E, CRP, Procalcitonin, LFTs, Creatinine, clotting screen)
Urine culture and dipstick
Management: Give 3 + 1
First: Source control: removal of indwelling catheter or infected tissue, drainage of abscess
Give O2 (start 40% FiO2)
IV fluids IV 0.9% saline at 30 ml/kg
IV antibiotics
Vasopressors indicated if MAP <65 (norepinephrine
FOR 5/5 (3): other considerations include VTE prophylaxis, Stress ulcer prophylaxis, nutritional help, glycemic control if diabetic, minimal sedation for early mobilization
How are blood cultures taken?
Aerobic and anaerobic tubes
Can viral infections cause sepsis?
Can fungal infections cause sepsis?
Yes to both
What is “Time zero”
Time of presentation => it is the time for triage at ED or first note made relating to sepsis
Lactate levels are a predictor of mortality where clearance of lactate is associated with improved survival. What is the presence of elevated lactate an indication of? What level would it be considered high (septic shock)? At what level would be extreme?
Indicates tissue hypo perfusion
2
4
What must be completed in the first hour of sepsis?
- Measure lactate -> remeasure if >2 mmol/L
- Obtain blood cultures before administering antibiotics
- Administer empiric antibiotics
- Begin IV resus of 30 ml/kg hartmann’s (esp if <90 systolic/40 below baseline or lactate ≥4mmol/L) 0.9%NaCl works
- Administer vasopressor if MAP<65 (Norepinephrine, Vasopressin, Epinephrine)
All of these need frequent reassessment
