Sepsis

Question 1

Define sepsis

Answer 1

Life threatening condition that arises when the body’s response to an infection injures its own tissues and organs

Question 2

Define septic shock

Answer 2

Subset of sepsis where circulatory, cellular and metabolic abnormalities increase mortality. Experience severely low BP

Question 3

Who is at risk of sepsis and why ?

Answer 3

Neonates - immature immune system
Elderly - weakened immune system
Immunocompromised
pregnant
hospital patients
post surgery

Question 4

Why is sepsis harder to spot in children ?

Answer 4

Different pathogens affects different age groups differently. They respond differently to treatment. They have different underlying health conditions to adults

Question 5

What is the pathophysiology of breathing in sepsis ?

Answer 5

Lungs involved in inflammatory process, causes PaCO2 (partial pressure carbon dioxide) increase and decrease in PaO2. Respiratory acidosis (accumulation of CO2), compensate by increased resp rate.

Question 6

Describe respiratory acidosis

Answer 6

Accumulation of CO2 = increase in carbonic acid = lowers PH of blood (acidic) = higher resp rate

Question 7

What are the red flags of breathing in sepsis ?

Answer 7

Sudden drop in resp rate and recession

Question 8

How does sepsis cause hypoxia ?

Answer 8

Sepsis causes endothelial cells to produce excess nitric oxide which is a vasodilator. Blood vessels dilate and leak fluid into surrounding tissues, making it harder for limited oxygen to diffuse to target cells. Later stages of sepsis when circulation fails a V/Q mismatch occurs, air is entering the lungs but the lungs are receiving limited blood flow (dead space). Leads to tissues not receiving enough oxygen (hypoxia). High flow oxygen is required.

Question 9

How does sepsis affect the circulatory system ?

Answer 9

• Widespread vasodilation and increased permeability causes drop in systematic vascular resistance (part of CS that causes BP
• Leaky capillaries
• Reducing in BP
• In response HR increases know as compensatory tachycardia to maintain BP
• Leads to compensatory circulatory failure – BP is maintained but patient shows abnormal perfusion to the skin
• Prolonged CRT
• Prolonged urine output

Question 10

Why does sepsis cause hypotension ?

Answer 10

Pro inflammatory cytokines cause endothelial and immune cells activation. They produce mediators of inflammation (nitric oxide, IL6, IL8, platelet activate factor, reactive oxygen species. Endothelial activation = vasodilation and increased permeability of blood vessel walls = excess fluid loss + reduced blood volume. Combined with vasodilation = hypotension.
Persistent hypotension despite fluid resuscitation will require vasopressors

Question 11

Factors of sepsis in the A-E assessment (D)

Answer 11

• Reduced tissue perfusion (hypoxia) lead to cell death and injury to the brain
• Hyperglycaemia – increase in blood glucose which is attributed to production of stress hormones glucagon, adrenaline and cortisol which the brain activates during stress
• As body is fighting infection, an inflammatory substance – C reactive protein is released to combat the infection, however it does induce insulin resistance meaning the body cannot effectively use its own insulin, which will result in raised blood sugar

Question 12

Factors of sepsis in the A-E assessment (E)

Answer 12

• Temperature – acute inflammatory response, release cytokines that enter blood stream and trigger hypothalamaus to increase temperature causing fever
• Low temperature is more of a concern as WBC work better at fighting infections at higher temperatrure

Question 13

What is included in the sepsis 6 ?

Answer 13

• Senior help
• Give 02 if saturations below 92%, aim for 94 – 94% 15L via non rebreathe mask
• If at risk of hypercarbia (increase in CO2 in the blood) use target range of 88-92%
• IV access and bloods
• IV antibiotics
• IV fluids
• Monitor

Question 14

What will you need to do once you have IV access ?

Answer 14

• Blood cultures – identify pathogen
• Blood glucose – response to sepsis causes gluconeogenesis.
• Lactate – signifies anaerobic respiration
• FBC – increase WBC indicates inflammation and whether a bacterial infection is present
• U&E – indication of renal function
• Lumbar puncture if indicated – if no concerns about raised intracranial pressure

Question 15

What IV fluids will you give ?
And how much ?

Answer 15

Crystalloids first line of treatment, molecules are bigger so stay circulating in the blood rather than leaking into tissues.Initial bolus of 20ml per Kg, can be delivered in divided fluid challenges of 500ml of crystalloid, if favourable response after each challenge

Question 16

What is the aim of fluid therapy ?

Answer 16

Correct hypovolaemia, increase pulse, BP, mental state, lactate, urine output

Question 17

What is the equation for cardiac output ?

Answer 17

stroke volume x heart rate

Question 18

What do you need to monitor in septic patients ?

Answer 18

Urine, lactate, fluids