Sepsis

Question 1

You are asked to review a 36-year-old female patient in the emergency department who has presented with lethargy and feeling generally unwell. Her partner says she has been confused and feverish. Her oxygen saturations on air are 95%, her respiratory rate is 29, her heart rate is 122 and her blood pressure is 83/52.

What are the priorities in the management of this patient?

Answer 1

Assessment, investigations, treatment…

Assessment:
* Carry out a rapid ABCDE assessment including a focused history and examination, treating any pathophysiology concurrently.

• Recognise the relevant indicators of sepsis and form a differential diagnosis based on the patient assessment to direct investigations.
• Escalate to senior medical and critical care teams as appropriate.

Question 2

What are the priorities in the management of this patient?

Continued…

Answer 2

Investigations:
* Attach continuous bedside monitoring and consider early invasive blood pressure monitoring (but this should not delay treatment).

• Do a urine dipstick and culture if appropriate.
• Order a portable chest X-ray (to take place in the emergency department).
• Blood tests should include a full blood count, urea and electrolytes,
  clotting and blood cultures. A venous or arterial blood gas should be done as soon as possible (note the lactate).

Question 3

What are the priorities in the management of this patient?

Continued…

Answer 3

Treatment:
* Titrated supplementary oxygen therapy.

• Fluid resuscitation through large bore intravenous access. Start with
  30 mL/kg crystalloid initially, but the patient may need several litres and should be reassessed following each bolus/infusion.
• Broad-spectrum intravenous antibiotics according to the local guidelines and suspicion of the likely source.
• Catheterise and strict monitoring of fluid balance.
• Consider vasopressor agents early if not fluid responsive.
• Refer and transfer to critical care if appropriate.

Question 4

What are the qSOFA criteria?

Answer 4

• The quick Sequential Organ Failure Assessment scoring system uses three criteria to assess the risk of morbidity and mortality in patients with sepsis:

1. Respiratory rate ≥22.
2. Altered mental status.
3. Systolic blood pressure <100 mmHg.

• Each criterion receives a score of 1, and a score of 2 or more indicates an increased risk of mortality and a prolonged critical care stay.

Question 5

What is the definition of sepsis?

Answer 5

• A life-threatening organ dysfunction due to a dysregulated host response to infection (2016 3rd International Consensus).

Question 6

What are the physiological targets in the early management of sepsis?

Answer 6

• Mean arterial pressure >65 mmHg.
• Lactate <4 mmol/L with lactate clearance.
• Individualised approach to cardiovascular system manipulation:
  adequate fluid resuscitation and assessment of cardiac function to determine whether inotropic agents are required.

Question 7

The patient requires vasopressors to maintain her systolic blood pressure, and she is admitted to intensive care where she is intubated.

How can the risk of ventilator-associated pneumonia be decreased?

Answer 7

• The measures within the ventilator care bundle aim to lower the risk of a patient developing a ventilator-associated pneumonia, and include:
• A daily sedation hold.
• Elevation of the head of the bed.
• Regular monitoring of endotracheal tube cuff pressures.
• Sub-glottic suction of secretions.
• Excellent hand hygiene when handling airway equipment.
• Use of closed circuits.