Sepsis

Question 1

A 78 year old woman has presented to A+E. She has been referred by her GP who saw her earlier today in her nursing home. Staff were concerned that she was increasingly drowsy and less talkative today. The GP was called after she vomited and spiked a temperature. The GP is concerned that she has a urine infection and needs treatment in hospital.

Her past medical history includes hypertension, hypercholesterolemia, coronary vascular disease and osteoarthritis. She has a history of cognitive impairment although she is normally alert and awake. She is mobile with a frame and able to do small tasks around the nursing home.

Her current observations are as follows:

Blood Pressure: 92/53
Heart Rate: 135 bpm. Irregular
Respiratory Rate:** 26**
Saturations: 91% on room air
Temperature: 38.8 degrees
GCS: 12/15 (E3, V4, M5)
You have been asked to see her on the medical take.

What are you most concerned about as you prepare to see this patient?

Answer 1

I would be most concerned about sepsis, as the pt is hypotensive, tachycardiac, tachypnoeic, with altered mental state. She meets the criteria for sepsis

Question 2

How would you acutely assess this patient?

Answer 2

ABCDE approach

A
* Ensure patent airway with no obstruction

B
* Continuous SpO2 monitoring
* High flow oxygen
* Listen to the chest - fluid, consolidation, wheeze, pneumothorax etc

C
- Monitor HR, BP
- Check CRT peripherally and centrally
- Check for signs of cyanosis
- 12-lead ECG
- Establish 1-2 IV access - take bloods at the same time (including blood cultures)
- Quick VBG would be helpful - acidosis
-** IV fluid** resusciation
- Broad spectrum IV antibiotics
- Monitor UO - catheter

D
- Blood sugar, temperature
- Pupils, GCS

E
- Fully examine the pt, focus on the abdomen and peripheries

Consider escalation status, check if any advance directive in place

Question 3

How would you define sepsis and septic shock?

Answer 3

Sepsis = a life-threatening organ dysfunction due to a dysregulated host response to infection

Septic shock = A subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality

Both consist of (despite adequate volume resuscitation)
- Persistent hypotension requiring vasopressors to maintain MAP ≥ 65 mmHg, AND
- Lactate ≥ 2 mmol/L

Question 4

What investigations would you do when you suspect sepsis?

Answer 4

Bedside
- Monitor SpO2, HR, BP
* 12-lead ECG
* VBG/ABG - glucose, lactate, pH

Bloods
- FBC, CRP, U&E, LFTs, Bone profile, coagulation screen
- Blood cultures, urine dip, urine MC&S, sputum MC&S if appropriate

Imaging
- CXR

Question 5

How would you treat someone with sepsis?

Answer 5

• High flow O2, monitor SpO2
• Start broad spectrum IV antibiotics (within 1h of sepsis being suspected)
• IV fluid resuscitation (bolus) > monitor BP
• Closely monitor UO - catheter, should be >. 0.5 mL/kg/h
• Once above done, identify source of infection
• Daily reassessment of ABx therapy with micro team

Question 6

What do you understand by the sepsis six?

Answer 6

1. Titrate oxygen to SpO2 ≥ 94%
2. Take Blood Cultures
3. Administer empiric IV antibiotics
4. Measure serum lactate and send FBC
5. Start IV fluids
6. Commence accurate UO measurement

Question 7

Are there any RFs you can think of that would make a pt more likely to develop sepsis?

Answer 7

Key RFs to make one more susceptible to sepsis
* Underlying malignancy
* Age > 65
* Immunocompromise
* Haemodialysis
* Alcoholism
* Diabetes mellitus

Question 8

Despite adequately resuscitating your pt with IV fluids and starting IV antibiotics, her blood pressure fails to respond. A lactate returns as 5.2 mmol/L. What is your next course of action?

Answer 8

This represents signs of septic shock
* Continue resuscitating with fluids
* Pt continues to deteriorate, escalation needs to be considered (HDU/ITU) for vasopressors and other organ support
* D/w with my registrar and seek their support
* If agreed for escalation, would refer to the critical care team

Question 9

Do you know what the prognosis for someone with sepsis is?

Answer 9

The mortality rate from sepsis has been estimated in a number of studies to be between 28% and 50%.

The SOAP study in Europe observed an overall hospital mortality of 36%

Question 10

You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover.

Answer 10

Situation: This is a 78 year old woman with sepsis, likely urinary source, who has been started on IV fluids and IV antibiotics.

Background: She was admitted from a nursing home where staff were concerned she was increasingly drowsy. She has a known history of cognitive impairment, however at baseline she is alert and independently mobile.

Assessment: Despite aggressive fluid resuscitation, she has remained hypotensive with a rising lactate of 5.2, suggesting she is in septic shock.

Recommendations: I have asked the ITU team to come and assess her and consider escalating her care to HDU/ITU for circulatory support. She urgently needs a senior medical review and discussion with her family about escalation of treatment and resuscitation. She will need hourly observations and recorded urine output whilst on the acute medical ward.