Sepsis

Question 1

Mortality rate of sepsis (UK and Europe)

Answer 1

36%

Question 2

Infection definition

Answer 2

‘Invasion by and multiplication of pathogenic microorganisms in a bodily part or tissue which produces inflammation’
OR
‘A microbe in a normally sterile site’

Question 3

Bacteraemia definition

Answer 3

‘Bacteria circulating in blood’

Question 4

Systemic inflammatory response syndrome (SIRS) definition

Answer 4

Systemic activation of the innate immune response, regardless of cause.
Two or more of:
- Temperature >38C or 90 bpm
- Respiratory rate >20/min or hyperventilation
(pCO2 12,000 or 10% immature cells

Question 5

Sepsis definition

Answer 5

SIRS + known or suspected infection

Question 6

Severe Sepsis definition

Answer 6

Sepsis with signs of acute organ dysfunction in any of the following systems:

- Cardiovascular (septic shock)
- Renal
- Respiratory
- Hepatic
- Haemostasis
- CNS
- Unexplained metabolic acidosis

Question 7

Septic shock description

Answer 7

State of inadequate organ perfusion due to sepsis (subgroup of severe sepsis).
Mostly measured by blood pressure, but may show in kidneys (reduced urine output), heart (tachycardia), lungs (SoB), skin (pale, clammy) or CNS (confusion, aggression, anxiety). Of course some of those are part of SIRS or severe sepsis…

Question 8

Why does sepsis lead to reduced cardiac output?

Answer 8

Massive immune response -> large-scale cytokine release -> vasodilation -> fall in resistance

Question 9

Multiple organ dysfunction syndrome (MODS) definition

Answer 9

MODS is characterised by the presence of altered function of two or more organs in an acutely ill patient, such that homeostasis cannot be maintained without intervention

Question 10

Advantages of fever

Answer 10

• Many pathogens replicate best at temperature of 37OC, and are adversely affected by higher temperatures
• Phagocytosis, T-cell proliferation, and antibody production all enhanced at raised temperatures

Question 11

Adverse effects of fever

Answer 11

• Febrile convulsion in young children

- Delirium especially in children and elderly

Question 12

Sepsis pathopysiology

Answer 12

Overreaction of immune system

Uncontrolled cascade of inflammation, coagulation and impaired fibrinolysis

Question 13

Common and less common sites that sepsis arises from

Answer 13

Common: Lungs, bowels, skin (wounds, injection sites…), soft tissues, urinary tract
Less common: Meninges, indwelling devices, spine, metal rods into bones

Question 14

Septic Screen

Answer 14

Most important: Blood cultures; CXR and sputum cultures; MSU; stool culture if diarrhoea; wound swabs
Also: Throat swab; CSF (LP); high vaginal swab

Question 15

Septic six

plus the other thing

Answer 15

1. High flow O2, 15L non-re-breathe mask
2. IV fluids
3. Lactate (>2 = ITU)
4. Monitor urine output. Consider catheterisation
5. Look for sites of infection, consider a septic screen
6. Begin IV antibiotics
   other thing: Inotropes - dopamine or noradrenaline (nb NOT adrenaline, phenylephrine or vasopressin)

Question 16

Mortality associated with inadequate management

Answer 16

2006 - retrospective study suggesting increase in mortality by 7.6% for every hour antimicrobial therapy delayed
Inadequate antimicrobial therapy in patients with a bacteraemia on critical care can increase by 218% or another way of looking at it is mortality is reduced where there is adequate antimicrobial therapy by 64% (61.9% compared to 28.4%)