Sepsis

Question 1

Whats severe sepsis? What is septic shock?

Answer 1

Septuc pts w/ evidence of organ hyperperfusion. Septic shock- when there is hypotension unresponsive to IV fluids.

Question 2

SIRS requirments

Answer 2

2 or more of: Body temp >38 or 90/ min RespR >20 breaths per min or PaCo2 12x10 9 WCC >12 000 or

Question 3

How would u manage SIRS? What are the therapeutic goals?

Answer 3

Systolic BP 3mmol/L ICU help 1. CVP : 8-12mmHg 2. Mean arterial pressure : >65mmHg 3. Urine output: 0.5mL/kg/hr 4. Central cenous saturation >65%

Question 4

What approach would u follow?

Answer 4

ICU assistance now, ABC !- high flow oxygen, secure good IV access, Give IV bolus 20mL/kg of 0.9% saline. May: trachea, intubation. Look for infection sources Check BMG- bedsite venous/capilary blood glucose- treat if hypolglycaemic. Blood cultures before giving antibiotics

Question 5

What happens if pt still hypotensive? Or lactate >3mmol/L ?

Answer 5

Require central venous and arterial catheterisation + IVI noradrenaline to maintain MAP >65mmHg And IV 0.9% saline every 20mins to maintain CVP 8-12mmHg (12-15mmHg in mechanicaly ventilated pts)

Question 6

What is Shock? How is it recognised?

Answer 6

Failure to adequately perfuse and oxygenate vital organs. 1. Hypotension- systolic 100/min 2. Altered consciousness +\or fainting esp on standing- may be ⬇️ cerebral perfusion. 3. Poor peripheral perfusion- cool peripheries, sweaty skin, pallor, ⬇️ capillary refill, 4. Oliguria : ⬇️ renal perfusion w/ UO Low BP, rapid HR, sx of end organ perfusion- ⬇️ urine output, confusion, loss of consciousness.

Question 7

When would a shocked pts not be tachycardic?

Answer 7

If he is taking b blockers or has a cardiac or neurological problem.

Question 8

Whats hypovolaemic shock?

Answer 8

1. Blood loss: trauma, GI bleed (haematemesis, melaena) , ruptured AA, ruptured ectopic pregn. 2. Fluid loss/redistribution: burns, GI loses; vomitting, diarrhoea, pancreatitis, sepsis.

Question 9

Cardiogenic shock- causes?

Answer 9

Primary: MI, arrythmias, valve dysfunction, myocardiris. Secondary: cardiac tamponade, massive PE, tension pneumotharax.

Question 10

Septic shock- what is it?

Answer 10

Extremes of age, DM, renal/hepatic F, and the immunocompromised- HIV, malignancy, post- splenectomy, steroid therapy. Fever, rigors, ⬆️WCC may not be present.

Question 11

What organisms are responsible for septic shock?

Answer 11

Gram +ve & gram -ve: Staph. Aureus, strep. Pneumoniae, N meningitidis, enterococci + bacteroids In immunocompromised pts: pseudomonas, viruses & fungi.

Question 12

What is neurogenic shock caused by? What hapoens? How do we manage it?

Answer 12

Spinal injury- Monitor ECG & BP. Interuption of sympathetic system in cord–> loss of vasomotor tone–> vasodilatation –> ⬆️ venous pooling + ⬇️ BP. IV fluids for hypotension and inotropes if CO ⬇️.

Question 13

How do you prevent fluid overload?

Answer 13

CVP monitoring.

Question 14

Other causes of shock

Answer 14

Poisoning, Addisons disease.

Question 15

How do you manage shock?

Answer 15

ABC- high flow O2 mask + good IV access. Bloods: FBC, U&E, Glucose, LFTs, lactate, coagulation screen + if needed, blood cultures. Monitor vitals- BP, SpO2, resp rate. Check ABGs Monitor ECG + 12 lead ECG + CXR Inesert urinary catheter + monitor UO. If circ. IV crystalloid (0.9% saline) . Further colloid +_ blood. Look for: echo, USS, CT, -+ surgical interv. Treat the cause.

Question 16

How would you treat?

Answer 16

Laparotomy- AAA, slpenic or liver trauma, ruptured ectopic, intra abdo sepsis. Angioplasty- MI Thrombolysis: PE Pericardiocentisis/ cardiac surgery: cardiac tamponade, aortic valve dysfunction. Antidotes: poisoning. Antibiotics: sepsis, co-amoxiclav + gentamicin+ metronidiazole. Inotropic + vasoactive therapy- + assisted ventilation…

Question 17

What is SIRS?

Answer 17

Septic pts have a systemic inflammatory response syndrome, due to infection.

Question 18

How would you manage a shocked patient?

Answer 18

ABC Secure airway- intubation- decrease work of breathing and guard for resp arrest. Oxygen supplementation, IV dluids, passive lef raising Blood transfusions if blood loss severe. Imp to keep person warm, manage pain + anxiety as they increase O2 consumption. Fluids: aggressive IV (1-2L of normal saline 0.9% bolus over 10-20 mins) kid-20ml/kg. crystalloids- less expensive. If still shocked- packed RBCs to keep Hb> 100gms.

Question 19

How would you manage Haemorrhagic shock?

Answer 19

IV fluids limited- penetrating thorax or abdomen injuries. Allow mild hypotension- “permissive hypotension” Target: mean arterial pressure 60mmHg, A systolic BP 70-90mmHg.

Question 20

What medications can be used if BP still persisting to be low?

Answer 20

Vasopressors- not effective for haemorrhagic shock or trauma. Used in neurogenic shock. Activated protein C or sodium bicarbonate- no effects on outcome…

Question 21

What are the treatment goals when managing shock?

Answer 21

To achive a urine output of greater than 0.5ml/kg/hr A central venous pressure of 8-12mmHg In trauma- goal is to stop bleeding- might require surgical intervention.