Sepsis

Question 1

What is sepsis?

Answer 1

Life threatening organ dysfunction due to dysregulated host response to infection

Question 2

What is septic shock?

Answer 2

persisting hypotension requiring treatment to maintain blood pressure despite fluid resuscitation

Question 3

What is bacteraemia?

Answer 3

The presence of bacteria in the blood (+/- clinical features) need culture, can appear well.

Question 4

What is septicemia?

Answer 4

Means generalized sepsis (outdated)

Question 5

How do we recognise sepsis?

Answer 5

Early Warning Score (EWS): Basic observations (RR, HR, Temp, BP)
Clinical features suggesting source (e.g. pneumonia; Respiratory and UTI)
Check for RED FLAG symptoms: High RR, Low BP, unresponsive

Question 6

What is Sepsis 6 management?

Answer 6

If the patient has red flag symptoms and immediate action is required.

1. Titrate O2 at saturation target 94% (unless have COPD as can get hypercapnic resp failure)
2. Take blood cultures (and others) consider source of control
3. Administer empirical abx
4. Measure serum lactate
5. Start IV fluid resuscitation
6. comment accurate urine output measurement

Question 7

What is meant by the term ‘Golden hour’?

Answer 7

Golden hour- if sepsis is caught and treated with in the hour outcome is improved
Progressive necrosis happens over a matter of hours not days. Blood supply to non-vital organs is loss, amputations to preserve life in some cases

Question 8

What abx would be a good choice for treatment of sepsis?

Answer 8

Meropenem (carbopenems- empirical abx and can be used with penicillin allergy)

Question 9

What urgent investigations would you undertake in some one presenting with potential sepsis?

Answer 9

• FBC, U&E’s, LFT, CRP
• EDTA bottle for PCR
• Blood sugar
• Coagulation (clotting) studies
• blood gases
• Other microbiology samples (CSF, urine etc.)

Question 10

Why would you measure lactate in a patient presenting with sepsis?

Answer 10

Lactic acidosis occurs during shock

Question 11

What is sepsis coagulation?

Answer 11

cytokines initiate production of thrombin and thus promote coagulation
Cytokines also inhibit fibrinolysis
Coagulation cascade leads to microvascular thrombosis and hence organ ischaemia, dysfunction and failure
microvascular injury is the major cause of shock and multi organ failure

Question 12

Discuss treatment options for sepsis (supportive and specific).

Answer 12

Supportive: 
- IV fluid to improve BP
- Pain relief 
- O2 to maintain oxygen supply with low BP
- urgent review 
- consider early referral to ITU 
Specific: 
- Antimicrobial: Empirical abx (meropenem) or Ceftriaxone (if symptoms of meningitis e.g. rash)

Question 13

Why is ceftriaxone the empiric choice for treatment of meningitis?

Answer 13

It penetrates into the CSF

Question 14

What agents can cause meningitis in newborns?

Answer 14

Group B streptococcus, streptococcus pneumoniae, e.coli, listeria moncytogenes

Question 15

What agents can cause meningitis in infants and children?

Answer 15

streptococcus pneumoniae, niesseria meningitidis, hemophilis influenza type B, Group B streptococcus

Question 16

What agents can cause meningitis in adolescents and young adults?

Answer 16

niesseria meningitidis, streptococcus pneumoniae

Question 17

What agents can cause meningitis in older adults

Answer 17

streptococcus pneumoniae, niesseria meningitidis, haemophilis influenza type B, Group B streptococcus, listeria moncytogenes

Question 18

In a 19 year old Female what is the most likely cause of meningitis?

Answer 18

Neisseria meningitidis

Question 19

What are the life threatening complications of meningitis/sepsis?

Answer 19

Irreversible hypotension
Respiratory failure
AKI 
Raised inter-cranial pressure 
Ischaemic necrosis of digits/hands/feet

Question 20

How would you confirm the diagnosis or meningitis?

Answer 20

Blood culture
PCR of blood
Lumbar puncture (if safe): microscopy and culture the CSF and PCR of CSF

Question 21

What is the CSF examined for after a lumber puncture is performed?

Answer 21

Glucose and protein (in biochem) 
Microscopy and culture (in micorbiology)
Appearance- turbidity and colour
microscopy- WBC and RBCs 
Gram stains 
Referral for PCR

Question 22

Describe Neisseria Meningitidis

Answer 22

Gram negative diplococcus
Numerous sub groups (A,B,C,W)
Polysaccharide capsular antigen
Outer membrane acts as an endotoxin

Question 23

What does the polysaccharide capsular antigen of neisseria meningtidis do?

Answer 23

Evades the immune response by preventing phagocytosis.

Question 24

Whats the most common Neisseria Meningitidis sub group in the UK

Answer 24

B

Question 25

How is Neisseria Meningitidis spread?

Answer 25

aerosols and nasopharyngeal secretions

Question 26

What techniques are used to prevent meningitis?

Answer 26

Vaccination

Antibiotic prophylaxis

Question 27

Why is the spleen so important?

Answer 27

Only organ that is in contact with the blood. Can produce B cells and T cells. 
- encapsulated bacteria 
Antibody production: 
- acute respons : IgM production 
- Long term protection: IgG production
Splenic macrophages:
- removal of opsonized microbes
- removal of immune complexes

Question 28

What bacteria to asplenic patients have increased susceptibility?

Answer 28

Encapsulated bacteria:

Haemophilus influenzae, streptococcus pneumoniae and Neisseria meningitidis

Question 29

what is the management of an asplenic patient?

Answer 29

Pencillin prophylaxis (life long)
Immunisation against encapsulated bacteria
Medic alert bracelet