SEPSIS Flashcards
What is sepsis
Life threatening organ dysfunction due to dysregulated host response to infection
SIRS / qSOFA + evidence of infection
SIRS now not really used
What is septic shock
Sepsis +
Persisting hypotension requiring vasopressors to maintain MAP >65 (hypo after 20ml/kg fluid)
or BP <90 or <40 below normal
Serum lactate >2mm (anaerobic respiration due to hypo-perfusion)
What is SIRS
2 of: Hypo / hyperthermia Tachycardia Tachypnooea PaCO2 <32 WBC <4000 or >12000 Altered mental state BG >7.7 with DM Sats <90 or PaO2 <70
What causes SIRS
Sepsis
Bruns
Pancreatitis
Trauma
What do you do if evidence of infection + 2+ qSOFA
SEPSIS 6
Assess frequently in 1st house
Look for septic shock / end organ dysfunction
What are red flags (Start sepsis 6)
Responding only to pain or voice Acute confusion SBP <90 HR >130 RR >25 O2 <92 Non-blanching / rash / mottled / cyanosis Not passed urine 18 hours Lactate >2 even if apyrexial Chemotherapy
What are RF for sepsis
Any condition that impacts on the immune system Age Co-morbid - COPD / DM Immunosuppresion - chemo / steroids Previous surgery / recent trauma e.g. burns Pregnancy Indwelling medical devices Virulence of organism Occupation Travel Hospital
What is qSOFA
Hypotension <100 or <40 below normal
Altered mental status
Tachypnoea >22
What is SEPSIS 6
WIRHIN 1 hour
Blood culture (2 sets A+An)
Blood lactate + bloods (easiest with VBG or ABG)
Urine output / catheter to get hourly urine output
Oxygen - 94-98%
IV Antibiotics
IV fluid
Inotropes / vasopressor in ITU if needed if BP is not responding
When should you do blood cultures
Fever Hypothermia Leucocytosis Neutropenia Unexplained organ dysfunction
What do you send lab tests of as
Emergency
Get results in 1 hour
How much fluid
Bolus 500ml over 15 minus
What Ax do you give
Cephalosporin + amox
Add vancomycin if resistant
Add metronidazole if GI
What is mortality from sepsis and septic shock
Sepsis - 10%
Septic shock - 40%
Mortality increases by 7.6% for each delay
What has different protocol
Neutropenic sepsis
What do you get ASAP
Senior input
When do you go to HDU
Low BP even with fluid High lactate >2 with fluid Increased creatinine Oliguria Liver dysfunction Bilateral. infiltrates
How do you get into ITU
Septic shock requiring vasopressor
Multi-organ failure
Incubation required
What are signs of end organ dysfunction / severe sepsis
Arterial hypoxaemia Hyptension BP <90 / MAP <65 Lactate >2 Oliguria <0.5ml/kg/hr for 2 hours AKI Coag abnormalities - raised PT / APTT Thrombocytopenia Hyperbilirubin Paralytic ileus Confusion as brain not perfused
What are inflammatory variables
Leucocytosis Leucopenia Normal WCC High CRP High procalcitonin
What are haemodynamic variables
Arterial hypotension
SvO2 >70%
Sats <90%
What shows poor perfusion
High lactate
Reduce perfusion
SKin mottling
What are signs of systemically unwell
N+V
Rigors
Poor appetite
What do you do if vomiting
U+E
ECG
AXR if think obstruction
What are amber flags
Deterioration Immunosuppresed Trauma / surgery <6 weeks RR 21-25 BP 90-100 HR 90-130 New arrhythmia Low temp
What are features of immunosuppression
Loss of delayed hypersensitivity
Inability to clear infection
Predisposed to other
When septic what do you become
Immunosuppressed as all energy into dealing with infection
What is phase 1
Release of bacterial toxin
What do gram -ve release
LPS (endotoxin)
What do gram +ve release
LTA (endotoxin)
Superantigens which can cause toxin shock syndrome
What is phase 2
Release of mediators in response to infection
What does LPS need
Binding protein to bind to macrophage and engulf it
LTA does not
What does super antigens (exotoxin) cause
Recognised by T cells
Cause large number of mediators to be released
Causes septic shock
What is phase 3
Effects of specific excessive mediators
What two types of mediators
Pro-inflammaotry
Anti-inflammatory
What are pro-inflammatory
TNFa - tumour necrosis factor
Il-1,2 - interleukin
IFN-y
What does pro-inflammatory cause
WCC adhesion
Increased vessel permeability = reduction in blood volume and hypoperfusion and oedema = reduced O2 to tissue
Release arachidonic acid
Complement activation
Vasodilation by NO
Increased coagulation - compromise perfusion
Increased consumption of platelets / clotting = thrombocytopenia / haemorrhage (DIC)
Hyperthermia
What are anti-inflammatory
TGF B
IL-1
What do anti-inflammatory cause
Inhibit TNFa
Inhibit coag
-ve feedback
If pro-inflammatory > compensatory
Septic shock
If compensatory >
Immune paralysis
Multi-organ failure
What is important to remember with neutropenic patients / immunosuppressed
May have normal observations / temp despite being very unwell
What bloods and why
FBC U+E LFT CRP Coagulation - look for DIC ABG - assess pH, lactate and glucose
What additional investigations for source of infection
Urine dip and culture
CXR
CT scan if suspect intra-abdominal
LP for meningitis
What organisms most common following splenectomy
Encapsulated
S.pneumona
H.inlfuena
Meningoccous
What do people get following splenectomy
Pneumococcal vaccine - 2 WEEKS BEFORE Meningococcal vaccine A+C H.infelunza B vaccine Annual flu Ax prophylaxis offered to all (penicillin or amoxicillin)
What is bacteraemia
Organism in a sterile site
What is infection
If bacteraemia causing symptoms
If suspect sepsis / red flags
999 and ambulance
Indications for splenectomy
Trauma Spontaneous rupture e.g. EBV Hypersplenism - hereditary spheryocytosis Malignancy Cyst / abscess
What are complications
Haemorrhage
Pancreatic fistula
INfection
Thrombocytosis so give aspirn
What happens post splenectomy
Platelet rise
Howell Jolly form
