Sepsis

Question 1

What does SIRS stand for?

Answer 1

systemic inflammatory response syndrome

Question 2

The development of septic shock

Answer 2

SIRS = temp, HR, RR, WBCs
Sepsis = SIRS + infection
Severe sepsis = sepsis + end organ damage
Septic shock = severe sepsis + hypotension

Question 3

What scoring system is used to identify sepsis

Answer 3

qSOFA, then SOFA (sepsis related organ failure assessment)

qSOFA =

1. hypotension systolic <100
2. tachypnoea - RR 22
3. altered mental states GCS <15

SOFA =

1. PaO2/FiO2 ratio
2. GCS
3. MAP
4. Vasopressors
5. creatinine/output
6. Bilirubin
7. Platelet count

if 2 or more then admit to ICU

Question 4

hospital mortality rate of patients with septic shock

Answer 4

40%

Question 5

3 phases in the pathogenesis of sepsis

Answer 5

1. release of bacterial toxin
2. release of mediators
3. effects of specific excessive mediators

Question 6

Types of bacterial toxin

Answer 6

gram negative - LPS

gram positive - superantigens and MAMPs

Question 7

Types of mediators

Answer 7

Th1 and Th2

Question 8

Mediator responses

Answer 8

Pro-inflammatory - vasodilate, produce arachidonic acid, hyperthermia, increase coagulation
Anti-inflammatory - inhibit TNF alpha, inhibit coagulation factors, provide negative feedback to pro-inflammatory markers

Question 9

When does septic shock happen in regard to the balance between the pro and anti-inflammatory mediators?

Answer 9

when pro-inflammatory markers outweigh the anti-inflammatory markers. Immunoparalysis occurs when it is the other way round

Question 10

Clinical features of sepsis - general groups (5)

Answer 10

general
organs
inflammatory
haemodynamic
tissue perfusion

Question 11

General features of sepsis (6)

Answer 11

Fever >38
Hypothermia <36 - especially in the elderly
Tachcardia >90bpm
Tachypnoea>20/min
Altered mental status
Hyperglycaemia

Question 12

Organ features of sepsis (5)

Answer 12

Brain - altered consciousness, confusion, psychosis
Lungs - tachypnoea, sats <90%
Liver - increased liver enzymes, decrease albumin, increase PT, hyperbilirubinaemia
Heart - hypotension, tachycardia
Kidneys - oligouria

Question 13

Inflammatory features of sepsis (5)

Answer 13

Leucocytosis - >12,00
Leucopenia- <4000
Normal WCC with greater than 10% immature forms (high turnover)
High CRP
High procalcitonin

Question 14

Haemodynamic features of sepsis (2)

Answer 14

Arterial hypotension

Sv02 >70%

Question 15

Tissue perfusion factors (3)

Answer 15

high lactate
skin mottling
reduced capillary refill

Question 16

Effect of host on sepsis presentation (4)

Answer 16

1. age
2. co-morbidities (COPD, diabetes, CFF, malignancy)
3. Immunosuppression (acquired, drug induced, congenital)

Question 17

Sepsis 6

Answer 17

Take 3:
blood culture (if spike in temp do 2 sets), blood lactate (more supportive biomarker of outcome), urine output

Give 3:
O2, IV antibiotics, IV fluid

(2 A,B,Cs)

Question 18

When to consider HDU?

Answer 18

Low BP responsive to fluids
Lactate >/ 2 despite fluid resuscitation 
elevated creatinine
Oligouria
Liver dysfunction 
Bilateral infiltrates§

Question 19

When to consider ITU?

Answer 19

SOFA >/2