Sepsis

Question 1

define sepsis

Answer 1

life threatening organ dysfunction caused by dysregulated host response to infection

Question 2

define septic shock

Answer 2

sepsis with persisting hypotension requiring vasopressors to maintain MAP >65mmHg and having serum lactate of >2mmol/l despite adequate volume resuscitation

Question 3

what scoring system can be used to assess a patient (>18yrs) with a suspected infection their risk of needing a prolonged stay in the ICU ?

Answer 3

qSOFA

Question 4

what are the categories for the qSOFA scoring system?

Answer 4

> altered mental state
hypotension (systolic BP less than 100mHg)
tachypnoea (>22/min)

Question 5

a qSOFA outcome of more than two suggest what?

Answer 5

a poorer outcome

Question 6

define SIRS ( septic inflammatory response syndrome)

Answer 6

2 or more of the following features:

> temperature less than 36C more than 38C
more than 90 bpm
resp. rate.: more than 20 b/min
PaCO2 less than 4.3kPa
WBC: less than 4 X 10^9
more than 12 X 10^9

Question 7

what features may be present consistent with immunosuppression?

Answer 7

> loss of delayed hypersensitivity
inability to clear infection
predisposition to nosocomial infections

Question 8

what is the first phase of the pathophysiology of sepsis?

Answer 8

release of bacterial toxins

Question 9

what bacterial toxin is released by gram negative bacteria?

Answer 9

lipopolysaccharide

Question 10

what bacterial toxin is released by gram positive bacteria?

Answer 10

> super-antigens (streptococcal exotoxins, staphylococcal toxic shock syndrome)

> microbial associated molecular pattern (lipoteichoic acid, muramyl dipeptides)

Question 11

what is stage 2 of the pathophysiology of sepsis?

Answer 11

release of mediators in response to infection

Question 12

stage 2 pathophysiology

describe the gram negative endotoxin release

Answer 12

produce lipopolysaccharides which need a binding protein to bind to macrophages

Question 13

gram positive organisms produce lipoteichoic acid in stage 2. do they need a binding protein to bind to macrophages?

Answer 13

no

Question 14

describe exotoxin release in stage 2 pathophysiology

Answer 14

small amounts of super-antigens produce large amounts of mediators to be secreted creating a cascade effect leading to a cytokine storm (patients can die within a few hours)

Question 15

what do pro-inflammatory mediators lead to?

Answer 15

septic shock

Question 16

what so compensatory anti-inflammatory mediators lead to?

Answer 16

immunoparalysis

Question 17

what is phase 3 of the pathophysiology of sepsis?

Answer 17

effects of specific mediators

Question 18

what are the effects of anti-inflammatory mediators in stage 3?

Answer 18

> inhibit TNF alpha
augment cute phase reaction
inhibit activation of anticoagulation system
creates negative feedback of proinflammatory mediators

Question 19

what are the effects of pro-inflammatory mediators?

Answer 19

> hyperthermia
promotes endothelial leukocytes adhesion
releases arachidonic acid metabolites
vasodilation via NO
increases coagulation (tissue factor release and membrane coagulants)

Question 20

what does the clinical manifestation of sepsis depend on?

Answer 20

> environment (travel, hospitalisation, occupation)

> organism (virulence factor and bioburden)

> host (immunosuppression, comorbidities, splenectomy, age)

Question 21

what are the general features of sepsis?

Answer 21

> fever more than 38C
> hypothermia less than 36C (elderly and young)
> tachycardia more than 90
> tachypnoea more than 20
> altered mental state
> hyperglycaemia more than 8 mmol/l

Question 22

what inflammatory variables can present in sepsis?

Answer 22

> leucoytosis
> leucopenia (immunocompromised)
> normal WCC with >10% immature forms
> high crp
> high procalcitonin

Question 23

what haemodynamic variables can present in sepsis?

Answer 23

> arterial hypotension (MAP <70mHg)

> SvO2 >70%

Question 24

what organ dysfunction variables can present in sepsis?

Answer 24

> arterial hypoxaemia
> increased creatinine
> coagulation abnormalities
> thrombocytopenia
> hyperbilirubinemia
> ileus (lack of digestive propulsion)

Question 25

what tissue perforation variables can present in sepsis?

Answer 25

> skin mottling > capillary perfusion > increased lactate

Question 26

Name sepsis 6

Answer 26

``` Blood cultures Blood lactate Urine output Oxygen IV antibiotics IV fluids ```

Question 27

what is type A lactate a marker of?

Answer 27

generalised hypoperfusion

Question 28

what is type B lactate a marker of?

Answer 28

> mitochondrial toxins > alcohol > malignancy > metabolism errors

Question 29

what is urine output a marker of?

Answer 29

renal dysfunction

Question 30

true or false | if the temperature spikes you should take 2 sets of blood cultures

Answer 30

true

Question 31

what is your aim for oxygen concentration in a septic patient?

Answer 31

94%-98%

Question 32

when should you refer your septic patient to HDU?

Answer 32

``` > decreasing BP unresponsive to fluids > lactate >2 > oliguria > liver dysfunction > elevated creatinine > bilateral infiltrates > hypoxaemia ```

Question 33

when is a septic patient admitted to ITU?

Answer 33

> septic shock | > multiorgan failure

Question 34

you see a patient with an increased resp. rate, BP 90/40 and who has not passed urine in 18 hours. they have ashen skin and cyanosis of the lips as well as a non blanching rash. are they high, moderate or low risk for sepsis?

Answer 34

high. you would also want to check from their history for objective evidence of altered mental state.

Question 35

what in a patients history may put them at moderate risk of sepsis?

Answer 35

> history of altered metal state > acute deteriorating ability to function > impaired immune system > trauma, surgery, or invasive procedure in last 6 weeks