Sepsis

Question 1

Define sepsis with sepsis -3 guidelines

Answer 1

life-threatening organ dysfunction caused by dysregulated host response to infection

Question 2

Define septic shock with sepsis -3 guidelines

Answer 2

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

Question 3

Body’s innate defences against sepsis

Answer 3

Physical barrier – skin, mucosa, epithelial lining

Innate immune system – dendritic cells/ macrophages

Adaptive immune system – lymphocytes, immunoglobulins

Question 4

Inflammatory variables/investigations in sepsis

Answer 4

WCC count - could be high/low/normal
CRP
Procalcitonin

Question 5

Haemodynamic variables/investigation findings in sepsis

Answer 5

Arterial hypotension (systolic <90mmHg or MAP <70mmHg)

SvO2 >70%

Question 6

Organ dysfunction variables/investigation findings in sepsis

Answer 6

Arterial hypoxaemia (PaO2/FiO2 < 50mmHg)
Oliguria (<0.5ml/kg/h)
Creatinine increase compared to baseline
Coagulation abnormalities (PT >1.5 or APTT >60s)
Ileus
Thrombocytopenia (<150,000/ml)
Hyperbilirubinaemia

Question 7

Tissue perfusion variables/investigation findings in sepsis

Answer 7

Lactate - high

Skin mottling

Question 8

Generally, gram -ve or gram +ve cause more cases of sepsis

Answer 8

gram +ve

Question 9

IV fluid challenge (part of sepsis 6) requires 4 components

Answer 9

• the type of fluid to be administered;
• the rate of fluid infusion
• the end points (e.g. mean arterial pressure of >65 mm Hg, heart rate of <110 beats per minute);
• the safety limits (e.g., development of pulmonary oedema).

Question 10

When to consider referral to high dependency unit

Answer 10

Low BP responsive to fluids
Lactate >2 despite fluid resuscitation
Elevated creatinine 
Oliguria/anuria
Liver dysfunction - Bil, PT, Plt
Bilateral infiltrates
hypoxaemia

Question 11

When to consider ITU

Answer 11

Septic shock
Multi-organ failure
Requires sedation, intubation and ventilation

Question 12

The use of the SIRS criteria (together with suspicion of infection) to diagnose sepsis remains in widespread clinical practice, despite their replacement by the Sepsis-3 definitions in 2016.

The SIRS criteria were replaced because, although they have a high sensitivity, their specificity is very low.

International guidance no longer recommends the use of the SIRS criteria in clinical practice when diagnosing sepsis in adults.

SIRS is defined by the presence of any two or more of the following clinical signs and laboratory investigation findings

Answer 12

Temperature >38.3°C (>101°F) or <36.0°C (<96.8°F)
Tachycardia >90 bpm
Tachypnoea >20 breaths/minute or PaCO₂ <4.3 kPa (<32 mmHg)
Leukocytosis (WBC count >12x10⁹/L [>12,000/microlitre])
Leukopenia (WBC count <4x10⁹/L [<4000/microlitre])
Normal WBC count with >10% immature forms
Hyperglycaemia (blood glucose >7.7 mmol/L [>140 mg/dL]) in the absence of diabetes mellitus
Acutely altered mental status.