sepsis

Question 1

what is sepsis?

Answer 1

the body’s extreme response to an infection

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

Question 2

what causes sepsis?

Answer 2

chemicals released by the immune system to fight an infection cause a systemic dysregulated response that triggers changes that can damage multiple body systems

Question 3

what is septic shock?

Answer 3

a subset of sepsis leading to profound circulatory or cellular/metabolic abnormalities which substantially increases mortality

(hypotension plus hypoperfusion plus elevated lactate)

Question 4

most common sites of infection leading to sepsis?

Answer 4

respiratory, such as pneumonia

urinary tract;

abdominal infection;

skin – surgical wounds, lesions, ulcers

Question 5

clinical phases of sepsis?

Answer 5

SIRS
sepsis
septic shock

Question 6

risk factors for developing sepsis?

Answer 6

immunodeficiencies (HIV, cancer)

chronic medical conditions (diabetes, lung disease, CKD)

post-op

IVDU

infants under 1 / children / older adults 65+

Question 7

what is SIRS?

Answer 7

systemic inflammatory response syndrome

Question 8

how is SIRS defined?

Answer 8

a combination of 2 or more of these symptoms:

1. Temperature of ≥38 ̊ C or <36 ̊ C
2. Heart rate > 90 bpm
3. Respiratory rate > 20 or PaCO2 < 32mmHg
4. WBC >12000 or <4000 (Peddleton, 2018).

Question 9

what can cause SIRS?

what is the significance of SIRS?

Answer 9

ischemia, inflammation, trauma, infection, or a combination of these factors

SIRS is non-specific (no known infection)
when combined with a source of infection, SIRS = sepsis.

Question 10

clinical definition of sepsis?

Answer 10

SIRS (x2+ symptoms) + infection (confirmed or suspected)

Question 11

pathophysiology of sepsis?

Answer 11

1. sepsis occurs when chemicals released by the immune system to fight an infection cause a systemic dysregulated response that triggers changes that can damage multiple body systems
2. the source of infection has left the local site → now in the circulation
3. deregulated release of inflammatory mediators leading to vasodilation, increased vascular permeability, ineffective tissue oxygen delivery and coagulation pathway activation
4. increase in anaerobic metabolism → lactic acid accumulation → metabolic acidosis
5. deranged Na+/K+ pump → Na+and water moves into the cells → fluid shift from ECF to ICF

Question 12

most common symptoms of sepsis?

Answer 12

Tachypnoea (99%) is the most common symptom closely followed by tachycardia (97%)

note that fever is not always present in the patient with sepsis

Question 13

acronym associated with recognising sepsis?

Answer 13

TIME

Temperature - higher or lower than normal

Infection - may have signs or symptoms

Mental decline - confused, sleepy, difficult to rouse

Extremely ill - pt feels severe pain or discomfort, feels they might die

Question 14

clinical manifestations of septic shock?

Answer 14

persistent hypotension requiring vasopressors to maintain, not responding to fluid replacement

cardiovascular dysfunction and haemodynamic instability

serum lactate greater than 2 mmol/L despite adequate volume resuscitation

Question 15

what is qSOFA?

Answer 15

quick Sequential Organ Failure Assessment Score

Question 16

what is a qSOFA score of more than 2 correlated with?

Answer 16

in-hospital mortality greater than 10%

Question 17

what things score a point on the qSofa scale?

Answer 17

Low blood pressure (SBP ≤ 100 mmHg)

High respiratory rate (≥ 22 breaths/min)

Altered mentation (GCS ≤ 14)

Question 18

management of sepsis?

Answer 18

first six steps within an hour

1. assessment - if pt shows signs of SIRS, request urgent medical review
2. two sets of blood cultures from seperate sites +/- other cultures (urine, sputum, wound etc)
3. administer antibiotics without delay
4. measure lactate
5. IV fluid resuscitation (rapid bolus, continue Ax)
6. administer oxygen (aim for 92-96%)
7. ongoing monitoring/escalation - ongoing obs, consider ICU, vasopressors
8. supportive care - mechanical ventilation, insulin therapy, may need blood products, IDC, enteral feeding

Question 19

management of potential complications of sepsis?

Answer 19

proton-pump inhibitor or histamine-2 blocker for stress ulcer prophylaxis

heparin

Question 20

complications of sepsis?

Answer 20

Multiple Organ Dysfunction Syndrome (MODS) – progressive physiologic failure of two or more organ systems

Acute Respiratory Distress Syndrome (ARDS) –
• Damage to small blood vessels in the lungs → fluid leakage into air spaces → impaired gas exchange → hypoxia

Disseminated Intravascular Coagulation (DIC)

Question 21

what is Disseminated Intravascular Coagulation (DIC)?

Answer 21

life-threatening complication that often manifests in response to a large amount of traumatized or dying tissue, quite common in septic shock

Question 22

key mechanisms involved in DIC?

Answer 22

the release of tissue factor from dying tissue, leading to activation of the coagulation cascade, thrombi and micro-emboli formation especially within peripheral blood vessels →

oxygen delivery and perfusion is diminished due to alterations to blood flow, leading to or exacerbating circulatory collapse →

a peculiar effect is these patients then begin to bleed, this is due to the lack of clotting factors that remain thus normal haemostasis does not occur

Question 23

fluid resus formula?

Answer 23

20 - 30mls per kg initially.