Sepsis Flashcards
sepsis is characterised by a
life-threatening organ dysfunction due to a dysregulated host response to infection and inflammation
septic shock
’ persistent hypotension despite fluid resuscitation’
a subset of sepsis where particularly profound circulatory, cellular and metabolic abnormalities substantially increase mortality
why are definitions of sepsis important?
- Use of a common language to improve communication between health professions and between healthcare and its patients - Use of language suitable to educate the public about the condition - The establishment of criteria and thresholds beyond which intervention is recommended - Provision of a criteria to determine eligibility for inclusion in a clinical trial
why is sepsis important?
- 5% of emergency department admissions - overall mortality rate of 28.9% - 250,000 cases a year in the UK - rising incidence of 11.5% a year
what happens in local infection
rubor tumor calor dolor
rubor
redness
tumor
swelling
calor
heat
dolor
pain
sepsis is
systemic inflammation
what happens in sepsis
- vasodilation 2. capillary leakage 3. amplification
sign of vasodilation
warm peripheries
purpose of capillary leakage
WBC to site of infection
sign of capillary leakage
swelling- may appear oedematous
amplification involves
upregulation of cytokines and mediator molecules
the thinking about sepsis’ effect on organ systems
think: ABCD
Airway
o No specific effect unless infection arises from throat or neck. However, decreased consciousness may be at risk of airway problem
Breathing
o Raised respiratory rate (tachypnoea). Fluids and proteins leaking into interstitial tissues lead to lung oedema and decreased lung compliance.
circulation
o Hypovolaemia due to vasodilatation and capillary leakage leading to hypotension
hypovolaemia leads to
(think of blood pressure = CO x TPR) - tachycardia - end organ damage (ischaemia- hypo perfusion of organs)
why is no urine output a sign?
due to hypo-perfusion of the kidney - due to hypovolaemia
disability
o Reduced blood flow to brain. May present as confusion, drowsiness, slurred speech, agitation, anxiety or decreased level of consciousness.
Exposure
o High temperature due to hypothalamic response to infection. o Beware hypothermia ( < 36°C) especially in elderly (don’t have same response as young- so sick cant mount temp response)
who is at risk of Sepsis
- Very young <1
- Elderly >75 or very frail
- Pregnant, post partum (within last 6 weeks
- Immunocompromised
- asplenic
- wound or injury
- invasive devices
think sepsis if….
patient is: - Is triggering an early warning score - Looks ill (to a health professional or an unusually concerned relative) - Has any sign of infection
what is used to give an early warning score
National early warning score (NEWS2)
National early warning score (NEWS2) used to
- Used to identify and respond to patients at risk of clinical deterioration
NEWS2 is validated for
use in non-pregnant adults (age 16 and over)
which physiological measurements are taken into consideration by NEWS2 (6)
o respiration rate o oxygen saturation o systolic blood pressure o pulse rate o level of consciousness or new confusion* o temperature
an elevated NEWS2 score
does not provide diagnosis- helps identify patients who need urgent clinical review - Clinical judgement important. Some patients may score high but constant review not appropriate e.g. end of life.
a NEWS2 score of >……… THINK SEPSIS
5
what is a more specific screen for sepsis than NEWS2
Red flag sepsis
Red flag sepsis
- Not a formal diagnosis but a criteria using measurements already done or easily obtainable bedside test to identify patients with a high likelihood of a degree of organ dysfunction - Patients are at high risk of deterioration
how to use red flag sepsis
is any one red flag present?
name the 9 red flags
- AVPU= VP or U (if changed from normal) - acute confusion - respiratory rate >25 - Needs O2 to keep spO2 above 92% (88% if COPD) - heart rate >130 bpm -systolic bp <90 mmHg - not passed urine in last 18h - non blanching rash, mottled/ ashen/cyanotic - recent chemotherapy (last six weeks)
AVPU
consciousness “alert, verbal, pain, unresponsive”
how is sepsis managed
sepsis 6
give the sepsis 6
3 in - give oxygen - give IV antibiotics - consider fluids 3 out - monitor urine output - take cultures - take HB and lactate
how to take a blood culture
- 5ml of blood taken into anaerobic and aerobic bottles 2. Put bottles into machine which sit on incubator for 5 days 3. If you have high levels of carbon dioxide (produced by bacteria) the blood culture precipitate at the bottom of the bottle will change colour and automatically feedback to the machine 4. Blood that tests positive has a gram stain 5. Also grown on agar plate with paper discs soaked in antibiotics to see if pathogen is resistant or susceptible to antibiotics
tumbler test
- If you add glass and it disappears- blanching - If the area stays red- non blanching
blanching=
sign of sepsis
supportive investigations
- Full blood count - Urea and Electrolytes - Blood sugar - Liver Function Tests - C-Reactive protein (CRP) - Coagulation (clotting) studies - Blood gases
specific investigations
- Cerebrospinal Fluid - Throat swab - EDTA bottle for PCR
cerebrospinal fluid
- Lumbar puncture - Urgent transport of CSF to lab - Glucose and protein estimation in biochemistry, microscopy and culture in microbiology
normal CSF
clear and colourless
CSF with infection
cloud or turbid- bacteria or WBC
meningococcus is caused by
Neisseria meningitis
Neisseria meningitis
gram negative diplococcus - 25% of young adults may be carriers -
Neisseria meningitis spread by
aerosols and nasopharyngeal secretions
endotoxin of Neisseria meningitis
LPS
treatment of meningitis
ceftriaxone
ceftriaxone is the first line
because needs to be able to cross the BBBq
prevention of meningitis
vaccination Men B, Men C, Men ACWY
prophylaxis for meningitis
for close contacts
Meningitis is a………..disease and N.meningitidis is a ………. organism
notifiable
complication of sepsis (due to cytokines)
DIC where multiple clots form within the vessels using up clotting factors. Cytokines trigger thrombin production, thereby promoting coagulation and also inhibiting fibrinolysis -> the coagulation cascade leads to microvascular thrombosis -> ultimately progressing to organ ischaemia, dysfunction and failure.
most likely causative organism varies by
age of the patient
classic symptoms of meningococcal meningitis
non-blanching purpuric rash (tested using the glass or tumbler test), a stiff neck, confusion, dislike of bright lights (photophobia), drowsiness, aching muscles and joints.
sign of meningitis in neonates
fontanelle (hole in the skull when born) might feel soft and bulging
what type of antibiotic is cephalosporin
ceftriaxone
antibotics given for sepsis with no signs of emningitis
meropenem (a carbopenom)
antibiotics when a severe gam negative sepsis is suspected
gentamicin
which fungus most liekly to cause sepsis
candida
Patient symptoms
- Severe muscle pain
- Less urine output (no perfusion to kidneys)
- Nausea
- Vomiting
- Diarrhoea
- Feeling faint
- Change in mental state
- Breathlessness
