Sepsis

Question 1

What is Sepsis

Answer 1

Lay definition of sepsis: the Merinoff definition ‘Sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs.’

Professional narrative definition of Sepsis: Singer M et al

Question 2

What happens in local infection

Answer 2

Inflammation occurs

Capillary leaks (initially for a good reason) to get supportive factors out to the tissue where it is needed - so get swelling (oedema)

Also get vasodilation - so blood flow speed decreases therefore, more leakage of contents of blood

Also get amplification of monocytes as part of immune system response

Question 3

Effect of sepsis on organ systems

Answer 3

Airways - No specific effect unless infection arises from throat or neck. (Swelling may block the upper airways. However, decreased consciousness may be at risk of airway problems.

Breathing - Raised respiratory rate (tachypnoea). Fluids and proteins leaking into interstitial tissues lead to lung oedema and decreased lung compliance

Circulation - Hypovolaemia due to vasodilatation and capillary leakage leading to hypotension. Blood Pressure = cardiac output x sytemic vascular resistance (TPR) - Tachycardia occurs to try and increase BP End organ damage, also due to lack of fluid in blood, urine levels drop so patient doesnt pee much at all

Disability - Reduced blood flow to brain (due to vasodilation/capillary leakage/ hypotension). May present as confusion, drowsiness, slurred speech, agitation, anxiety or decreased level of consciousness.

Expsoure - High temperature due to hypothalamic response to infection. Beware hypothermia (t < 36°C) especially in elderly.

Question 4

Why is sepsis important and diagnosis

Answer 4

sepsis accounts for

• 5% of emergency department admissions,
• 28.9% overall mortality rate
• 250,00 cases a year in the UK,
• rising incidence of 11.5% a year

Who is at risk: - Very young (< 1 year old).
Elderly (>75 years) or very frail.
Pregnant, post partum (within last 6 weeks).
Patients with impaired immune system due to illness or drugs. (HIV)

How is sepsis diagnosed? - Think Sepsis if the patient is -
Triggering an early warning score (this is done using the national early warning score)
Looks ill
Has any signs of infection

National Early Warning Score (NEWS2):
Single system endorsed by NHS England. Used to identify and respond to patients at risk of clinical deterioration.
Developed by Royal College of Physicians as NEWS in 2012 - Updated to NEWS2 Dec 2017.
Validated for use in non-pregnant adults (age 16 and over).
Mandated use in all acute and ambulance settings.

Scores allocated to six difference physiological measurements

1. respiration rate
2. oxygen saturation
3. systolic blood pressure
4. pulse rate
5. level of consciousness or new confusion
6. temperature.

NEWS2 Score - An elevated score does not provide a diagnosis. It helps to identify patients who need an urgent clinical review
NEWS2 of 5 or more - think Sepsis

Clinical judgment important - some patients may score high but constant review not appropriate i.e. they are near end of life

Question 5

Red flag sepsis

Answer 5

Term developed by UK Sepsis Trust in collaboration with NHS England and Royal
Colleges.

Not at ‘formal diagnosis’.

Criteria using measurements already done or easily obtainable bedside tests to identify patients with a high likelihood of a degree of organ dysfuction.

These patients are at high risk of deterioration.

Question 6

How is sepsis managed

Answer 6

Sepsis 6 is a set of six tasks (known as a care bundle) that has been shown to greatly increase the patient’s chance of survival if delivered within the first hour following recognition of sepsis.

Each hour delay in giving antibiotics increases mortality by 7.6%.

Designed to aid sepsis management by junior health professionals working in a team.

You take 3 things and give 3 things:
Take: 1) blood cultures 2)Hb and lactate level 3) take/monitor urine output
Give: 1) oxygen 2) antibiotics 3) give/consider giving fluids (need to be wary of people with heart problems)

Sepsis 6 and further investigations and supplements:
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 - Obtained by lumbar puncture
Urgent transport of CSF to laboratory
Glucose and protein estimation in biochemistry, microscopy and culture in microbiology
Appearance –cloudy turbidity and colour - shows that there are WBC and bacteria present - we would want it to appear clear
Microscopy WBCs, RBCs
Gram stain
Referral for PCR

Question 7

Meningococcus

Answer 7

Up to 25% young adults may be carriers
Spread by aerosols and nasopharyngeal secretions

Acquisition