Sepsis

Question 1

what is bacteraemia?

Answer 1

presence of live bacteria in bloodstream

occurs in healthy individuals and presents with no symptoms

Question 2

causes of bacteraemia

Answer 2

surgery
dental procedures
tooth brushing

Question 3

what is septicaemia ?

Answer 3

presence of a pathogen in the bloodstream leading to sepsis

Question 4

what is SIRS?

Answer 4

systemic inflammatory response syndrome

clinical signs in response to the systemic inflammation

Question 5

triggers of SIRS?

Answer 5

infection 
surgery 
trauma 
malignancy 
chronic inflammatory disease 
burns 
pancreatitis

Question 6

what is sepsis

Answer 6

SIRS triggered by primary localised infection

can progress to severe sepsis and septic shock

Question 7

clinical signs of SIRS

Answer 7

2 or more of:
temperature <36 or >38 
tachycardia = HR >90bpm 
RR >20 or PaCO2 <4.3kPa 
WCC >12 x 10^9/L or <4 x 10^9/L

Question 8

clinical features of sepsis

Answer 8

2 or more of the SIRS signs resulting from infection

Question 9

clinical features of severe sepsis

Answer 9

sepsis plus signs of organ hypo-perfusion 
hypoxaemia
oliguria
lactic acidosis 
acute altered mental state

Question 10

clinical features of septic shock

Answer 10

severe sepsis with hypotension or requirement of vasoactive drugs despite adequate fluid resuscitation

Question 11

pathophysiology of sepsis

Answer 11

cytokines
release of TNF-alpha and IL-1b from mononuclear leukocytes in response to endotoxins
stimulates release of other cytokines - IL-6,8,10
causes fever
initiates clotting cascade
mass release of pro-inflammatory cytokines which exert systemic effects
causes tissue injury
dysfunction of organ systems
tissue injury is mediated by polymorphs

Question 12

what are polymorphs?

Answer 12

neutrophils

Question 13

what are the groups of systemic effects of sepsis?

Answer 13

cardiac
respiratory 
rena
haematological
lactic acidosis

Question 14

cardiac effects

Answer 14

hypotension
due to cytokines stimulating nitric oxide synthesis and thus vasodilation
reduced SVR
tachycardia in response to reduced SVR

Question 15

respiratory effects

Answer 15

tachypnoea
hypoxaemia
respiratory alkalosis
ARDS caused by leakiness of pulmonary capillaries leading to alveolar oedema and neutrophil activation

Question 16

renal effects

Answer 16

acute renal failure due to cytokine-mediated vasodilation and hypotension causing decreased renal perfusion

Question 17

haematological effects

Answer 17

DIC

cytokine-mediated activation of extrinsic coagulation cascade

Question 18

lactic acidosis

Answer 18

due to tissue hypoxia from tissue hypoperfusion as a result of hypotension and arteriovenous shunting

Question 19

diagnosis/investigations for sepsis

Answer 19

clinical suspicion/diagnosis - require tests to identify trigger
CXR
blood cultures
FBC
U&Es 
LFTs 
ABG
urine dipstick

Question 20

management of sepsis

Answer 20

sepsis 6

Question 21

sepsis 6

Answer 21

high flow oxygen
take blood cultures
give empirical IV antibiotics - broad-spectrum before causative organism is identified 
IV fluid resuscitation 
check Hb and lactate on ABG/VBG
monitor urine output

Question 22

antibiotic treatment for sepsis

Answer 22

check local guidelines
e.g. benzylpenicillin 1.2g IV QDS + gentamicin 5mg/kg IV OD
in penicillin allergy give vancomycin
give targeted antibiotic therapy once causative organism has been identified

Question 23

treatment for severe sepsis/ septic shock

Answer 23

referral to ITU
identify and treat causative organism
supportive treatment

Question 24

supportive treatment

Answer 24

restore cardiac output and BP

ensure adequate ventilation and oxygenation

Question 25

how to restore cardiac output and BP

Answer 25

expand circulating volume using colloids, crystalloids or blood products
inotropes, vasopressors or vasodilators to improve cardiac function

Question 26

ventilation and oxygenation

Answer 26

maintain patent airway using oropharyngeal airway, endotracheal tube or emergency tracheostomy
high flow oxygen

Question 27

monitoring in sepsis

Answer 27

arterial line to monitor BP and ABG
ECG
insert catheter to monitor urine output 
temperature probe 
central venous catheter

Question 28

aims of supportive treatment

Answer 28

mean arterial pressure >65mmHg
CVP >8-12mmHg
urine output >0.5ml/kg/hour

Question 29

prognosis of sepsis

Answer 29

most people make a full recovery
takes time
physical and emotional symptoms may continue for months or years
post-sepsis syndrome

Question 30

what is post-sepsis syndrome?

Answer 30

tiredness
weakness
difficulty sleeping 
lack of appetite 
more prone to illness
changes in mood 
anxiety 
depression 
nightmares
flashbacks
PTSD

Question 31

mortality from severe sepsis

Answer 31

25-56%

Question 32

Management pathway for sepsis

Answer 32

ABCDE

airway, breathing, circulation, disability, exposure

Question 33

disability

Answer 33

assess consciousness using AVPU 
GCS 
assess pupils 
drug chart review 
blood glucose, if raised check ketones 
CT head if suspected intracranial pathology 
maintain airway 
reassess

Question 34

maintaining airway in sepsis

Answer 34

GCS of 8 or less requires help from anaethetist

Question 35

exposure

Answer 35

prioritise patient dignity and conservation of body heat
ask about pain
inspect for non-blanching rash, mottling, ashen or cyanosis
review catheter and surgical drain output
inspect wounds for infection measure temperature - can present with hypothermia or pyrexia
urinalysis
catherterisation
reassess