Sepsis Flashcards
what is bacteraemia?
presence of live bacteria in bloodstream
occurs in healthy individuals and presents with no symptoms
causes of bacteraemia
surgery
dental procedures
tooth brushing
what is septicaemia ?
presence of a pathogen in the bloodstream leading to sepsis
what is SIRS?
systemic inflammatory response syndrome
clinical signs in response to the systemic inflammation
triggers of SIRS?
infection surgery trauma malignancy chronic inflammatory disease burns pancreatitis
what is sepsis
SIRS triggered by primary localised infection
can progress to severe sepsis and septic shock
clinical signs of SIRS
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
clinical features of sepsis
2 or more of the SIRS signs resulting from infection
clinical features of severe sepsis
sepsis plus signs of organ hypo-perfusion hypoxaemia oliguria lactic acidosis acute altered mental state
clinical features of septic shock
severe sepsis with hypotension or requirement of vasoactive drugs despite adequate fluid resuscitation
pathophysiology of sepsis
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
what are polymorphs?
neutrophils
what are the groups of systemic effects of sepsis?
cardiac respiratory rena haematological lactic acidosis
cardiac effects
hypotension
due to cytokines stimulating nitric oxide synthesis and thus vasodilation
reduced SVR
tachycardia in response to reduced SVR
respiratory effects
tachypnoea
hypoxaemia
respiratory alkalosis
ARDS caused by leakiness of pulmonary capillaries leading to alveolar oedema and neutrophil activation
renal effects
acute renal failure due to cytokine-mediated vasodilation and hypotension causing decreased renal perfusion
haematological effects
DIC
cytokine-mediated activation of extrinsic coagulation cascade
lactic acidosis
due to tissue hypoxia from tissue hypoperfusion as a result of hypotension and arteriovenous shunting
diagnosis/investigations for sepsis
clinical suspicion/diagnosis - require tests to identify trigger CXR blood cultures FBC U&Es LFTs ABG urine dipstick
management of sepsis
sepsis 6
sepsis 6
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
antibiotic treatment for sepsis
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
treatment for severe sepsis/ septic shock
referral to ITU
identify and treat causative organism
supportive treatment
supportive treatment
restore cardiac output and BP
ensure adequate ventilation and oxygenation
how to restore cardiac output and BP
expand circulating volume using colloids, crystalloids or blood products
inotropes, vasopressors or vasodilators to improve cardiac function
ventilation and oxygenation
maintain patent airway using oropharyngeal airway, endotracheal tube or emergency tracheostomy
high flow oxygen
monitoring in sepsis
arterial line to monitor BP and ABG ECG insert catheter to monitor urine output temperature probe central venous catheter
aims of supportive treatment
mean arterial pressure >65mmHg
CVP >8-12mmHg
urine output >0.5ml/kg/hour
prognosis of sepsis
most people make a full recovery
takes time
physical and emotional symptoms may continue for months or years
post-sepsis syndrome
what is post-sepsis syndrome?
tiredness weakness difficulty sleeping lack of appetite more prone to illness changes in mood anxiety depression nightmares flashbacks PTSD
mortality from severe sepsis
25-56%
Management pathway for sepsis
ABCDE
airway, breathing, circulation, disability, exposure
disability
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
maintaining airway in sepsis
GCS of 8 or less requires help from anaethetist
exposure
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
