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Acute > Sepsis > Flashcards

Sepsis Flashcards

1
Q

Define infection

A

The invasion of normally sterile host tissues by microorganisms

  • Any infection can give way to sepsis but not all infections lead to sepsis
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2
Q

Define sepsis

A

Life threatening organ dysfunction due to a dysregulated host immune response

Definite or likely infection + one red flag

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3
Q

Define septic shock

A

Septic patient remaining hypotensive even though fluids have been given

A subset of sepsis in which particularly profoud circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality

Persisting hypotension - requires vasopressors (press on vessels) to keep MAP above 65

+ lactate >2 despite adequate fluid resuscitation

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4
Q

Epidemiology of sepsis

A

1/5 deaths worldwide are caused by sepsis

150,000 people in the UK have sepsis every year

20-30% mortality from sepsis

50% people with septic shock die

1 person dies every 4hrs from sepsis in UK

£1.5billion cost to NHS per year

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5
Q

What are the most common infections that cause sepsis in the UK?

A
  • Pneumonia: strep pneumonia = 35%
  • UTI: E.coli = 25%
  • Intra-abdominal infections: gram negative & anaerobes = 11%

Skin & soft tissue: staph aureus = 11%

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6
Q

How is sepsis clinically assessed?

A

NEWS2 = 5+

NEWS2 = 3 in any one parameter

Any red flags?

Signs of infection?

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7
Q

Sepsis red flags

A
  1. New/ altered mental state
  2. Resp rate >25
  3. Systolic BP <90 or 20% less than normal
  4. Sats <94% (not COPD)
  5. >40% oxygen needed to maintain sats
  6. Oliguria/ anuria/ AKI/ no urine for 8-12hrs
  7. Lactate >2mmol/L
  8. Coagulopathy/ rash/ mottled/ ashen/ cyanotic
  9. HR >130bpm
  10. Chemo within last 2-3 weeks

**If any one of the above is present and an infection is the suspected cause - escalate**

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8
Q

Sepsis physiology

A
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9
Q

Explain the pathophysiology of sepsis related to the lungs

A
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10
Q

Important to remember about communicating sepsis as a differential

A

SEPSIS IS NOT A DIAGNOSIS - IT HAS TO BE ‘SEPSIS SECONDARY TO…’

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11
Q

What are the sepsis 6?

A

Bloods Urine Fluids Antibiotics Lactate Oxygen

The 6 things done to manage sepsis

  1. Give oxygen: keep sats >94%
  2. Cultures
  3. Antibiotics
  4. Fluids
  5. Lactate level
  6. Urine output
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12
Q

Discuss giving oxygen in sepsis

A

Aim: maintain sats >94%

*Unless the patient has T2 hypercapnic respiratory failure

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13
Q

Cultures in sepsis

A

At least 1 set, ideally 2

10mls blood in each bottle

  • Allows for targetted antibiotic therapy
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14
Q

Anibiotics in sepsis

A

GIVE WITHIN FIRST HOUR

Use trust antibiotic guidelines to pick the appropriate antibiotic - very broad spectrum given until cultre results available

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15
Q

IV fluids in sepsis

A

Optimises oxygen delivery to tissues

>16yrs: use crystalloids that contain sodium in the range 130–154 mmol/litre with a bolus of 500 ml over less than 15 minutes

If hypotensive or lactate >2mmol/L give IV fluid bolus injection up to 30mls/kg fluid over first 1-2hrs

If, despite fluids, BP and lactate do not improve, consider referral to ICU

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16
Q

Lactate in sepsis

A

Lactate rises becase lack of oxygen = anaerobic respiration = lactate production

High lactate = poor prognosis

*Sepsis is not the only cause of a raised lactate*

17
Q

Urine output in sepsis

A

Urine output reflects cardiac output - we can’t measure CO on the ward so this is the way to do it

Patient doesn’t need to have a catheter

Minumun of 0.5mls urine/kg/hr e.g. 35mls in 70kg human

Fall in urine production may be the first sign that CO is falling, even if B is normal

18
Q

Rsik factors for sepsis

A

Very young (<1yr)/ very old (>75yrs)

Immunocompromised: cancer, DM, splenectomy, steroids, immunosuppressant drugs

Recent surgery

Breach of skin integrity: cuts/ burns/ blisters

IV drug use

Indwelling lines/ catheters

19
Q

Why do we measure urine output in sepsis?

A

It is a marker of cardiac output via kidney function

20
Q

What is your responsibility in cases of suspected sepsis

A
  1. Do sepsis 6 (BUFALO) within 1hr
  2. Escalate to reg/ consultant
  3. Regularly review patient
  4. Refer to ICU if no improvement
21
Q

What is post-sepsis syndrome?

A

Subtle symptoms that occur following sepsis

  • Sadness/ anxiety
  • Dysphagia
  • Weakness
  • Clouded thinking
  • Insomnia
  • Poor memory
  • Poor concentration
  • Fatigue
22
Q

Compliations of sepsis

A

Death

Loss of fingers/ toes/ limbs due to dry gangrene

Impact on life and ability to work

Post-sepsis syndrome

23
Q

Finding the source of infection in sepsis

A
  • PMH: immunosuppression
  • Vaccinations: travel immunisation
  • Recent hospital stay: SSI/ indwelling devices
  • Contacts: family/ friends/ co workers
  • Pets: psittacosis, campylobacter
  • Travel: location, food, sexual contacts, Legionnaires
  • Occupation: farmers, animal handlers, healthcare worker (GI infections/TB/blood borne), sewage (leptospirosis)
  • Food: shellfish (Hep A), poultry (campylobacter/ salmonella)
  • Leisure activities: tick bites (Lyme disease), swimming, canoeing (leptospirosis)
  • Blood borne: IVDU/ tattoos
  • Sexual history
24
Q

Risk assessment - NICE sepsis guidance

A

If sepsis is suspected the risk of severe illness is stratified

Behaviour and history: not waking, continuous cry, appears ill, carer concerned, impaired immune system

Breathing: grunting, apnoea, low sats, nasal flaring, crackles in chest, needing 40% oxygen to maintain sats >94%

Circulation: > <60bpm, cap refill 3+ seconds, cold peripheries, leg pain

Skin

Temperature

Urine

25
Q

Risk factors for sepsis

A

Age >65yrs

Immunocompromised

Any skin breaches e.g. lines, surgery, haemodialysis, IV drug use

Pregnant

Alcoholic

26
Q

Are sepsis rates affected by season?

A

Yes - 1.4x more likely in winter

27
Q

Aetiology of sepsis

A

62% = gram negative e.g. pseudomonas spp. end e.coli

47% gram positive e.g. staph aureus

19% fungal

*Causative agent not always found

28
Q

Investigations in sepsis

A

Cultures: take bloods before antibiotics atrted - but don’t delay antibiotic administration as a result

If a line infection is suspected, remove the line and culture the tip

Serum lactate: marker of stress and worse prognosis, high lactate = hypoperfusion

Urine output: measure hourly - low output suggests AKI and low CO

FBC: thrombocytopenia of non-haemorrhagic origin can occur in sepsis

U&E: renal function

LFTs: end organ dysfunction (esp. raised bilirubin)

Baseline ECG to rule out differentials, also arrhythmias often seen in older people with sepsis

CRP: sensitive but not specific for sepsis

29
Q

Differentials for sepsis

A

Depends on what you think sepsis is secondary too

  • Non-infectious inflammatory response
  • MI
  • Acute pancreatitis
  • Massive PE
  • Malignant yperthermia
  • Drug induced fever and coma
30
Q

What is APACHE 2 scoring system?

A

Used to establish illness severity in ICU and predict risk of deaht

25+ = high risk of death

31
Q

Management of sepsis

A

General

  • Establish venous access early to allow for IV antibiotics and fluids to be given

Antibiotics: broad spec within 1hr

Fluids: 500mL crystalloid over <15mins and repeat if clinically indicated but don’t exceed 30mL/ kg i.e. 2L

Oxygen: sats >94% or 88-92 if T2RF

Measure urine output hourly

BUFALO mnemonic

Consider continuous monitoring or at least every 30 mins

32
Q

Antibiotic choice in sepsis

A

Surviving sepsis campaign suggests 2 antibiotics of different classes aimed at the most likely bacterial pathogen for the intial management

33
Q

Fluid resus in sepsis

A

Seems to be a marginal benefit using balanced crystalloid over normal saline

*Colloids no longer used in emergency med in the UK

34
Q

Most common site of infection leading to sepsis?

A

Resp tract

35
Q

Which antibiotics are used if meningococcal sepsis is suspected?

A

Hospital: IV ceftriaxone

Community: benzyl penicillin

36
Q

How much crystalloid is given in sepsis before giving a vasopressor?

A

2-3L

37
Q

Examples of vasopressors

A
  • Norepinephrine
  • Epinephrine
  • Vasopressin (Vasostrict)
  • Dopamine
  • Phenylephrine
  • Dobutamine
38
Q

What is the qSOFA score?

A

quick Sequential Organ Failure Assessment

A way to assess for sepsis

Consider sepsis and commence treatment if any one or more of the following present:

RR >22

Systolic BP <100

Altered mental status (lower GCS than normal)

39
Q

What is neutropenic sepsis?

A

Systemic radio or chemotherapy can cause bone marrow suppression and limit the ability to respond to infection

Patients with neutropenic sepsis can rapidly deteriorate without warning so ensure they receive immediate treatment

Suspect in patients with signs of illness and a neutrophil count of <0.5 x 10*9/L

Acute (22 decks)

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