Sepsis Flashcards
Define infection
The invasion of normally sterile host tissues by microorganisms
- Any infection can give way to sepsis but not all infections lead to sepsis
Define sepsis
Life threatening organ dysfunction due to a dysregulated host immune response
Definite or likely infection + one red flag
Define septic shock
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
Epidemiology of sepsis
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
What are the most common infections that cause sepsis in the UK?
- Pneumonia: strep pneumonia = 35%
- UTI: E.coli = 25%
- Intra-abdominal infections: gram negative & anaerobes = 11%
Skin & soft tissue: staph aureus = 11%
How is sepsis clinically assessed?
NEWS2 = 5+
NEWS2 = 3 in any one parameter
Any red flags?
Signs of infection?
Sepsis red flags
- New/ altered mental state
- Resp rate >25
- Systolic BP <90 or 20% less than normal
- Sats <94% (not COPD)
- >40% oxygen needed to maintain sats
- Oliguria/ anuria/ AKI/ no urine for 8-12hrs
- Lactate >2mmol/L
- Coagulopathy/ rash/ mottled/ ashen/ cyanotic
- HR >130bpm
- Chemo within last 2-3 weeks
**If any one of the above is present and an infection is the suspected cause - escalate**
Sepsis physiology
Explain the pathophysiology of sepsis related to the lungs
Important to remember about communicating sepsis as a differential
SEPSIS IS NOT A DIAGNOSIS - IT HAS TO BE ‘SEPSIS SECONDARY TO…’
What are the sepsis 6?
Bloods Urine Fluids Antibiotics Lactate Oxygen
The 6 things done to manage sepsis
- Give oxygen: keep sats >94%
- Cultures
- Antibiotics
- Fluids
- Lactate level
- Urine output
Discuss giving oxygen in sepsis
Aim: maintain sats >94%
*Unless the patient has T2 hypercapnic respiratory failure
Cultures in sepsis
At least 1 set, ideally 2
10mls blood in each bottle
- Allows for targetted antibiotic therapy
Anibiotics in sepsis
GIVE WITHIN FIRST HOUR
Use trust antibiotic guidelines to pick the appropriate antibiotic - very broad spectrum given until cultre results available
IV fluids in sepsis
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
Lactate in sepsis
Lactate rises becase lack of oxygen = anaerobic respiration = lactate production
High lactate = poor prognosis
*Sepsis is not the only cause of a raised lactate*
Urine output in sepsis
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
Rsik factors for sepsis
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
Why do we measure urine output in sepsis?
It is a marker of cardiac output via kidney function
What is your responsibility in cases of suspected sepsis
- Do sepsis 6 (BUFALO) within 1hr
- Escalate to reg/ consultant
- Regularly review patient
- Refer to ICU if no improvement
What is post-sepsis syndrome?
Subtle symptoms that occur following sepsis
- Sadness/ anxiety
- Dysphagia
- Weakness
- Clouded thinking
- Insomnia
- Poor memory
- Poor concentration
- Fatigue
Compliations of sepsis
Death
Loss of fingers/ toes/ limbs due to dry gangrene
Impact on life and ability to work
Post-sepsis syndrome
Finding the source of infection in sepsis
- 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
Risk assessment - NICE sepsis guidance
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
Risk factors for sepsis
Age >65yrs
Immunocompromised
Any skin breaches e.g. lines, surgery, haemodialysis, IV drug use
Pregnant
Alcoholic
Are sepsis rates affected by season?
Yes - 1.4x more likely in winter
Aetiology of sepsis
62% = gram negative e.g. pseudomonas spp. end e.coli
47% gram positive e.g. staph aureus
19% fungal
*Causative agent not always found
Investigations in sepsis
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
Differentials for sepsis
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
What is APACHE 2 scoring system?
Used to establish illness severity in ICU and predict risk of deaht
25+ = high risk of death
Management of sepsis
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
Antibiotic choice in sepsis
Surviving sepsis campaign suggests 2 antibiotics of different classes aimed at the most likely bacterial pathogen for the intial management
Fluid resus in sepsis
Seems to be a marginal benefit using balanced crystalloid over normal saline
*Colloids no longer used in emergency med in the UK
Most common site of infection leading to sepsis?
Resp tract
Which antibiotics are used if meningococcal sepsis is suspected?
Hospital: IV ceftriaxone
Community: benzyl penicillin
How much crystalloid is given in sepsis before giving a vasopressor?
2-3L
Examples of vasopressors
- Norepinephrine
- Epinephrine
- Vasopressin (Vasostrict)
- Dopamine
- Phenylephrine
- Dobutamine
What is the qSOFA score?
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)
What is neutropenic sepsis?
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
