Sepsis

Question 1

Aerobic vs anerobic respiration

Answer 1

Aerobic:
Sufficient ATP for cell to function and survive
Waste products – water and CO2

Anaerobic respiration produces:
Much less ATP
Cell dysfunction or death
Waste products – water, CO2 and Lactic acid

Question 2

How to calculate blood pressure

Answer 2

Blood pressure = Cardiac Output (CO) x Peripheral Resistance (PR)

Question 3

compensatory mechanisms for low bp

Answer 3

If a drop in B.P. is detected the body will try to bring it back to normal by altering CO (^HR) and PR (vasoconstriction)

Question 4

SPECIFIC (Adaptive) IMMUNITY

Answer 4

Specific Antibodies

Question 5

NON SPECIFIC (Innate)IMMUNITY

Answer 5

White blood cells (leukocytes), lymphocytes, complement

Question 6

PHYSICAL / CHEMICAL BARRIER

Answer 6

Skin, Mucosa, Tonsils, Sweat, Tears

Question 7

what causes inflammation?

Answer 7

the release of cytokines (chemicals released by the immune system that have an affect on other cells)
- Cytokines include:
- Histamine from mast cells - powerful vasodilator
- Nitric oxide – powerful vasodilator
Tumour Necrosis Factor, Interleukin1 and many others

Vasoldilation
- Also triggers change in core temperature – pyrexia or
hypothermia

Question 8

Describe the process of sepsis

Answer 8

In Sepsis release of pro-inflammatory cytokines systemically (throughout the body) – which cause:

Systemic Vasodilation:
- drop in Peripheral Vasc. Resistance = drop in B.P.
- Compensatory mechanisms fail (Angtiotension II &
Noradrenaline)
- Causes blood vessels to become leaky
- Causes widespread oedema
- Fluid from oedema comes from systemic circulation
= relative hypovolaemia

Question 9

Drop in B.P. (if not managed) causes

Answer 9

Anaerobic respiration from hypoxaemia -> Mitochonrial dysfunction

Lactic acid production = Metabolic Acidosis

Metabolic Acidosis – leads to cell death and further inflammatory reaction

Question 10

A-E assessment of sepsis pt

sepsis risk assesment

Answer 10

A- make sure airway is patent

B- 21 – 24 = Moderate risk
>24 = High risk
Or new need for >40% oxygen to maintain SaO2 more than 92% = High risk

C- HR
91 – 130 = Moderate risk
>131 = High risk

Systolic B.P.
91 – 100 = Moderate risk
<90mmHg = High Risk

Not passed urine in past 12 – 18 hours = Moderate risk
Not passed urine > 18hrs = High risk

D- GCS< 15 (of new onset)

E/F -
Raised white cell count

Temp - Pyrexia>38C or Hypothermia <36 C = Moderate Risk

Mottled / ashen appearance / non blanching rash = High Risk

Signs of infection – redness / swelling / discharge

Cyanosis = High Risk

Question 11

What groups are at high risk of sepsis

- name at least 3

Answer 11

Infants (under 1 year)

Elderly (over 75 years)

Impaired immune system:
- Cancer patients – active treatment
- Immuno-therapy – organ transplant or rheumatoid
arthritis

AIDS

Diabetes Mellitis

Recent surgery (less than 6 weeks)

Pregnancy, recent birth / termination / miscarriage (within 6 weeks)

Any breach of the skin

IV drug users

Indwelling lines or catheters

Question 12

Describe the steps of the sepsis care bundle

Answer 12

Within first hour of arrival:
Measure lactate – remeasure if >2mmol/l

Obtain blood cultures before administering antibiotics

Administer broad spectrum antibiotics

Rapid administration 30ml/kg crystalloid fluid if hypotensive / Lactate > 4mmol/l

Give vasopressors if hypotensive during or after fluid – keep MAP >65mmHg

Question 13

Priorities of care of the sepsis pt (A+B)

Answer 13

Airway
 Ensure patency (esp. GCS< 8)

Breathing
Maintain SaO2 > 94% (88-92% in COPD)

Consider if cause of infection is respiratory e.g.
pneumonia

May require ventilation

Question 14

Priorities of care of the sepsis pt (c)

Answer 14

Maintain systolic B.P. >90mmHg

IV fluid resuscitation if hypotensive – 30ml/kg OR / AND Lactate >4mmol/litre

May require IV vasopressors if hypotensive despite fluids

Question 15

Name and describe 4 vasopressors a pt might receive if they are still hypotensive despite IVT

Answer 15

Adrenaline – increases force of myocardial contraction, heart rate and peripheral resistance (vaso-constrict)

Noradrenaline – increases heart rate and increases peripheral resistance

Dopamine – increases heart rate and increases peripheral resistance

Dobutamine – stimulates beta 1 adrenergic receptors in heart – increases force of myocardial contraction and heart rate

Question 16

Priorities of care of the sepsis pt (D)

Answer 16

Decreased GCS = risk to airway

Determine the cause of altered conscious state:

Question 17

What are some causes of an altered mental state

Answer 17

BGL?
Trauma?
Stroke?
Hypoxia?
Hypotension?
Toxins?
Medication?

Question 18

Priorities of care of the sepsis pt (E)

Answer 18

Rashes may not appear OR may be a very late sign

Log roll patient and expose all of patient – check skin folds, soles of feet

Monitor temperature – may be hyperthermic – BUT – could also be hypothermic

Question 19

how does low bp relate to a build up of waste products and associated complications

Answer 19

low perfusion -> anaerobic respiration -> increased buildup of waste products -> low perfusion also inhibits waste removal and lactic acid starts to build up in the kidneys -> AKI and acidosis

Question 20

Sepsis causes _____ acidosis

Answer 20

metabolic

due to the build-up of lactic acid

Question 21

what requirements are needed of the

• blood
• vessels
• heart

to maintain Bp and homeostasis

Answer 21

• blood: enough volume, needs to have the right components
• vessels: intact, sight size
• heart: contraction, rate

Question 22

mast cell purpose

Answer 22

trigger inflammation by releasing histamine, heparin

Question 23

What is the normal range for lactate

Answer 23

<2mmol/L

Question 24

why do you not give vasopressor infusions via a peripheral line?

(typically given through a central line)

Answer 24

Vasopressors cause vasoconstriction, if an IV infusion is running over an extended period of time this can lead to ischemia

Question 25

how soon should the sepsis care bundle be completed

Answer 25

within one hour of arrival