Sepsis and Septic Shock

Question 1

What is sepsis?

Answer 1

Systemic illness caused by microbial invasion of normally sterile parts of the body?

Question 2

What is SIRS?

Answer 2

Systemic inflammatory response syndrome

Question 3

What is septic shock?

Answer 3

Clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain MAP >65 and having a serum lactate of >2mmol/L despite adequate resuscitation

Question 4

What are the features of the qSOFA score?

Answer 4

Hypotension systolic BP <100mmHg
Altered mental state
Tachypoea RR>22/min

Question 5

What qSOFA score suggests a greater risk of a poor outcome?

Answer 5

More than or equal to 2

Question 6

What are the body’s physical defences agains sepsis?

Answer 6

Skin
Mucosa
Epithelial lining

Question 7

How does the body’s innate immune system defend against sepsis?

Answer 7

IgA in gastrointestinal tract
Dendritic cells
Macrophages

Question 8

How does the body’s adaptive immune system defend against sepsis?

Answer 8

Lymphocytes

Immunoglobulins

Question 9

What are the 3 stages of the pathogenesis of sepsis?

Answer 9

Release of bacterial toxins
Release of mediators
Effects of specific excessive mediators

Question 10

What are the commonly released bacterial toxins during the 1st stage?

Answer 10

Lipopolysaccharide (gram +)
Microbial associated molecular pattern (gram -)
Superantigens

Question 11

What are the 2 types of mediators that are released in the 2nd stage?

Answer 11

Pro-inflammaatory mediators

Compensatory anti-inflammatory reaction

Question 12

What do pro-inflammatory mediators cause?

Answer 12

Inflammatory response that characterises sepsis

Question 13

What does the compensatory anti-inflammatory reaction cause?

Answer 13

Immunoparalysis

Question 14

What are the effects of the pro-inflammatory mediators?

Answer 14

Promote endothelial cell-leukocyte adhesion 
Release of arachidonic acid metabolites 
Vasodilation of blood vessels by NO 
Increase coagulation 
Cause hyperthermia

Question 15

What are the effects of the anti-inflammatory mediators?

Answer 15

Inhibit TNF alpha
Augment acute phase reaction
Inhibit activation of coagulation system
Provide negative feedback mechanism to pro-inflammatory mediators

Question 16

What are the general features of sepsis?

Answer 16

Fever >38 c (presents as chill, riggers, flushes, cold sweats, night sweats) 
Hypothermia <36 c 
Tachycardia >90bpm 
Tachypnoea >20/ min 
Altered mental state 
Hyperglycaemia >8mmol/L

Question 17

What are the inflammatory variable in sepsis?

Answer 17

Leucocytosis (WCC>12000/ml) 
Leucopenia (WCC<4000/ml) 
Normal WCC with more than 10% immature forms 
High CRP 
High procalcitonin

Question 18

What are the haemodynamic variables in sepsis?

Answer 18

Arterial hypotension (systolic <90mmHgor MAP <70mmHg) 
SvO2> 70%

Question 19

What are the organ function variables in sepsis?

Answer 19

Arterial hypoxaemia (PaO2/FiO2 <50mmHg)
Oliguria (0.5ml/kg/h)
Creatinine increase compared to baseline
Coagulation abnormalities (PT>1.5 or APTT>60s)
Ileus
Thrombocytopenia (<150000/ml)
Hyperbilirubinaemia

Question 20

What are the tissue perfusion variables in sepsis?

Answer 20

High lactate
Skin mottling
Reduced capillary perfusion

Question 21

What effect can the host have on the presentation of sepsis?

Answer 21

Age
Immunosuppression
Splenectomy

Question 22

What is the sepsis 6?

Answer 22

Blood cultures
Blood lactate
Measure urine output (Take 3)

Oxygen aim sats 94-98%
IV antibiotics
IV fluid challenge (Give 3)

Question 23

What is type A lactate caused by?

Answer 23

Hypoperfusion

Question 24

What is type B lactate caused by?

Answer 24

Mitochondrial toxins
Alcohol
Malignancy
Metabolism errors

Question 25

How much fluid should be given for sepsis?

Answer 25

30ml/kg

Question 26

When should you consider HDU referral?

Answer 26

Low BP responsive to fluids 
Lactate >2 despite fluid resuscitation 
Elevated creatinine 
Oliguria 
Liver dysfunction 
Bilateral infiltrates, hypoxaemia

Question 27

When should you consider ITU referral?

Answer 27

Septic shock
Multi-organ failure
Requires sedation, intubation, ventilation