Sepsis and Septic Shock

Question 1

What is sepsis?

Answer 1

A systemic illness caused by bacterial infection of normally sterile parts of the body; characterised by SIRS + Infection.

Question 2

What is SIRS?

Systemic Inflammatory Response Syndrome

Answer 2

An inflammatory response to a number of things including infection, exercise, trauma, burns;

• Hyperthermia or Hypothermia
• Tachycardia
• Tachypnoea
• PaCO2 <32
• High or low WCC

Question 3

What are the 2 classifications of sepsis?

Answer 3

Sepsis - the organ dysfunction caused by the body’s dysregulated response to infection. Define by SOFA score.

Septic Shock - sepsis has progressed to persisting hypotension requiring vasopressors and having a serum lactate >2mmol/l

Question 4

What is the hospital mortality rate of septic shock?

Answer 4

40%

Question 5

What does the qSOFA score tell you?

Answer 5

Prognosis in sepsis quickly - likelihood of prolonged ICU stay or death.

Question 6

What 3 factors are looked at in the qSOFA score?

Answer 6

1. Hypotension <100 mmHg
2. Altered Mental State
3. Tachypnoea - RR >22 /min

Question 7

What percentage of patients in the acute setting will have some form of sepsis?

Answer 7

30%

ropey one

Question 8

How does sepsis compare in terms of annual deaths?

Answer 8

Behind stroke and CHD but ahead of lung cancer, bowel cancer and breast cancer

Question 9

What is the relationship between sepsis survival and delay of antibiotic treatment?

Answer 9

For each hour delay; mortality increases by 7.6%

TIME IS LIFE

Question 10

What 3 broad barriers must bacteria evade to cause sepsis?

Answer 10

Physical barrier
Innate immunity (IgA in GIT, dendritic cells/macrophages)
Adaptive immunity (lymphocytes and immunoglobulins)

Question 11

What are the 3 phases of sepsis pathogenesis?

Answer 11

1. Release of bacterial toxins
2. Release of mediators
3. Effects of specific excessive mediators

Question 12

What are some commonly released bacterial toxins?

Answer 12

Endotoxins and Exotoxins

Gram negative: Lipopolysaccharide (LPS) (endotoxin)

Gram positive:

• Microbial Associated Molecular Pattern (MAMP) (endotoxin)
• Superantigens (exotoxin)

(Lecture was wrong - check the diagrams)

Question 13

What are the two types of mediators released in sepsis?

Answer 13

Th1 - produce pro-inflammatory mediators

Th2 - compensatory anti-inflammatory

Question 14

What is the balance of immune mediators in septic shock and immunoparalysis?

Answer 14

Septic shock - pro>anti

Immunoparalysis - anti>pro

Question 15

What are the general features of sepsis?

Answer 15

• Fever or Hypothermia
• Tachycardia
• Tachypnoea
• Altered mental state
• Hyperglycaemia in absence of DM
• Thrombocytopaenia (low platelets)
• Oliguria
• Jaundice
• Ileus
• Hypoxia

Question 16

What inflammatory signs may be seen in sepsis?

Answer 16

• Leucocytosis or leucopenia
• Immature white cells
• High CRP
• High procalcitonin

Question 17

What haemodynamic features may be seen in sepsis?

Answer 17

Hypotension and SvO2>70%

Question 18

What variables would we look at to tell tissue perfusion in sepsis?

Answer 18

LACTATE - high

Skin mottling and reduced capillary perfusion

Question 19

What is the split of where bacteria tend to cause infection?

Answer 19

Gram Positive - above diaphragm

Gram Negative - below diaphragm

Question 20

What are the Sepsis 6?

Answer 20

Take 3: Give 3

Take:

• Blood Culture
• Blood Lactate (blood gas - look at type A)
• Urine output (catheter)

Give:
- Oxygen - Sats 94-98% (or 88-92 in COPD)
- IV Abx
IV Fluid (crystalloid)

Question 21

How many sets of cultures do you take if you are thinking endocarditis?

Answer 21

3

Question 22

When giving fluids in sepsis what else might you consider?

Answer 22

Stop any antihypertensives temporarily

Question 23

When would you think about referring to HDU or ITU?

Answer 23

• HDU - single organ failure, low BP response to fluid

- ITU - septic shock and multiorgan failure (intubation, sedation, ventilation)