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Infection > Sepsis and Septic Shock > Flashcards

Sepsis and Septic Shock Flashcards

1
Q

What is sepsis?

A

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

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2
Q

What are the features of systemic inflammatory response syndrome?

A 
Temperature > 38 or < 36 degrees celsius 
Heart rate > 90 
Respiratory rate > 20 
PaCO2 < 32 
WBC > 12,000 or < 4,000 or > 10% bands
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3
Q

What are the characteristics of severe sepsis?

A

Sepsis and end organ damage

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4
Q

What are the characteristics of septic shock?

A

Severe sepsis and hypotension

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5
Q

When should systemic inflammatory response syndrome (SIRS) be considered to be serious?

A

If there are signs of infection - SIRS occurs in many situations as a normal physiological response

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6
Q

What is sepsis 3?

A

The third international consensus definition for sepsis and septic shock

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7
Q

How is sepsis defined by sepsis 3?

A

Life-threatening organ dysfunction caused by a dysregulated host response to infection

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8
Q

How is organ dysfunction defined?

A

Acute change in total SOFA score > 2 points, consequent to the infection

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9
Q

What does a SOFA score > 2 reflect?

A

Overall mortality risk of approximately 10% in a general hospital population with suspected infection

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10
Q

How is septic shock defined by sepsis 3?

A

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

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11
Q

What is the hospital mortality of patients with septic shock?

A

40%

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12
Q

What effect does sepsis have on morbidity and mortality?

A

Both are increased

For each hours delay in administering antibiotics in septic shock, mortality increased by 7.6%

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13
Q

What is the SOFA score?

A

Sequential Organ Failure Assessment score

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14
Q

When might qSOFA be used?

A

To promptly identify patients with suspected infection who are likely to have a prolonged ICU stay or die in the hospital

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15
Q

Features of qSOFA

A

Hypotension systolic BP < 100mmHg
Altered mental status
Tachypnoea with respiratory rate > 33/min

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16
Q

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

A

2 or more

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17
Q

What are the bodies defences against sepsis?

A

Physical barrier - skin, mucosa, epithelial linings
Innate immune system - IgA, dendritic cells, macrophages
Adaptive immune system - lymphocytes, immunoglobulins

Pathogens can’t cause infection without first invading through these defences

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18
Q

Pathophysiology of sepsis

A

Uncontrolled inflammatory response
Loss of delayed hypersensitivity
Inability to clear infection

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19
Q

What is the change of the sepsis syndrome over time?

A

Initial increase in inflammatory mediators

Later, shift towards anti-inflammatory immunosuppressive phase

20
Q

What are the phases in the pathogenesis of sepsis?

A

Release of bacterial toxins
Release of mediators
Effects of specific mediators

21
Q

Features of phase 1 of sepsis

A

Bacterial invasion into the body, source of toxins

Commonly gram negative or gram positive toxins

22
Q

Features of phase 2 of sepsis

A

Effects of infections due to endotoxin release
Effects of infections due to exotoxin release
Mediator role on sepsis

23
Q

Features of exotoxin release in sepsis

A

Pro-inflammatory response

Small amounts of super-antigens cause a large amount of mediators to be secreted, resulting in a cascade effect

24
Q

What types of mediators are released in sepsis?

A

Pro-inflammatory (cause inflammatory response that characterises sepsis)
Compensatory anti-inflammatory (can cause immunoparalysis)

25
Q

Effects of pro-inflammatory mediators in phase 3 of sepsis

A

Pro-inflammatory mediators

  • promote endothelial cell-leucocyte adhesion
  • release arachidonic acid metabolites
  • complement activation
  • vasodilation of blood vessels by NO
  • increased coagulation by release of tissue factors and membrane coagulants
  • causes hyperthermia
26
Q

Effects of anti-inflammatory mediators in phase 3 of sepsis

A

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

27
Q

Clinical features of sepsis and septic shock depend on what factors?

A

Host
Organism
Environment

28
Q

Clinical features of organ dysfunction due to sepsis/septic shock

A 
Altered consciousness, confusion, psychosis 
Tachypnoea (PaO2 < 70mmHg, sats < 90%) 
Jaundice 
Decreased platelets 
Increased PT/APTT 
Decreased protein C 
Increased D-dimer 
Tachycardia 
Hypotension 
Oliguria, anuria 
Increased creatinine
29
Q

General features of sepsis/septic shock

A 
Fever > 38 - chills, rigors, flushes, cold sweats, night sweats 
Hypothermia < 36 
Tachycardia > 90bpm 
Tachypnoea > 20/min 
Altered mental status 
Hyperglycaemia
30
Q

Inflammatory variables in sepsis/septic shock

A 
Leucocytosis 
Leucopenia 
Normal WCC with > 10% immature forms 
High CRP 
High procalcitonin
31
Q

Haemodynamic variables in sepsis/septic shock

A

Arterial hypotension

SvO2 > 70%

32
Q

Organ dysfunction variables in sepsis/septic shock

A 
Arterial hypoxaemia 
Oliguria 
Creatinine increased 
Coagulation abnormalities 
Thrombocytopenia 
Hyperbilirubinaemia
33
Q

Tissue perfusion variables in sepsis/septic shock

A

High lactate

Skin mottling and reduced capillary perfusion

34
Q

Host features which can affect sepsis presentation

A

Age
Co-morbidities
Immunosuppression
Previous surgery

35
Q

Organism features which can affect sepsis presentation

A

Gram positive vs gram negative
Virulence factors
Bioburden

36
Q

Features of environment which can affect sepsis presentation

A

Occupation e.g. farming, exposed to uncommon infections
Travel e.g. malaria
Hospitalisation

37
Q

Features of sepsis 6

A 
Air enriched with O2 
Antibiotics after blood culture 
Blood culture 
Blood gas with lactate 
Crystalloid Bolus 
Catheter if severe sepsis or septic shock
38
Q

Oxygen aim in sepsis

A

Saturation 94-98%

39
Q

Blood cultures in sepsis

A

Make microbiological diagnosis
30-50% positive
2 sets should be taken if there is a spike in temperature

40
Q

What is lactate a marker of in sepsis?

A

Generalised hypoperfusion
Severe sepsis
Poor prognosis

41
Q

What is low urine output a marker of in sepsis?

A

Renal dysfunction

42
Q

IV fluids in sepsis

A

30ml/kg fluid challenge e.g. 2.1L for 70kg patient

43
Q

When should HDU referral be considered?

A 
Low BP responsive to fluids 
Lactate > 2 despite fluid resuscitation 
Elevated creatinine 
Oliguria 
Liver dysfunction 
Bilateral infiltrates
Hypoxaemia
44
Q

When should ITU referral be considered?

A

Septic shock
Multi-organ failure
If patient requires sedation, intubation and ventilation

45
Q

Factors to consider regarding antibiotic treatment of sepsis

A 
Working diagnosis from history and examination 
Local antibiotic guidelines 
Allergy 
Previous MRSA, ESBL or CPE 
Antibiotic toxicity and interaction
46
Q

What are the commonly released toxins?

A

Gram positive
- lipopolysaccharides

Gram negative

  • Microbial associated molecular pattern (MAMP) - lipoteichoic acid, muramyl dipeptides
  • Superantigens - staphylococcal toxic shock syndrome toxin, streptococcal exotoxins
47
Q

What is the difference between LPS and LTA in endotoxin release?

A

LPS needs an LPS-binding protein to bind to macrophages, LTA do not need such proteins

Infection (14 decks)

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