Sepsis and Septic Shock

Question 1

What is the definition of sepsis according to the Sepsis-3 guidelines?

Answer 1

Sepsis = SIRS + Infection

Question 2

What is the definition of septic shock according to the Sepsis-3 guidelines?

Answer 2

Septic shock = severe sepsis + hypotension

Question 3

What is the mortality rate of hospital patients with septic shock?

Answer 3

40%

Question 4

Why is it so important to administer antibiotics quickly in septic shock?

Answer 4

For every hour’s delay in administering antibitoics, mortality increases by 7.6%

Question 5

What are the components of qSOFA score?

Answer 5

Hypotension - Systolic BP < 100

Altered mental status - GCS < 15

Tachypnoea - RR > 22

Question 6

What qSOFA score indicates that a patient is likely to have a poor outcome and a prolonged ICU stay?

Answer 6

qSOFA > or = 2

Question 7

What is the pathophysiology of sepsis?

Answer 7

1 - Breach of integrity of host barrier, either physical or immunological

2 - Organism enters the bloodstream creating a septic state

3 - Septic state creates an uncontrolled inflammatory response

Question 8

What are the phases in the pathogenesis of sepsis?

Answer 8

1 - Release of toxins

2 - Release of mediators

3 - Effects of specific excessive mediators (pro-inflammatory and compensatory anti-inflammatory mediators)

Question 9

What are the effects of pro-inflammatory mediators?

Answer 9

• Leukocyte adhesion
• Release of arachidonic acid metabolites
• Relase of cytokines
• Vasodilation of blood vessels
• Increased coagultation due to release of tissue factors and membrane coagulants
• Cause hyperthermia (caused by TNF-alpha)

Question 10

What are the effects of anti-inflammatory mediators?

Answer 10

• Inhibit TNF alpha
• Augment acute phase reaction
• Inhibit coagulation system
• Provides a negative feedback to pro-inflammatory mediators

Question 11

In septic shock, what is the balance between pro-inflammatory and anti-inflammatory mediators?

Answer 11

There is a higher volume of pro-inflammatory mediators compared to the anti-inflammatory mediators

Question 12

What is the clinical presentation of sepsis?

Answer 12

• Fever (>38c)
• Hypothermia (<36c)
• Altered mental status (especially in elderly)
• Tachypnoea (>20/min)
• Oxygen sats <90%
• Tachycardia (>90bpm)
• Hypotension
• Decreased urine output
• Hyperglycaemia (in absence of diabetes)
• High serum lactate

Question 13

What factors can affect the signs and symptoms of sepsis?

Answer 13

• Host (age, co-morbidities, immunosuppression, previous surgery - splenectomy)
• Infecting organism (infection above diaphragm most likely gram +ve, below diaphragm most likely gram -ve)
• Environment (occupation, travel, hospitalisation)

Question 14

How is sepsis managed according to the Sepsis 6?

Answer 14

Take 3:

• Blood culture
• Urine output
• Serum lactate levels

Give 3:

• Oxygen (aim for 94-98% sat)
• IV Antibiotics
• IV fluids

Question 15

What is the importance of the individual components of the sepsis 6?

Answer 15

Blood cultures - to know what the infecting organism is so antibiotic therapy is correct (if high temp take 2 sets)

Lactate - A marker of generalised hypoperfusion and poorer patient outcomes (>4)

Urine output - marker of renal dysfunction

IV Fluids - to restore perfusion pressure

Question 16

A qSOFA score greater than what indicates poor outcomes and organ dysfunction?

Answer 16

2

Question 17

What criteria are used to indicate if a patient has SIRS?

Answer 17

Temperature > 38 OR < 36

HR > 90

RR > 20

PaCO2 < 32

WCC >12,000 OR <4,000

Question 18

What is the definition of severe sepsis?

Answer 18

Sepsis + end organ damage