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Infection > Sepsis and Septic Shock > Flashcards

Sepsis and Septic Shock Flashcards

1
Q

Sepsis definition [2]

A
  • Life threatening organ dysfunction

- Caused by a dysregulated host response to infection

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2
Q

What defines septic shock in the model? [2]

A
  • severe sepsis and hypotension
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3
Q

Clinical definition of septic shock [2]

What is hospital mortality of patients with septic shock?

A

Criteria of septic shock:

> > persisting hypotension requiring vasopressors to maintain MAP >65mmHg

> > serum lactate of 2mmol/l despite adequate vol resus

Hospital mortality of 40%

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4
Q

What 3 criteria constitute qSOFA?

How many criteria is associated with greater risk of poor outcome?

A

> > Hypotension systolic BP <100 mmHg
altered mental status - confusion
Tachypnoea RR >22/min

  • at least 2 suggests greater risk of poorer outcome)
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5
Q

Why is quick intervention key in sepsis?

A

Chance of mortality increases with each hour of delay of antibiotic administering

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6
Q

What intervention is key in reducing sepsis associated mortality and cost? [6]

A 
SEPSIS 6
Give 3
Oxygen
IV Ab
IV fluid challenge

Take 3
Bloods
Lactate
Urine output

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7
Q

What is the bodys defences against sepsis?

3 main headings

A

> Physical barrier: skin, mucosa, epithelial lining

> innate immune system: IgA in GI tract, dendritic cells/macrophages

> adaptive immune system - lymphocytes, immunoglobulins

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8
Q

Pathophysiology of sepsis [4]

A

Sepsis originates from breach of host barrier.
Organism enters bloodstream creating septic state
»uncontrolled inflammatory response
»immunosuppression features (loss of delayed hypersensitivity/unable to clear infection/predisposed to nosocomial infection)
»Likely change of sepsis syndrome over time
(initial inc. in inflammatory mediators. Later shift towards anti-inflam immunosuppressive phase. Depends on patient health)

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9
Q

What are the 3 phases in pathogenesis of sepsis?

A
  1. release of bacterial toxins
  2. release of mediators
  3. effects of specific excessive mediators
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10
Q

Discuss phase 1: release of bacterial toxins?
Define [1]
Name commonly released toxins by gram +ve [1] bacteria
Name 2 commonly released toxins by gram -ve bacteria

A

-bacterial invasion into body tissues is source of dangerous toxins
-commonly released toxins:
>gram +ve (lipopolysaccharide)
>gram -ve (MAMP, superantigens)

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11
Q

Discuss phase 2: release of mediators in response to infection?
Endotoxin vs Exotoxin release

A

Effects of infections due to endotoxin release
>LPS needs LPS-binding protein to bind to macrophages. LTA doesnt need a protein

Effects of infections due to exotoxin release
>pro-inflammatory response
>small amount of superantigens will cause lots of mediators to be secreted (cascade effect)

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12
Q

Discuss phase 3: effects of specific excessive mediators?
Name 6 effects of pro-inflammatory mediators
Name 4 effects of anti-inflammatory mediators

A

Pro-inflammatory mediators

  • promote endothelial cell (leukocyte adhesion)
  • release of arachidonic acid metabolites
  • complement activation
  • vasodilation of blood vessels by NO
  • inc coagulation by release of tissue factors and membrane coagulants
  • cause hyperthermia

Anti-inflammatory mediators

  • Inhibit TNF alpha
  • augment acute phase reaction
  • inhibit activation of coagulation
  • provide negative feedback mechanisms to pro-inflammatory mediators
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13
Q

What can over production of pro-inflammatory mediators lead to?

A

septic shock with multi organ failure and death

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14
Q

What can over production of anti-inflammatory mediators lead to? [2]

A
  • Immunoparalysis with uncontrolled infection

- multi organ failure

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15
Q

What are some general features of sepsis? [6]

A
  • Fever >38 degrees (chills, rigors, flushes, cold sweats)
  • Hypothermia <36 degrees (esp in elderly/young/immunosuppressed)
  • Tachycardia >90bpm
  • Tachynpoea >20 breaths/min
  • altered mental status (esp in elderly)
  • Hyperglycaemia >8mmol/l in absence of diabetes
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16
Q

What are inflammatory variables in sepsis? [5]

A
  • Leucocytosis (WCC>12000/ml)
  • Leucopenia (WCC<4000/ml)
  • Normal WCC with >10% immature forms
  • high CRP
  • High calcitonin
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17
Q

What are some haemodynamic variables in sepsis? (3)

A
  • Arterial hypotension (systolic <90mmHg or MAP <70mmHg)

- SvO2 >70%

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18
Q

What are some organ dysfunction variables in sepsis? (7)

A
  • Arterial hypoxaemia (PaO2 <50mmHg)
  • Oliguria (<0.5ml/kg/h)
  • creatinine inc compared to baseline
  • coag. abnormalities (PT>1.5/APTT>60s)
  • Ileus
  • Thrombocytopenia (<150000/ml
  • Hyperbilirubinaemia
19
Q

Tissue perfusion variables in sepsis:

What are 3 indicators of tissue hypo perfusion?

A
  • High lactate
  • Skin mottling
  • Reduced capillary perfusion
20
Q

What can affect sepsis presentation in a host? [6]

A
  • Age
  • Co-morbidities (COPD, DM etc)
  • Immunosuppression (acquired - HIV/AIDS.
  • Drug induced - steroids/chemo/biologics. Congenital
  • Previous surgery - splenectomy
21
Q

Type of bacteria if infection is above/below diaphragm? [2]

A
  • Gram positive (infections above diaphragm)

- Gram negative (infections below diaphragm)

22
Q

Patient presents with fever nausea, vomiting, abdominal pain. Other than sepsis what could the diagnosis be?

A

Acute pancreatitis

23
Q

What is the SEPSIS6? (remember: take 3 give 3)

A

Take:

  • blood cultures
  • blood lactate
  • measure urine output

Give:

  • Oxygen aim sats 94-98%
  • IV antibiotics
  • IV fluid challenge
24
Q

Details of SEPSIS 6

  • blood cultures [2]
  • blood lactate [1]
  • low urine output [1]
A

Blood cultures

  • If suspected IE, take 3 sets
  • if temp spike take 2 sets

Blood lactate
-marker of generalised hypoperfusion, severe sepsis, poorer prognosis

Low urine output
-marker of renal dysfunction

25
Q

How do you determine what antibiotics to give patient? [1] and what must you consider? [3]

A
  • Based on working diagnosis from Hx +Exam
  • Local antibiotic guidelines

Consider

  • allergy
  • previous MRSA, ESBL, CPE
  • Abx toxicity/interactions
26
Q

What do Type A [1] and B [4] lactate biomarkers indicate?

A 
Type A: hypoperfusion
Type B: 
mitochondrial toxins
alcohol
malignancy
metabolism errors
27
Q

What is the volume of IV fluids given for a fluid challenge?

A

30ml/kg fluid challenge (so 2.1L for 70kg patient)

28
Q

When do you consider HDU referral? [6]

A
  • low bp responsive to fluids
  • lactate >2 despite fluid resus
  • elevated creatinine
  • oliguria
  • liver dysfunction, bilirubin, PT, platelet count
  • bilateral infiltrates, hypoxaemia
29
Q

When do you consider ITU? [3]

A
  • Septic shock
  • multi organ failure
  • needs sedation, intubation and ventilation
30
Q

What is defined as organ dysfunction according to the SOFA score?

A

Organ dysfunction identified as an acute change in total SOFA score >2 points

31
Q

What does the SOFA score tell us in terms of mortality rest?

A

> > SOFA score >2 reflects overall mortality risk of approx 10% in general hospital population with suspected infection

32
Q

What are 2 MAMP toxins

A

LTA

Muramyl dipeptides

33
Q

What are 2 super antigen toxins

A

Staphylococcal toxic shock syndrome toxin

Streptococcal exotoxins

34
Q

With regards to phase 2 of sepsis pathogenesis:
What are the 2 types of mediators that can be released
Which ones are associated with pro-inflammatory and anti-inflammatory response

A

Mediator role on sepsis
>two types of mediators can be released: TH1 and TH2
>TH1: pro-inflammatory mediators causes inflammatory response that characterises sepsis
>TH2: compensatory anti-inflammatory reaction can cause immunoparalysis

35
Q

What are 2 signs of the end point of a fluid challenge

A

MAP > 65mm Hg

HR <110 BPM

36
Q

What 2 congenital problems can affect sepsis presentation in a host?

A

agammaglobulinaemia/phagocytic defects)

37
Q

SOFA

A

Sequential organ failure assessment

38
Q

Investigation
Bloods [6]
Other investigations [2]

A

Bloods:
- VBG (glucose and lactate), FBC, CRP, U&E and creatinine, clotting

Other ix:
- urinalysis and CXR

39
Q

Red flag criteria [9]

A
  • Responds to only voice or pain or unresponsive
  • Acute confusional state
  • SBP <90 or drop >40 from normal
  • HR >130bpm
  • Needs oxygen to keep >92%
  • Non-blanching rash, mottled, ashen, cyanotic
  • Failure to pass urine in last 18h or urine output <0.5ml/kg/h
  • Lactate >2 mmol/L
  • Recent chemo
40
Q

Amber flag criteria [10]

A
  • Relatives concern about mental status
  • Acute deterioration in functional ability
  • Immunosuppresson
  • Trauma or surgical procedure in last 6w
  • RR 21-24
  • BP 90-100mmHg
  • HR 91-130 or new arrhythmia
  • Failure to pass urine in last 12-18h
  • Temperature <36
  • Clinical signs of wound, device or skin infection
41
Q

Management of sepsis by HDU or critical care team [6]

A
  • Glycaemic control
  • Vasopressors or inotropes
  • Corticosteroids
  • DVT prophylaxis
  • Nutrition
  • Blood transfusion
42
Q

Management of sepsis source unknown [3]

If penicillin allergy or known MRSA? [3]

A
  • Amoxicillin 1g 8hrly IV
    + Gentamicin
    +/- Metronidazole 500mg 8hrly IV (if anaerobic cover rqd)
  • Gentamicin
    + Vancomycin
    +/- Metronidazole 500mg 8hrly IV
43
Q

Bacterial sepsis causative organisms [5]

A

Gram positive:

  • Staph aureus
  • Strep pneumonia

Gram negative:

  • E. Coli
  • Kleb spp
  • Pseudomonas aeruginosa

Infection (20 decks)

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