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3rd Year Infection > Sepsis and Septic Shock > Flashcards

Sepsis and Septic Shock Flashcards

1
Q

What is SIRS?

A

Temp high or low
HR >90
RR >20/PaCO2 <32
WBC >12000 or <4000

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2
Q

What is sepsis?

A

SIRS + Infection

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3
Q

What is severe sepsis?

A

Sepsis + end organ damage

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4
Q

What is septic shock?

A

Severe sepsis + Hypotension

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5
Q

How is sepsis defined?

A

Life-threatening organ dysfunction caused by dysregulated host-response to infection
SOFA score >2

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6
Q

A SOFA score >2 reflects what?

A

Overall mortality risk of 10%

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7
Q

How is septic shock defined?

A

Sepsis with persisting hypotension requiring vasopressors to maintain MAP >65mmHg
AND serum lactate >2mmol/l

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8
Q

What is the qSOFA definition of sepsis?

A

Systolic BP <100mmHg
Altered mental state
Tachypnoea >22/min

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9
Q

Survival in septic shock is inversely proportional to what?

A

Time taken to give antibiotics

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10
Q

How does septic shock mortality correlate with with delay in administration?

A

Each hour = 7.6% increase in mortality risk

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11
Q

What are the body’s defences against sepsis?

A

Physical barrier
Innate immune system
Adaptive immune system

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12
Q

What structures make up the physical barrier against sepsis?

A

Skin
Mucosa
Epithelial lining

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13
Q

What structures make up the

innate immune system against sepsis?

A

IgA in GIT

Dendritic cells/macrophages

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14
Q

What structures make up the

adaptive immune system against sepsis?

A

Lymphocytes

Immunoglobulins

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15
Q

What is the pathophysiology of sepsis?

A

Uncontrolled inflammatory response
Features consistent with immunosuppression
Probably change to sepsis syndrome

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16
Q

Why is sepsis said to have features consistent with immunosuppression?

A

Loss of delayed hypersensitivity
Inability to clear infection
Predisposition to nosocomial infection

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17
Q

What is the change of sepsis to sepsis syndrome?

A

Initial increase in inflammatory mediators

Later shift towards an anti-inflammatory immunosuppressive phase

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18
Q

The change to sepsis syndrome depends on what?

A

Health of the individual patient

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19
Q

What are the phases of sepsis pathogenesis?

A
  1. Release of bacterial toxins
  2. Release of mediators
  3. Effects of specific excessive mediators
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20
Q

What is the first phase of sepsis?

A

Release of bacterial toxins
Bacterial invasion into body tissues
May or may not be cleared by immune system

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21
Q

What are the commonly released toxins of gram -ve bacteria?

A

Lipopolysaccharide (LPS)

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22
Q

What are the commonly released toxins of gram +ve bacteria?

A

Microbial-associated molecular pattern (LTA)
(Lipoteichoic acid, Muramyl dipeptides)
Superantigens (TSST, streptococcal exotoxins)

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23
Q

What is the 2nd phase of sepsis?

A

Release of mediators in response to infection

Endo/exotoxin release effects

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24
Q

What is the effect of endotoxin release in sepsis?

A

LPS needs an LPS binding protein, LTA do not

These bind to macrophages and trigger mediator release

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25
Q

What is the effect of exotoxin release in sepsis?

A

Pro-inflammatory response

Small amount of superantigens release large amounts of mediators

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26
Q

What is the cascade effect of exotoxin release?

A

Small amount of superantigens release large amounts of mediators

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27
Q

Superantigens act on what?

A

T-lymphocytes

28
Q

When Superantigens act on T-lymphocytes, they release what?

A

IL-2

IFN-y

29
Q

IL-2 effects what?

A

Macrophage to release mediators

30
Q

IFN-y effects what?

A

Macrophage to release mediators

Endothelial cells to release NO

31
Q

What are the types of mediators released in sepsis?

A

Pro-inflammatory mediators

Compensatory anti-inflammatory reaction

32
Q

What can the Compensatory anti-inflammatory reaction cause?

A

Immunoparalysis

33
Q

What is stage 3 of sepsis?

A

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

34
Q

What are the effects of pro-inflammatory mediators?

A 
Promote endothelial cell-leukocyte adhesion
Release arachidonic acid metabolites
Activate complement
Vasodilation (NO)
Increase coagulation
Cause hyperthermia
35
Q

What are the effects of anti-inflammatory mediators?

A

Inhibit TNF alpha
Augment acute phase reaction
Inhibit activation of coagulation system
Provide negative feedback mechanisms

36
Q

What is septic shock?

A

Imbalance between pro-inflammatory mediators and anti-inflammatory mediators (too much pro-)

37
Q

What is immunoparalysis with uncontrolled infection?

A

Imbalance between pro-inflammatory mediators and anti-inflammatory mediators (too much anti-)

38
Q

The clinical manifestation of sepsis depends on what?

A

Host
Organism
Environment

39
Q

What are the neurological effects of sepsis-induced organ dysfunction?

A

Altered consciousness
Confusion
Psychosis

40
Q

What are the respiratory effects of sepsis-induced organ dysfunction?

A

Tachypnoea
Low PaO2
Reduced O2 saturation

41
Q

What are the hepatic effects of sepsis-induced organ dysfunction?

A

Jaundice
Increased liver enzymes
Low albumin
Increased INR

42
Q

What are the haematological effects of sepsis-induced organ dysfunction?

A

Decreased platelets
Decreased protein C
Increased D-dimer

43
Q

What are the cardiac effects of sepsis-induced organ dysfunction?

A

Tachycardia

Hypotension

44
Q

What are the renal effects of sepsis-induced organ dysfunction?

A

Oliguria
Anuria
Increased creatinine

45
Q

What are the general features of sepsis?

A 
Fever - chills/rigors/flushes
Hypothermia 
Tachycardia
Tachypnoea
Altered mental state - esp. elderly
Hyperglycaemia
46
Q

Hypothermia is a more common sepsis symptom in who?

A

Elderly
Very young
Immunosuppressed

47
Q

What inflammatory markers are changed in sepsis?

A

↑ or ↓ WCC (may be normal)
↑ CRP
↑ Procalcitonin

48
Q

What are the tissue perfusion variables in sepsis?

A

High lactate
Skin mottling
Reduced capillary perfusion

49
Q

What factors in the host can effect the presentation of sepsis?

A

Age
Co-morbidities
Immunosuppression
Previous surgery i.e splenectomy

50
Q

What are the main forms of immunosuppression?

A

Acquired
Drug induced
Congenital

51
Q

What are the common causes of Drug induced immunosuppression?

A

Steroids
Chemotherapeutic agents
Biologics

52
Q

What are the common causes of Congenital immunosuppression?

A

Agammaglobulinaemia
Phagocytic defects
Defects in complement

53
Q

What factors in the pathogen can effect the presentation of sepsis?

A

Gram +ve vs -ve
Virulence factors
Bioburden

54
Q

What are the Sepsis 6?

A

Take 3:Give 3
2As, 2Bs, 2Cs

Air enriched with O2
Antibiotics after blood culture
Blood culture
Blood gas + lactate
Crystalloid bolus (fluids)
Catheter if severe
55
Q

What is the diagnostic criteria for sepsis?

A 
Infection - documented and suspected plus some of:
General variables
Fever or Hypothermia 
Tachycardia
Tachypnea
Altered mental status
Significant edema or positive fluid balance
Hyperglycemia (in the absence of diabetes)
Inflammatory variables
Leukocytosis
Leukopenia 
Normal WBC count with greater than 10% immature forms
Elevated plasma CRP
Elevated procalcitonin
Hemodynamic variables
Arterial hypotension 
Organ dysfunction variables
Arterial hypoxemia 
Acute oliguria 
Creatinine increase 
Coagulation abnormalities 
Ileus
Thrombocytopenia
Elevated biliruben
Tissue perfusion variables
Hyperlactatemia
Decreased capillary refill
Mottling
56
Q

What does lactate tell us?

A

Marker of generalised hypoperfusion/severe sepsis

57
Q

What does oliguria tell us?

A

Renal dysfunction

58
Q

What do blood cultures tell us?

A

Microbiological diagnosis

59
Q

How should blood cultures be taken if theres a spike in temperature?

A

Take 2 sets

60
Q

What must be considered when giving antibiotics for sepsis?

A 
Working Dx
Guidelines 
Allergy
Previous infection
Consider toxicity/interactions
61
Q

What is type A lactate?

A

Hypoperfusion

62
Q

What is type B lactate?

A

Mitochondrial toxins
Alcohol
Malignancy
Metabolism errors

63
Q

What does lactate tell us about sepsis?

A

Prognostic indicator

64
Q

How should fluids be given in sepsis?

A

30ml/kg

65
Q

When should you consider a HDU referral?

A 
Low BP response to fluids
Lactate >2 despite fluids
Elevated creatinine
Oliguria
Liver dysfunction (Bilirubin, PT, Platelets)
Hypoxaemia
66
Q

When should you consider ITU?

A

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

3rd Year Infection (16 decks)

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