Sepsis and septic shock

Question 1

How is sepsis defined?

Answer 1

Life threatening organ dysfunction caused by dysregulated host response to infection

Question 2

How is organ dysfunction graded in sepsis?

Answer 2

SOFA score

Question 3

What SOFA score identifies sepsis?

Answer 3

> 2 consequent to infection

Question 4

What is septic shock?

Answer 4

Sepsis with persisting hypotension requiring vasopressors to maintain MAP of over >65mmHg with serum lactate >2mmol/l despite adequate volume resus

Question 5

What are the criteria in qSOFA?

Answer 5

Hypotension - Systolic BP<100
Altered mental status - GCS<15
Tachypnoea - RR>22

Question 6

What does qSOFA stand for?

Answer 6

Quick Sequential Organ Failure Assessment

Question 7

What physical barrier does the body have against sepsis?

Answer 7

Skin
Mucosa
Epithelial lining

Question 8

How does the innate immune system protect the body from sepsis?

Answer 8

IgA in GI tract
Dendritic cells
Macrophages

Question 9

How does sepsis originate?

Answer 9

Breach of integrity of host barrier - physical or immunological
Organism enters the blood stream

Question 10

What is the pathophysiology of sepsis?

Answer 10

Uncontrolled inflammatory response
Features consistent with immunosuppression - loss of delayed hypersensitivity, inability to clear infection, predisposition to nosocomial infection

Question 11

What are the three phases in sepsis pathogenesis?

Answer 11

Release of bacterial toxins
Release of mediators
Effects of specific excessive mediators

Question 12

What are common toxins released by bacteria in sepsis?

Answer 12

Gram negative - Lipopolysaccharide
Gram positive - Microbial-associated molecular pattern
Superantigens

Question 13

What are examples of superantigens?

Answer 13

Staphylococcal toxic shock syndrome toxin

Streptococcal exotoxins

Question 14

What happens as a result of exotoxin release?

Answer 14

Pro-inflammatory response - small amounts of superantigens cause a large amount of mediators to be secreted

Question 15

What are the 2 types of mediators?

Answer 15

Pro-inflammatory

Anti-inflammatory

Question 16

What effects does excessive pro-inflammatory mediators have?

Answer 16

Promote endothelial cell - leukocyte adhesion
Release arachidonic acid metabolites
Complement activation
Vasodilation of blood vessels by Nitric Oxide
Increase coagulation by release of tissue factors and membrane coagulants
Cause hyperthermia

Question 17

What effects does excessive anti-inflammatory mediators have?

Answer 17

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

Question 18

What is the outcome of sepsis when pro-inflammatory mediators outbalance anti-inflammatory mediators?

Answer 18

Septic shock with multiorgan failure and death

Question 19

What is the outcome of sepsis when anti-inflammatory mediators outbalance pro-inflammatory mediators?

Answer 19

Immunoparalysis with uncontrolled infection and multiorgan failure

Question 20

What are neurological features of sepsis?

Answer 20

Altered consciousness
Confusion
Psychosis

Question 21

What are respiratory features of sepsis?

Answer 21

Tachypnoea
PaO2<70mmHg
Sats<90%

Question 22

What are liver features of sepsis?

Answer 22

Jaundice
Raised LFTs
Decrease albumin
Increased prothrombin time

Question 23

What are haematological features of sepsis?

Answer 23

Decreased platelets
Increased prothrombin time/activated prothromboplastin time
decreased CRP
Increased D-dimer

Question 24

What are cardio features of sepsis?

Answer 24

Tachycardia

Hypotension

Question 25

What are renal features of sepsis?

Answer 25

Oliguria Anuria Increased creatinine

Question 26

What are general features of sepsis?

Answer 26

Fever >38 - chills, rigors, flushes, cold sweats Hypothermia in young and elderly - immunosuppressed Tachycardia >90 Tachypnoea>20 Altered mental status Hyperglycaemia in absence of diabetes

Question 27

What is leucocytosis?

Answer 27

WCC>12/l

Question 28

What is leucopenia?

Answer 28

WCC<4/l

Question 29

What are features of perfusion in sepsis?

Answer 29

High lactate | Skin mottling and reduced capillary fusion

Question 30

What factors of the host affect sepsis presentation?

Answer 30

Age Co-morbidities ie COPD, diabetes, etc Immunosuppression - HIV, drug induced, congenital Previous surgery

Question 31

What factors of the causative organism effect sepsis presentation?

Answer 31

Gram positive or negative Virulence factors Bioburden

Question 32

What environmental factors effect sepsis presentation?

Answer 32

Occupation Travel Hospitilisation

Question 33

What is SIRS?

Answer 33

Systemic Inflammatory Response Syndrome

Question 34

What is the sepsis 6?

Answer 34

``` Take blood cultures Take blood lactate Take urine output Give Oxygen Give IV antibiotics Give IV fluids ```

Question 35

What is the time frame for the sepsis 6?

Answer 35

Within an hour of presenting

Question 36

Why do we take blood cultures?

Answer 36

Make a microbiological diagnosis

Question 37

How many blood cultures should be taken?

Answer 37

2

Question 38

Why do we take lactate?

Answer 38

It is a measure of generalised hypoperfusion

Question 39

Why do we take urine output?

Answer 39

Marker of renal dysfunction

Question 40

What is type A lactate a sign of?

Answer 40

Hypoperfusion

Question 41

What is type B lactate a sign of?

Answer 41

Mitochondrial toxins Alcohol Malignancy Metabolism errors

Question 42

How much fluid is given in sepsis?

Answer 42

30ml/kg

Question 43

When should HDU referral be considered?

Answer 43

``` Low BP responsive to fluids Lactate>2 despite fluid resus Elevated creatinine Oliguria Liver dysfunction Bilateral infiltrates ```

Question 44

When should ITU be considered?

Answer 44

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