sepsis and septic shock

Question 1

what is septic shock ?

Answer 1

clinical construct of sepsis with persisting hypertension
requires vasopressors to maintain MAP >65mmHg
serum lactate >2mmol/l
mortality 40%

Question 2

what is the qSOFA score ?

Answer 2

systolic BP <100mmHg
altered mental status
tachypnoea RR >22

2+ suggests greater risk of poor outcome

Question 3

what is the pathophysiology of sepsis ?

Answer 3

uncontrolled inflammatory response
features consistent with immunosuppression
initially increase in inflammatory mediators, later shift to anti-inflammatory immunosuppressive phase

phases;

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

Question 4

what are commonly released toxins by gram negative bacteria ?

Answer 4

lipopolysaccharide LPS

Question 5

what are commonly released toxins by gram positive bacteria ?

Answer 5

microbial-associated molecular pattern MAMP - lipoteichoic acid LTA, maramyl dipeptides
superantigens - staphylococcal toxic shock syndrome toxin (TSST), strep exotoxins

Question 6

what happens with endotoxin release ?

Answer 6

LPS needs LPS-binding protein to bind to macrophages

LTA does not need proteins

Question 7

what happens with exotoxin release ?

Answer 7

pro-inflammatory response

small amounts of superantiens cause are amount of mediators to be secreted

Question 8

what is the effect of the pro-inflammatory mediators ?

Answer 8

promote endothelial - leukocyte adhesion
release arachidonic acid metabolites
complement activation
vasodilation by NO
increase coagulation
cause hyperthermia

Question 9

what is the effect of anti-inflammatory mediators ?

Answer 9

inhibit TNF alpha
augment acute phase reaction
inhibit activation of coagulation system
provide negative feedback mechanisms to pro-inflammatory mediators

Question 10

what are general features of sepsis ?

Answer 10

fever >38 - riggers, flushes, night sweats
hypothermia <36 - elderly and very young
tachycardia >90
tachypnoea >20
altered mental status
hyperglycaemia >8mmol/l

Question 11

what are inflammatory variables in sepsis ?

Answer 11

leucocytosis >12,000
leucopenia <4000
normal WCC with >10% immature forms

high CRP
high procalcitonin

Question 12

what are organ dysfunction variables in sepsis ?

Answer 12

arterial hyperaemia 
oliguria <0.5ml/kg/h
increased creatinine
coagulation abnormality, thrombocytopenia
ileum
hyperbilirubinaemia
high lactate
skin mottling, reduced perfusion

Question 13

what is the sepsis 6 ?

Answer 13

blood culture
blood lactate
measure urine output
oxygen 
IV antibiotics
IV fluid

Question 14

what are the types of lactate and what do they show ?

Answer 14

type A - hypoperfusion

type B - mitochondrial toxins, alcohol, malignancy, metabolism