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Year 3: Block 1: Infection > Sepsis and septic shock > Flashcards

Sepsis and septic shock Flashcards

1
Q

What is sepsis (Definition)

A

meaning decay or decomposition.

Systemic illness caused by microbial invasion of normally sterile parts of the body

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2
Q

What is the traditional model of sepsis and features of

A
  • SIRS >38 degrees, HR> 90, RR>20 OR PaCo2<32, WBC> 12,000
  • Sepsis = SIRS and Infection
  • Severe sepsis = Sepsis and End organ damage
  • Septic shock = severe sepsis and hypotension
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3
Q

Examples of SIRS (3)

A

Pancreatitis
Burns
Trauma

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4
Q

What is sepsis (medical)

A

life-threatening organ dysfunction caused by dysregulated host response to infection

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5
Q

What is organ dysfunction

What SOFA score reflects an overall mortality risk?

A

be identified as an acute change in total SOFA score >2 points consequent to the infection

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

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6
Q

What is septic shock (medical)

What values need to be maintained?

A

sepsis with persisting hypotension requiring vasopressors to maintain MAP >65mmHg and having a serum lactate of >2mmol/l despite adequate volume resuscitation
Patients with septic shock have a hospital mortality of 40%

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7
Q

a qSOFA sepsis score

A

Hypotension - sys BP <100 mmHg
Altered mental status
Tachypnoea RR >22/min

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8
Q

Importance of sepsis (4)

A

Common condition
Becoming more common
Increased morbidity
Increased mortality

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9
Q

Survival in septic shock is based on

A

antimicrobial delay

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10
Q

Features of the septic six?

A 
temp 
HR
WCC
RR
MEN STATE
GLUCOSE
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11
Q

Body’s defence against sepsis:
physical barrier:
Innate immune system:
Adaptive immune system:

A

skin, mucosa, epithelial lining
IgA in gastrointestinal tract, dendritic cells / macrophages
– lymphocytes, immunoglobulins

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12
Q

Origin of sepsis

A

breach of integrity of host barrier, whether physical or immunological
Organism enters the bloodstream creating a septic state

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13
Q

Pathophysiology of sepsis

A

Uncontrolled inflammatory response

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14
Q

Patients with sepsis have features consistent with immunosuppression: - what are they? (3)

A

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

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15
Q

What are the three phases in the pathogenesis of sepsis

A

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

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16
Q

Phase 1: Release of bacterial toxins - features

name some commonly released toxins

A
  • Bacterial invasion into body tissues is a source of dangerous toxins
- Gram negative
Lipopolysaccharide (LPS)
Gram positive
Microbial-associated molecular pattern (MAMP)
Lipoteichoic acid
Muramyl dipeptides
Superantigens
Staphylococcal toxic shock syndrome toxin (TSST)
Streptococcal exotoxins
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17
Q

Phase 2: Release of mediators in response to infection - endotoxin release

A

LPS needs an LPS-binding protein to bind to macrophages

LTA do not need such proteins

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18
Q

Phase 2: Release of mediators in response to infection - exotoxin release

A

Pro-inflammatory response

Small amounts of superantigens will cause a large amount of mediators to be secreted: cascade effect

19
Q

Phase 2: Release of mediators in response to infection: iator role in sepsis (Th1 vs Th2)

A

Two types of mediators can be released
Pro-inflammatory mediators – causes inflammatory response that characterises sepsis
Compensatory anti-inflammatory reaction – can cause immunoparalysis

20
Q

Phase 3: Effects of specific excessive mediators - give features of pro-inflammatory mediators

A

Promote endothelial cell – leukocyte adhesion
Release of arachidonic acid metabolites
Complement activation
Vasodilatation of blood vessels by NO
Increase coagulation by release of tissue factors and membrane coagulants
Cause hyperthermia

21
Q

Phase 3: Effects of specific excessive mediators - give features of anti-inflmmatory mediators

A

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

22
Q

Septic shock with multi organ failure has a higher?

A

Pro-Inflammatory response

23
Q

Immunoparalysis with uncontrolled infection and multiorgan failure has a higher?

A

Compensatory anti-inflammatory response

24
Q

The clinical features of sepsis depends on a number of factors- what are they

A

Host
Organism
Environment

25
Q

Organ dysfunction - clinical features

A

Altered consciousness
Confusion
Psychosis

Tachypnoea
PaO2: <70mmHg
Sats: <90%

Jaundice
↑ Liver enzyment
↓ Albumin
↑ PT

↓ Platelets
↑ PT/APTT
↓ Protein C
↑ D-dimer

Tachycardia
Hypotension

Oliguria
Anuria
↑ Creatinine

26
Q

General features of sepsis and how they present

A

Fever >38oC – presenting as chills, rigors, flushes, cold sweats, night sweats, etc

Hypothermia <36oC – especially in the elderly and very young children (remember the immunosuppressed)

Tachycardia >90 beats/min
Tachypnoea >20 /min

Altered mental status – especially in the elderly
Hyperglycaemia >8mmol/l in the absence of diabetes

27
Q

Inflammatory variables in sepsis (5)

A 
Leucocytosis (WCC > 12,000/ml)
Leucopenia (WCC < 4,000/ml)
Normal WCC with greater than 10% immature forms
High CRP
High procalcitonin
28
Q

Haemodynamic variables in sepsis (2)

A

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

SvO2 >70%

29
Q

Organ dysfunction variables in sepsis (7)

A

Arterial hypoxaemia (PaO2/FiO2 < 50mmHg)

Oliguria (<0.5ml/kg/h)

Creatinine increase compared to baseline

Coagulation abnormalities (PT >1.5 or APTT >60s)

Ileus

Thrombocytopenia
(<150,000/ml)

Hyperbilirubinaemia

30
Q

Tissue perfusion variables in sepsis (2)

A

High lactate

Skin mottling and reduced capillary perfusion

31
Q

Effect of host on sepsis presentation (3) + examples

A

Age
Co-morbidities (COPD, DM, CCF, CRF, disseminated malignancy)

Immunosuppression
Acquired – HIV/AIDS
Drug-induced – steroids, chemotherapeutic agents, biologics
Congenital – agammaglobulinaemia, phagocytic defects, defects in terminal complement component

Previous surgery - splenectomy

32
Q

Effect of organism on presentation of sepsis

A

Gram positive versus Gram negative
Virulence factors (example: MRSA, toxin secretion, ESBL, KPC, NDM-1)
Bioburden

33
Q

The sepsis 6

A 
oxygen
blood culture
antibiotics 
fluid challenge
lactate 
urine output
34
Q

The sepsis 6 - 2A’S , 2b’s and 2’cs

A 
Air enriched with o2
Antibes after blood culture
blod culture
blood gas with lactate
crystalloid bolus
catheter if sep shock or severe sepsis
35
Q

Why take blood cultures

A

make microbiological diagnosis (30-50% positive)

- if spike in temperature, take 2 sets

36
Q

Lactate and low urine output are markers of

A

Lactate – marker of generalised hypoperfusion/severe sepsis/poorer prognosis
Low Urine output – marker of renal dysfunction

37
Q

What Antibiotics - 5 criteria for prescribing

A 
Based on working diagnosis from History and Examination
Local antibiotic guidelines
BUT consider allergy 
BUT consider previous MRSA, ESBL, CPE
BUT consider Abx toxicity/interactions
38
Q

Administer effective intravenous antimicrobials within the first hour of

A

of septic

shock (Grade 1B) and severe sepsis without septic shock (Grade 1C) as the goal of therapy.

39
Q

Lactate - type A and B

A

Type A - Hypoperfusion
Type B – Mitochondrial toxins, Alcohol, Malignancy, metabolism errors
Of available biomarkers, lactate has the most support to identify adverse outcomes

40
Q

IV fluids in sepsis

A

30ml/kg fluid challenge (expert opinion)

2.1L 70kg patient

41
Q

When to consider HDU referral

A 
Low BP responsive to fluids
Lactate >2 despite fluid resuscitation
Elevated creatinine 
Oliguria
Liver dysfunction, Bil, PT, Plt
Bilateral infiltrates, hypoxaemia
42
Q

When to consider ITU

A

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

43
Q

Patients with severe sepsis and septic shock may experience ineffective arterial circulation
due to?

A

vasodilatation associated with infection or impaired cardiac output.

44
Q

Fluid challenges require the definition of four components:- what are they

A

the type of fluid to be
administered; 2) the rate of fluid infusion (e.g., 500 mL to 1,000 mL over 30 minutes); 3) the
end points (e.g., mean arterial pressure of >65 mm Hg, heart rate of <110 beats per minute);
and 4) the safety limits (e.g., development of pulmonary edema).

Year 3: Block 1: Infection (14 decks)

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