Sepsis and Septic shock - Part 1 - DONE Flashcards
What is the new definition of sepsis?
sepsis is a life-threatening organ dysfunction caused by dysregulated host response to infection
What is the definition of organ dysfunction?
acute change in total SOFA score consequent to the infection
What is SOFA score (google)?
Sepsis-related organ failure assessment score
qSOFA (google/PP):
quickSOFA
- qSOFA is a mortality predictor, NOT a diagnostic test for sepsis
- A “positive” qSOFA Score (≥2) suggests high risk of poor outcome in patients with suspected infection.
QuickSOFA: 2 of following 3:
- respiratory rate more 22/min
- altered mental status (GCS less than 15 points)
- systolic pressure less than 100mmHg
What is the definition of septic shock?
septic shock is a subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality than with sepsis alone
What are the risk factors of sepsis?
- Chronic diseases:
- Acquaried immunodeficiency syndrome
- Chronic obstructive pulmonary desease
- Cancers
- Diabetes
- Hepatic cirrhosis
- Immunosupresion
- Elderly and infant patients
- Males
- Blacks
- Invasive procedures
Etiology of sepsis:
- gram-negative bacteria
- gram-positive bacteria
- fungi (e.g. candida)
- anaerobic bacteria
What are the gram-negative bacteria that causes sepsis?
- pseudomonas
- escherichia
- klebsiella
- acineobacter
- enterobacter
What are the gram-positive bacteria that causes sepsis?
- staph aureus
- streptococcus
- staph epidermidis
What are the source of infection in sepsis?
- pneumonia (most common)
- intraabdominal infection
- bacteremia without known origin
- urine tract infection
- soft tissue and wound infections
- blood catheter releated
- CNS infection
What is the most common source of infection in sepsis?
pneumonia
PRP (google):
Pattern recognition receptors (PRRs): play a crucial role in the proper function of the innate immune system.
- pathogen-associated molecular patterns (PAMPs), which are associated with microbial pathogens,
- and damage-associated molecular patterns (DAMPs), which are associated with components of host’s cells that are released during cell damage or death
Pathophysiology - coagulation abnormalities:
- Sepsis is almost invariably associated with altered coagulation which may lead to disseminated intravascular coagulation (DIC)
- Impaired anticoagulant mechanism (protein C and antithrombin)
- Depression of fibrinolytic system
Pathophysiology - Immunosuppression:
- Reduced expression of HLA-DR on myeloid cell
- Ongoing infections foci despite antimicrobial therapy
- Enhanced apoptosis of B cells, CD 4 cells, follicular dendritic cells
Pathophysiology - Organ dysfunction:
about oxygen delivery
decreased oxygen delivery which leads to:
- hypotension
- reduced red cell deformability
- microvascular thrombosis
Pathophysiology - Organ dysfunction:
about vascular endothelium
- dysfunction of vascular endothelium
- induced by inflammation
- accompanied by cell deaths
- loss of barrier integrity
- subcutaneous and body - cavity edema
Pathophysiology - mitochondria:
- mitochondrial damage caused by oxidative stress
- decreased cellular oxygen use
- injured mitochondria released alarmins into the extracellular environment (mitochondrial DNA, peptides)
- activation of neutrophils and further tissue injusry
What are alarmins (google):
Any endogenous substance that signals tissue and cell damage.
What are the clinical manifestation of sepsis?
- Elevated or decreased (often in elderly, immunocompromised and infants) body temperature
- Shivering, muscle pain
- General malaise
- Tachycardia, tachypnea
- Obtundation or delirium
- Decreased capillary refill
- Mottling
- Jaundice
- Hypotonia
- Oliguria
Hypotonia def (google):
Hypotonia, commonly known as floppy baby syndrome, is a state of low muscle tone
Oliguria def (google):
Oliguria, the production of abnormally small amounts of urine.
Sepsis general variables:
- Fever > 38,3 C or hypothermia < 36 C
- Heart rate > 90/min
- Tachypnea
- Altered mental status
- Significant edema or positive fluid balance (>20 mL/kg over 24 hr)
- Hyperglicemia (plasma glucose > 140 mg/dL or 7,7 mmol/l) in the absence of diabetes
Sepsis organ dysfunction variables:
- Arterial hypoxemia (PaO2/Fio2< 300)
- Acute oliguria (urine output< 0,5mL/kg/h for at least two hours despite adequate fluid resuscitation
- Creatinine increase >0,5 mg/dL or 44,2 umol/L
- Coagulations abnormalities (INR>1,5 or aPTT >60 s)
- Ileus (absent bowel sounds)
- Thrombocytopenia (platelet count < 100000/ul)
- Hyperbilirubinemia (plasma total bilirubin > 4 mg/dl or 70 umol/L)
Sepsis infalammatory variables:
- Leukocytosis (WBC count > 12000/ul
- Leukopenia (WBC count < 4000 ul/l)
- Normal WBC count with greater than 10% immature forms
- Elevated plasma C reactive protein value
- Elevated plasma procalcitonin value
Sepsis tissue perfusion variables:
- Hyperlactatemia (> 2 mmol/L)
- Decreased capillary refill
- Mottling
Microbiological diagnosis:
- Obtaining appropriate cultures before antimicrobial therapy if such cultures do not cause significant delay (>45 minutes) in the start of antimicrobial administration
- At least two sets of blood cultures (both aerobic and anaerobic bottles) with at least one drawn percutaneously and one drawn through each vascular access device unless device was recently (<48 hrs) inserted
Cultures from other sites considered to be a source of infection:
- Urine
- Cerebrospinal fluid
- Wounds
- Respiratory secretions
- Other body fluids
Microbial diagnosis - Intravascular catheter (in place > 48 hours):
- at least one blood culture set should be obtained from the catheter
- along with simultaneous peripheral blood cultures
Suspicion of invasive candidiasis:
- 1,3 β-d-glucan
- mannan
- Anti-mannan antibody assays
Imaging studies
- CT, ultrasound, X-ray
- Identifications of potential source of infection that requires removal of a foreign body or drainage
