Sepsis definitions - qSOFA, Septic shock

Question 1

The qSOFA (Quick SOFA - sequential organ failure assessment score) Score for Sepsis identifies high-risk patients for in-hospital mortality with suspected infection outside the ICU. (mortality predictor, not diagnostic for sepsis) What are the three things measured in qSOFA to predict the patients mortality? What score indicates a high risk prediction?

Answer 1

Adult patients outside of ICU with suspected infection are identified as being at heightened risk of mortality if they have quickSOFA (qSOFA) score meeting >= 2 of the following criteria

• * RR >/= 22bpm
• * SBP = </=100
• Altered mental status
• qSOFA >/=2 -> think sepsis

Question 2

Image shows disease continuum –> * Colonisation * Infection * SIRS * Sepsis * Septic shock

What is SIRS?

What is needed for a SIRS classification?

Answer 2

SIRS - systemic inflammatory response syndrome A non-specific response including >/=2 of the following

• * Temp >38 degrees or <36 degrees
• Pulse rate >90bpm
• * Resp rate >20/min
• * WBC count >12,000/mm3 > 12 or <4

Question 3

What is SEPSIS defined as?

Answer 3

Sepsis is defined as

• * SIRS with a presumed or confirmed infectious process * or * NEWS >/5 and infection

Question 4

What is septic shock?

Answer 4

Septic shock is defined as sepsis plus sign of at least one acute organ dysfunction Septic shock is also hypotension refractory to adequate volume resuscitation -> SBP 40mmHg from normal

Question 5

Septic shock * Renal * Resp * Hepatic * Haematological eg DIC * CNS * Unexplained metabolic acidosis * Cardiovascular –> hypotnesion

State different indicators of severe organ damage? - ie the tests that would show this

Answer 5

* Renal - urine output 1.5) * Cardiovascular - SBP 40mmHg drop from normal

Question 6

Within one hour of thinking sepsis, the sepsis 6 bundle must be started - known as THE GOLDEN HOUR

What is given here?

Answer 6

BUFALO

• * Blood cultures - and other cultures, urine, wound swabs
• * Urine output - catheterise and monitor hourly output
• * Fluids - IV fluid challenge 30ml/kg within the first 3 hours of sepsis (can give 500mls crystalloid STAT (within 15 minutes))
• * Antibiotics - IV antibiotics
• * Lactate and FBC
• * Oxygen - high flow
• Order may be * O2, Fluid, Blood cultures, Abx, Lactate/FBC, Urine

Question 7

Which antibiotics are given for the empirical treatment of sepsis?

Answer 7

IV amoxicillin, metronidazole and gentamicin

Question 8

Septic shock can also be defined based on the lactate levels and MAP How does NICE define sepsis based on these?

Answer 8

Septic shock can be defined as sepsis with

• * persisting hypotension despite fluid correction and inotropes (requiring vasopressors to maintain a mean arterial pressure [MAP] of 65 mmHg or more),
• * and hyperlactataemia with a serum lactate level of greater than 2 mmol/L

(if lactate level >4, mortality rate of 38%)

(Septic shock can also be defined as sepsis with a suspected calculated mortality of over 50%)

Question 9

Why is there an increase in lactate levels in septic shock?

Answer 9

Partly a marker of underlying cellular hyperoperfusion and a shift to anaerobic metabolism

It is also a sign of sympathetic nervous system activation where we see an increases in criculating adrenaline and non-adrenaline release which drives lactate production

Question 10

What is the intial fluid bolus given to a patient who has presented with sepsis?

What is the initial fluid bolus given to a patient presneting with septic shock?

Answer 10

• • The recommendation, for the initial fluid resuscitation from sepsis-induced hypoperfusion, is to infuse at least 30 mL/kg of intravenous crystalloid fluid within the first three hours.
• • Fluids should be administered for hypotension or septic shock (lactate ≥ 4 mmol/L or unable to keep MAP>65mmHg without vasopressors)
• • The recommendation is to provide initial fluid resuscitation rapidly; do not infuse using an IV pump. o For example, give 1-liter IV fluid over 15 minutes using a pressure bag

Question 11

What drug aside from fluids and vasopressor may be given to patients presenting with septic shock although is controversial?

Answer 11

Consider human albumin solution 4–5% for fluid resuscitation only in patients with septic shock

Some evidence albumin may improve organ function in critically ill hypoalbuminaemic patients

Question 12

What are the vasopressor agents given in septic shock when fluids fail to maintain the blood pressure?

Answer 12

1st choice vasopressor agent is usually noradrenaline

If blood pressure does not come up with this, can try giving dobutamine

followed by adrenaline and later vasopressin when multiple vasoactive agents are required

Question 13

How does dobutamine work?

Why must it never be given before noradrenaline?

Answer 13

Dobutamine is predominantly a β1-adrenergic agonist, with weak β2 activity, and α1 selective activity, although it is used clinically in cases of cardiogenic shock for its β1 inotropic effect in increasing heart contractility and cardiac output

Dobutamine has peripheral vasodilatory properties and therefore must never be given before noradrenaline as it can completely hypoperfuse the patient - it should only be given after noradrenaline as noradrenaline will counteract this effect