Sepsis workshop

Question 1

What is SIRS?

Answer 1

Systemic Inflammatory Response Syndrome (SIRS) occurs in response to either an infective*** or a ***non-infective insult to the body (pancreatitis, burns, trauma, infection). It is a clinical syndrome of dysregulated inflammation, where physiological mechanisms of repair go into overdrive and become pathophysiological.

• Tissue damage → inflammatory cytokines (to blood) → coagulation factors, vasodilators and complement factors

Question 2

What is the criteria for SIRS?

Answer 2

It is defined as having 2 or more of:

1) Temperature: > 38.3°C (to stop infection) or < 36°C (usually immunocompromised & after pyrexia usually VERY bad)

2) Heart rate: > 90 beats per minute

3) Respiratory rate: > 20 breaths/minute

4) White cell count: >12 or <4 x 10⁹ cells/L

5) Altered mental state

6) Capillary glucose > 7.7mmol/L (non-diabetics)

→ Early recognition of SIRS is vital (can be diagnosed without lab results).

Question 3

What is sepsis? (& red flags)

Answer 3

This is the presence of SIRS with evidence of infection as the cause of inflammation (i.e. positive swabs/blood cultures, clinical signs of infection (e.g. CXR)).

RED FLAGS

RED FLAGS which raise suspicion are HR >130, RR >25, SBP <90, GCS > A (A for alert in AVPU → as worried about PERFUSION to brain), Needs O2 (to keep high O2 sats), non-blanching rash (meningococcal meningitis)/cyanotic, recent chemotherapy (immunocompromised → LOW WBC → HIGH risk of sepsis with NO other side effects (other than not looking well) as have little immune response, not passed urine in 18hours (as kidneys NOT perfused adequately)

Question 4

What are the different severities of sepsis?

Answer 4

• Sepsis (10% Mortality)
  
  • Presence of SIRS with evidence of an infective cause.
• Severe Sepsis (35% Mortality)
  
  • This is sepsis with signs of organ hypo-perfusion/dysfunction (e.g. AKI, low GCS, Hypotension or Lactic Acidosis).
• Shock (50% Mortality)
  
  • This is severe sepsis with BP <90mmHg (clinical shock). This causes severe organ hypo-perfusion and must be aggressively managed to prevent mortality.

Question 5

How do we clinically diagnose sepsis-induced organ failure?

Answer 5

qSOFA → do when patient LOW BP and HIGH risk of. SEPSIS

The presence of >2 factors suggests a likely poor outcome.

RR >22bpm,

SBP <100mmHg,

GCS <15.

Question 6

What do you think it could be if a patient has a NEWS score of 5 or more?

Answer 6

SEPSIS

In a patient with a NEW score of 5 or more and a known infection or signs/symptoms of infection, think “could this be sepsis?” and escalate care immediately.

Question 7

What do you think it could be if a patient has a NEWS score of 3 or more in ONE parameter?

Answer 7

THINK SEPSIS

In a patient with a score of 3 or more in a single parameter (i.e. a RED box is ticked) and a known infection or signs/symptoms of infection, think “could this be sepsis?” and escalate care immediately.

Question 8

What are the differential diagnosis’s of sepsis?

Answer 8

• UTI
• Chest infection
  
  • PNEUMONIA (consolidation seen on CXR)
  • LRTI (lower respiratory tract infection)
• Pneumothorax
• Infective endocarditis
• Lung cancer

Question 9

What investigations would you do for someone with sepsis?

Answer 9

Bedside - Observations (NEWS score – detect sepsis)

Sputum Sample (send for MC&S to identify pathogen)

ECG (due to tachycardia/chest pain)

Tests -

FBC (WCC – assess for inflammatory response).

U&Es (Low BP and dehydration/sepsis may affect renal function).

CRP (assess for inflammatory response).

BLOOD CULTURES (due to pyrexia) → greatest chance in picking up bacteraemia

+/- LFTs, LACTATE (if severe), VBG/ABG

Imaging

CXR (history of chest pain and SOB).

Question 10

What is this ECG illustrate? (condition)

Answer 10

Sinus tachycardia

(has normal sinus rhythm)

Question 11

What do these blood tests tell us?

Answer 11

• Raised WCC – predominantly neutrophils which indicates likely bacterial infection.
• Urea is slightly raised – higher than creatinine therefore dehydration is a likely contributing factor to reduced renal function.
• Low eGFR (?acute vs chronic).
• Raised CRP – indicates current inflammatory process (likely infection).

Question 12

What does this X-ray show?

Answer 12

Right Lower Zone Consolidation → Consistent with Pneumonia

Airway central, Right lower lung field contains an area of consolidation. No pneumothorax, cardiac borders appear normal and heart size is within normal limits on this PA film. CP angles are clear, no pneumoperitoneum. No fractures or soft tissue masses evident.

Question 13

What is the management of sepsis?

Answer 13

(if have HF - heart failure, give little fluid and check on how respond as oedema)

Question 14

What is the sepsis SIX?

Answer 14

Should be done WITHIN the first hour of suspected sepsis

Question 15

Why would you STOP amlodipine when treating LOW BP?

Answer 15

Amlodipine → anti-hypertensive hence, inevitable DECREASING BP further (put on hold when LOW BP)

Question 16

What is pneumonia and what are the types?

Answer 16

DEFINITION: Lower respiratory tract infection with abnormalities on chest x-ray → Pneumonia can only be diagnosed with
a CXR showing consolidation

Types:

• Community Acquired Pneumonia (CAP) → at home/community
  
  • Typical Pneumonias
  • Atypical Pneumonias
• Hospital acquired pneumonia (HAP) → been in hospital for more than 24 hours (different bugs & treatment)
• Aspiration Pneumonia → inhaling food down trachea and possible death

Question 16

What is pneumonia and what are the types?

Answer 16

DEFINITION:Lower respiratory tract infection with abnormalities on chest x-ray → Pneumonia can only be diagnosed with CXR showingconsolidation

Types:

• Community Acquired Pneumonia (CAP) → at home/community
  
  • Typical Pneumonias
  • Atypical Pneumonias
• Hospital acquired pneumonia (HAP) → been in hospital for more than 24 hours (different bugs & treatment)
• Aspiration Pneumonia → inhaling food down trachea and possible death

Question 17

What are the symptoms & signs of pneumonia?

Answer 17

Symptoms:

• Fever (+/- Rigors)
• Breathlessness
• Cough (+ Sputum production → green/brown colour)
• Inspiratory Chest Pain → pleuritic chest pain
• CONFUSION (Elderly)

Signs:

• Reduced Chest Expansion
• Dull percussion
• Increased vocal resonance
• Coarse Crackles (improve on cough) → infective material on lung and when cough removed from alveoli for a short time
• Temperature
• Low Oxygen Saturations

Question 18

What are the types of pneumonia? (& explain them)

Answer 18

CAP

Typically caused by Streptococcus Pneumoniae and Haemophilus Influenza (a bacterial infection). Usually causes a LOBAR pneumonia and is likely to respond to first-line treatment.

HAP

Pneumonia which develops >48 hours after admission to hospital. Categorised separately due to the change in likely causative pathogens, therefore different first-line treatment.

AspP

Chemical pneumonitis caused by food inhalation promotes infective environment – usually leading to anaerobic infection. Consider in elderly/neurology patients (e.g. stroke) with history of recurrent pneumonia. More common in RIGHT LUNG (easier passage of aspirate down vertical bronchus).

Atypical Pneumonias: (NOT need to know)

• Legionella Pneumonia (short prodrome with dry cough +/- diarrhoea, HYPONATRAEMIA, deranged LFTs. Diagnose with legionella urinary antigen. Classical presentation follows exposure to stagnant water (e.g. poor air conditioning on holiday)).
• Staphylococcal Pneumonia (This is more common in IVDU and patients with underlying disease such as CF. CXR shows focal cavitating consolidation).
• Mycoplasma Pneumonia (Presents with flu-like symptoms (e.g. malaise, headache) and a dry cough. CXR shows interstitial shadowing localised to a lobar region. Associated with erythema multiforme, Guillain-Barre and Stevens-Johnson syndrome).
• Fungal Pneumonia (Causes cavitating lesions on CXR. If present, screen patient for immune compromise).
• Pneumocystis Pneumonia (Presents with exertional dyspnoea, dry cough and bilateral signs. CXR shows diffuse interstitial shadowing. Associated with HIV diagnosis).
• Klebsiella Pneumonia (Associated with alcoholism).
• Pseudomonas (Associated with Cystic Fibrosis/HAP).
• TB (Caseating lesions within lung apices associated with calcification).

Question 19

What investigations need to be done with someone with pneumonia?

Answer 19

BEDSIDE - Observations + NEWS Score (assess for signs of chest sepsis). Sputum sample (to send for Sputum MC&S).

Urine antigens (Legionella/Pneumococcal antigen) *only if suspecting atypical pneumonia.

ECG (sinus tachycardia, new AF (can be triggered by pneumonia)).

TESTS

Blood tests - FBC, U+Es, LFTs, CRP

• Blood cultures* (if patient is pyrexial).
• ABG* (if patient is hypoxic/significantly unwell).

IMAGING

CXR (assessing for consolidation)

Sometimes: (if pneumonia RESISTANT to treatment/immunocompromised people)

Bronchoscopy/Bronchiolar Lavage

Pleural Fluid Aspiration

Question 20

Draw a rough anterior cross-section of the lungs

Answer 20

Question 21

What will different locations of pneumonia on an CXR look like?

Answer 21

RUL Pneumonia = Consolidation with no border loss.

RML Pneumonia = Loss of R heart border.

RLL Pneumonia = Loss of R Hemi Diaphragm.

LUL Pneumonia = Loss of L Heart Border.

LLL Pneumonia = Loss of L Hemi Diaphragm.

In pneumonia, the air spaces become filled with infective material (e.g. pus, dead cells) which increases the density within the lungs. Therefore, there is no difference between the mediastinum and the lung tissue, so they blend together.

This happens similarly with the diaphragm.

Question 22

What does this CXR show?

Answer 22

Right Upper Lobe Pneumonia

No loss of borders. Consolidation is confined above the Horizontal Fissure.

Question 23

What does this CXR show?

Answer 23

Right Lower and Middle Lobe Pneumonia

Loss of R Heart Border & R Hemi Diaphragm.

Question 24

What does this CXR show?

Answer 24

Left Lower Lobe Pneumonia

Blurring of L Hemi Diaphragm.

Question 25

Explain CURB-65 and the scoring system

Answer 25

• Calculate this to determine risk of mortality → hence alter treatment given

Question 26

What is the management of someone with pneumonia?

Answer 26

STEP 1

Oxygenation (e.g. nasal cannula)

NEXT

IV Fluids (dehydration)

PO/IV Antibiotics (guided by trust guidelines/CURB Score)

FOLLOW UP

CXR after 6 weeks to ensure resolution → takes 6 weeks heal (if frequent pneumonia possible lung cancer as cancer INCREASES risk of pneumonia)

Question 27

What are the complications of pneumonia?

Answer 27

Effusion

Para-pneumonic effusion develops due to pleural inflammation surrounding the infection. This allows some exudative fluid to pass into the pleural space.

Empyema

This is an infective effusion (i.e. pus in pleural cavity → need to be drained). Requires USS guided chest drain in order to prevent damage to the pleural membranes. Suspect in patients with a resolving pneumonia who spike a new fever.

Lung Abscess

Incompletely treated pneumonia/atypical pneumonia (e.g. Staph)/aspiration pneumonia. Causes a ring lesion with an air-fluid level.

Pericarditis

Surrounding infection irritates the pericardium. May present with a pleural rub, may also cause ECG changes and chest pain (relieved on sitting forwards).

Question 28

What do patients with kidney stones present with?

Answer 28

Loin to groin pain

Question 29

What is a urinary tract infection and what are the common causes?

Answer 29

Urinary Tract Infection (UTI) is caused by bacterial proliferation within the sterile urinary tract. This causes irritation of the urothelium which leads to Dysuria, Frequency and Urgency and may cause urge incontinence and haematuria. Very likely to cause CONFUSION in older patients.

Common bacterial causes of UTI include:

E.COLI, PROTEUS (high relationship with renal stones), STAPH SAPROPHYTICUS.

Question 30

What is bacteriuria?

Answer 30

Bacteriuria is the presence of bacteria in the urine and can be
classified as symptomatic or asymptomatic. Asymptomatic
bacteriuria in elderly patients does not require treatment, however
asymptomatic bacteriuria in pregnancy does require treatment due
to risk of effects on pregnancy. (HIGH risk in pregnancy)

Question 31

What are the risk factors for UTI?

Answer 31

PREGNANCY

increases UTI risk due to renal pelvis dilation in order to accommodate the additional volume of urine excreted (additional waste from foetus). This causes some urinary stagnation and increases risk of infection developing.

MENOPAUSE

increases UTI risk due to thinning of the urothelium secondary to reduction in oestrogen production. This makes the lining more vulnerable to damage and infection.

(chronic health conditions) -> Diabetes Mellitus is the main chronic health condition to significantly increase UTI risk. Excess glucose is excreted in urine and makes a favourable environment for bacterial growth.

Sexual activity

Easier for bacteria to migrate from one site to another. Encouraging patients to pass urine/void their bladder after intercourse can significantly reduce the risk of UTI.

Renal Stones/Bladder (tract blockages)

stones cause obstruction of the urinary tract. This causes urinary stagnation and increases infective proliferation. UTIs can also increase the future risk of stones (particularly Proteus infections)

Catheters

introduce a foreign body into a sterile urinary tract. Bacteria can colonise around the tubing and lead to infection.

Note:

• Higher risk of atypical bacterial infection.
• Catheter change with antibiotic cover (if infection suspected).
• Asymptomatic colonisation of catheter does not require treatment (do not routinely send Catheter urine specimens).

Question 32

What are the investigations of someone with a UTI?

Answer 32

Bedside

Observations (NEWS score – detect sepsis).

Urine Dip (Leukocytes &/or Nitrites positive – Leukocytes sensitive, Nitrites specific).

Urine Cultures (to confirm empirical treatment is appropriate).

Tests

Consider bloods if patient is unwell…

May be able to treat empirically if patient is well.

FBC, U&Es, CRP

+/- Blood Cultures

Imaging

Consider urinary tract investigations in recurrent UTIs.

Question 33

What is the management of someone with a UTI?

Answer 33

Management:Conservative: Fluids/Hydration.Medical: Antibiotics (see table).

Question 34

What are the complications of someone with a UTI?

Answer 34

Complications:

Urinary Tract Stones – Some infections increase stone development (i.e. Proteus).

SEPSIS – Urinary Tract Infection with associated SIRS. Can cause severe illness (particularly in elderly).

_PYELONEPHRITIS_ (a lot of pain to touch & increase risk of blood in urine)– higher urinary tract infection (in the kidneys). This is associated with flank pain (loin-groin pain), fever, rigors and haematuria. Something to do some more reading about!