Septic shock Flashcards
Define sepsis
The presence (probably or documented) of infection together with systemic manifestations of infection”
What is meant by “systemetic manifestations of infection”?
- pyrexia
- pallor
- tachycardia
- raised infection markers in blood (CRP, WCC)
define severe sepsis
“Sepsis PLUS sepsis-induced organ dysfunction or tissue hypoperfusion”
Give 5 signs of severe sepsis
- Low urine output (<0.5ml/kg/hour)
- low arterial oxygen concentrations
- changes in blood clotting (INR>1.5)
- Raised bilirubin (>70micromol/L)
- raised lactate (>1mmol/L)
define septic shock
aka SIRS
“Sepsis-induced hypotension persisting despite fluid resuscitation”
SBP <90mmHg
OR
Mean arterial blood pressure below 70mmHg
Where are the infections that cause sepsis?
Infections anywhere in the body can cause sepsis
What are the risk factors for sepsis?
- Immunocompromised (HIV infection or cancer chemotherapy)
- Neonates and infants
- chronic disease
- recent surgery
- invasive procedures (central lines, urinary catheters)
Describer the pathophysiology of sepsis
- septic shock is a deregulated inflammatory response
- bacterial proteins activate cellular defence mechanisms
- release of inflammatory cytokines (TNF, IL-1, IL-6)
- nitric oxide release, which triggers vasodilation
- activation of complement which causes cell requirement of lymphocytes, leucocytes and macrophages
- endothelial action which is nitric oxide mediated, allows immune cells to stick and stay where needed, causes capillaries to become more porous
What does vasodilation cause in sepsis?
- a reduction in systemic vascular resistance
- hypotension
- reduction in consciousness
What happens when the body becomes fluid deplete as a result of vasodilation?
- hypovalaemia
- tissue oedema
- perfusion of tissues is reduced
Reduced perfusion of tissues causes what?
- tissue ischaemia
- increasing lactate
What are the sepsis 6? When do you have to them?
Do within 1 hour:
- administer oxygen
- take blood cultures
- give broad spectrum antibiotics
- give fluid resuscitation
- Measure lactate and haemoglobin
- measure urine output
Mnemonic: OBAFLU
With regards to oxygen administration, what are the goals?
- Increase blood oxygenation
- increase oxygen delivery to organs
When giving oxygen, what is the treatment?
What are the indicators?
100% Oxygen through face-mask (=24L/min flow)
Indicators are lactate and venous oxygen saturation
What is the guidance regarding blood cultures?
- Start smart, then focus
- Do not delay antibiotics waiting for blood cultures
- empirical therapy based on likely organism
- Note: most patients with sepsis will be culture negative after a single dose of antibiotic
What are the goals and treatment of broad spectrum antibiotics?
What are the indicators?
-Treatment depends on what you’re treating
-empirical therapy for first 48 hours
Indicators are:
-Inflammatory makers (CRP, temperature, WCC, Procalcitonin)
What does “start smart, hit hard and fast” mean?
Maximum dose
Maximum frequency
Describe empirical antibiotic therapy
Gram negative and positive cover at first:
-3rd generation cephalosporin (e.g. ceftriaxone)
What do you add in to antibiotic therapy in the case of neutropenia?
- Use broad spectrum penicillin to give greater Pseudomonas cover (piperacillin)
- add in aminoglycoside, but make sure it is a single dose as needs to be renal sparing
What do you add in to antibiotic therapy in the case of an acute abdomen infection?
-add in metronidazole to fight anaerobes
what do you do when cultures are returned?
Choose more appropriate, narrow spectrum antibiotics
Antibiotics for Staphylococci infections
- Flucloxacillin
- Rifampicin (if a bone or joint infection)
- Vancomycin (if MRSA)
Name 2 coliforms
1) Penicillin sensitive
2) penicillin resistant
1) Co-amoxiclav
2) Carbapenem
Pseudomonas infection, what do you give?
Ceftazidime (if penicillin sensitive)
Goals of fluid resuscitation
- restoration of circulating blood volume
- improving tissue perfusion
indicators for fluid resuscitation
- lactate
- venous oxygen saturation
- urine output
- blood pressure
Treatment for fluid resuscitation
- 0.9% sodium chloride infusion given AS FAST as POSSIBLE
- blood and plasma
1) What is lactate a marker of?
- anaerobic respiration
- byproduct of glucose metabolism
- alerts tissue hypoxia
Normal reference range of lactate?
0.5-2mmol/L
Why is urine output monitored?
-marker of kidney function
why is creatinine not monitored as much as urine output?
Creatinine is a poor marker of acute kidney injury
What is a good urine output? What is it a sign of?
> 0.5mL/kg/hour
- adequate kidney perfusion
- clearing the fluid administered
- sign of adequate organ perfusion
Golden Hours of sepsis
-Completed within 3 hours
3 hours:
- measure lactate level
- obtain blood cultures prior to antibiotic administration
- administer broad spectrum antibiotics
- administer 30mL/kg crystalloid for hypotension or lactate >4mmol/L(or equal to)
Golden hours of sepsis
-complete within 6 hours
- apply vasopressors for hypotension that does not respond to initial fluid resuscitation to maintain MAP of >65mmHg
- in event of persistent arterial hypotension despite resus or initial lactate above or equal to 4, measure CVP and ScVO2
- remeasure lactate if initial lactate was elevated
What is CVP?
Central venous pressure
What is ScVO2?
Central venous oxygen saturation
What are the 2 most impactful interventions in sepsis management?
- Blood cultures
- antibiotics
Twice as many survivors in the intervention group than those who didn’t receive the intervention
