Shock and sepsis

Question 1

Diagnostic criteria for spesis

Answer 1

1. Infection
\+ 2 positive features of SIRS
2. Temperature >38.3°C (101°F) or 90 bpm
4. Tachypnoea >20 breaths/minute
5. PCO2 6.66 mmol/L [120 mg/dL])
 in absence of diabetes mellitus
7. Acutely altered mental status
8. WBC count >12x10^9/L (12,000/microlitre) 
or 10% immature forms.

Question 2

What is severe sepsis

Answer 2

Sepsis with evidence of acute organ dysfunction or hypoperfusion

Question 3

What is septic shock

Answer 3

Sepsis with hypotension that does not respond to IV fluid administration

Question 4

Assessment overview

Answer 4

1. ABCDE
2. AVPU, GCS
3. Evidence of end organ dysfunction
4. Antibiotics

Question 5

Management in septic shock

Answer 5

1. Airway, Oxygen
2. Breathing
3. Circulation->IV access, fluid bolus resuscitation
4. Blood cultures, bloods for investigations
5. Antibiotics
   Unknown->Vancomycin and genatmicin
   Cholangitis: Gent + amoxycillin
   Perforation: Gent + amoxycillin + metronidazole
   Endocarditis: Gent + benzylpencillin + flucloxacillin
   Female genital tract: Ceftriaxone IV + metronidazole IV + azithromycin IV
   Respiratory: Ceftriaxone IV or piptaz
   Skin: Flucloxacillin
   GU: Gent + amoxycillin
6. Senior help, admission
7. May require ionotropic support, vasopressors->dobutamine, NE
8. PPI
9. DVT prophylaxis
10. Nutrition
11. Glycemic control
12. transfusion if required
13. Steroid may help if fluid non-responsive

Question 6

Empirical therapy for febrile neutropenia

Answer 6

1. Piperacillin + tazobactam within one hour of ED presentation

Question 7

Investigations

Answer 7

1. Identify organism
Cultures X 2
Stool, urine, sputum
Wounds, catheters, implants, pleural/peritoneal fluid
2. Evaluate organ function
ABG, oxygen saturation
UEC->deranged electrolytes, ++Cr/Urea
Glucose
LDH->prognostic
CRP
INR
FBC->PLTs, differentials
LFTs->+bilirubin
Urine output
ECG
3. Identify source
Clinical findings
CXR
USS
TOE
Urinalysis
LP
4. Prognosticate with lactate

Question 8

Evidence of organ dysfunction

Answer 8

1. -ve O2, or +O2 needed to keep >90%
2. Acute oliguria
3. Serum Cr >176
4. INR >1.5, aPTT >60
5. Thrombocytopenia
6. ++bilirubin
7. Hyotension
8. +lactate

Question 9

Risk factors for sepsis

Answer 9

1. Underlying malignancy
2. Aged >65 years
3. Immunocompromised
4. Haemodyalysis
5. Alcoholism
6. Diabetes mellitus