5. SIRS, sepsis and septic shock

Question 1

Definition of sepsis pathophysiological aspect

Answer 1

Sepsis is a complex syndrome caused by the bacteria or their metabolic products, invading the bloodstream and resulting in a generalized response of the host, based on an interplay between the immune, inflammatory and procoagulant responses

Question 2

Definition of sepsis easy

Answer 2

Infection + systemic response (SIRS)

Question 3

How many % of bacterial cultures will be negative, even in case of clinically evident infection?

Answer 3

60 %

Question 4

What tests can you do in addition of culture - if it´s not reliable?

Answer 4

• WBC
• CRP, plt
• Other inflammatory mediators (IL-1b, IL6, IL8, TNFa, TGFb)

Question 5

SIRS criteria

Answer 5

Non-specific, not so recommended anymore

1) Temperature (<36 or >38)
2) HR > 90
3) RR > 20 or PaCO2 <32 mmHg
4) WBC (<4000 or >12000 or > 10% bands)

Question 6

PIRO

Answer 6

Sepsis

• Predisposition
• Infection
• Response
• Organ dysfunction

Question 7

New sepsis definition

Answer 7

Life-treathening organ dysfunction caused by a dysregulated host response to infection

Question 8

qSOFA

Answer 8

Quick Sepsis related Organ Failure Assessment

• BP (SBP < 100 mmHg)
• RR (> 22 /min)
• Altered mental state (GCS < 15)

Question 9

SOFA

Answer 9

• Respiration (PaO2)
• Coagulation (Plt)
• Liver (Bilirubin)
• Cardiovascular (MAP or require medications)
• CNS (GCS)
• Renal (Creatinine, urine output)

Question 10

LODS

Answer 10

Scoring system for sepsis (Logistic Organ Dysfunction Score)

Question 11

CARS

Answer 11

Compensatory anti-inflammatory response syndrome (related to sepsis)

• Tissue damage
• Apoptosis
• Structural dysfunction - hard to recover (weeks)

Question 12

MARS

Answer 12

Mixed antagonistic response syndrome (related to sepsis)

Question 13

Severe sepsis

Answer 13

Sepsis + sepsis-induced organ dysfunction / tissue hypoperfusion (lactate / oliguria)

Question 14

Septic shock

Answer 14

Sepsis-induced hypotension persisting despite adequate fluid resuscitation

Question 15

SIRS

Answer 15

• Hypoperfusion
• Hyperinflammation
• Functional type of dysfunction - easy to recover (1-4 days)

Question 16

CARS lung

Answer 16

• Alveolar hyaline
• Destruction of lung tissue
• Alveolar dead-space and alveolar collapse

Question 17

ARDS signs and symptoms

Answer 17

• Bilateral pulmonary infiltration
• Decreased O2 diffusion
• Cardiac origin excluded
• Tachypnoe (> 25 /min)
• PaCO2 < 32 mmHg
• Increased dead-space ventillation

Question 18

CARS cardiovascular system

Answer 18

• Myocardial depression
• Vasoplegia
• Coronary hypoperfusion
• Decreased contractility
• Venous pressures = / increased
• CO decreased
• Lactate increased

Question 19

CARS gastrointestinal system

Answer 19

Mucosal: translocation

General:

• Necrosis
• Endocrine response (CCK, GLP, PYY)
• Increased immune activation

Question 20

CARS renal

Answer 20

• Renal (SIRS: prerenal)

- Acute tubular necrosis

Question 21

Steps of sepsis therapy

Answer 21

1) Source control
2) Resuscitation of circulation (fluids)
3) Resuscitation of circulation (vasopressors)
4) Maintaining O2 supply (“ventilatory support”)
5) Maintaining homeostasis (“renal support”)
6) Treat individual organ dysfunction

Question 22

Source control in sepsis

Answer 22

1) Remove implants
2) Drain abscesses
3) Wound opening, nectrectomy, amputation
4) Peritoneal lavage, drainage or enterostomy
+
1) Blood cultures
2) Broad-spectrum, high dose AB
3) Pseudomonas coverage (piperacillin, ceftazidime, cefepime, imipenem, meropenem)

Question 23

Fluid resuscitation sepsis

Answer 23

Initial: 1000 ml crystalloid over 30 min - repeat as needed

• MAP > 65 mmHg
• Urine output > 0,5 ml/kg/h

Question 24

Vasopressors sepsis

Answer 24

Indicated in severe hypotension (<90 mmHg SBP)

• Norepinephrine (0,01-3 microgr/kg/min)
• Epinephrine (same as above)
• Dopamine - only in special cases

Question 25

Goal of ventilatory support sepsis

Answer 25

Keep arterial saturation > 90 %

Question 26

Homeostasis / renal therapy sepsis

Answer 26

• Loop diuretics
• Osmotic diuresis
• CRRT or iRRT