Emergency: Sepsis

Question 1

In neonates, early onset sepsis is most commonly caused by…

Answer 1

Group B streptococcus

E. coli

Question 2

In neonates, late onset sepsis is most commonly caused by..

Answer 2

Coagulase negative staphylococcus - staphylococcus epidermis

Question 3

Which causes of sepsis have declined since immunisation introduction?

Answer 3

Neisseria meningitidis
Haemophilius influenzae
Streptococcus pneumonia

Question 4

What clinical features of sepsis are there (history)?

Answer 4

Fever
Poor feeding
Miserable, irritable, lethargy
History of focal infection: meningitis, osteomyelitis, gastroenteritis, cellulitis
Predisposing conditions: sickle cell disease, immunodeficiency

Question 5

What examination findings can indicate sepsis?

Answer 5

Fever
Tachycardia
Tachypnoea
Low BP
Purpuric rash (meningococcal septicaemia)
Features that suggest source (e.g pneumonia, UTI, meningitis etc)

Question 6

What does septic shock mean?

Answer 6

Persisting hypotension requiring treatment to maintain blood pressure despite fluid resuscitation

Question 7

What must be started without delay?

Answer 7

Antibiotics

Question 8

What is the sepsis 6 for paediatrics?

Answer 8

Oxygen: aim sats >94%
IV/IO access: blood culture, blood gas, FBC, CRP, U&E, coagulation, LP unless contraindicated
Fluids: 20ml/kg of 0.9% normal saline over 5-10 minutes (can repeat x3 depending on response)
IV/IO antibiotics (broad spectrum)
Escalation
Consider inotropic support early e.g adrenaline infusion

Question 9

Why is significant hypovolaemia usually present?

Answer 9

Fluid maldistribution - due to release of vasoactive mediators by host immune response

Question 10

What monitoring may be required to guide assessment of fluid balance?

Answer 10

Catheter

Central venous pressure

Question 11

Why may inotropic support be required?

Answer 11

Due to myocardial dysfunction, which occurs as inflammatory cytokines and circulating toxins depress myocardial contractility

Question 12

Can sepsis be cause by viral or fungal infections?

Answer 12

Yes but bacterial is by far most common cause

Question 13

What are common causes of sepsis?

Answer 13

Respiratory tract infections 
UTIs
Congenital infections
Bloodstream infections 
Abdominal infections 
Infected wounds
Indwelling lines and catheters 
Cellulitis

Question 14

In children, sepsis is defined as a suspected or proven infection with a Systemic Inflammatory Response (SIRS). SIRS is the presence of…

Answer 14

At least 2 of the following, one of which must be abnormal temperature or WCC:

• core temp > 38.5 or <36
• tachycardia for age in absence of external stimulus
• tachypnoea for age or mechanical ventilation for an acute process
• WCC elevated or depressed

Question 15

When should a paediatric sepsis screening and action tool be done?

Answer 15

PEWS or POPS scoring 3 or more
Healthcare professional concern
Parental concern of sepsis

Question 16

What should any red flags on sepsis screening and action tool prompt?

Answer 16

Immediate review by clinician at ST4 or above

Paediatric sepsis 6 actions completed within one hour of time zero

Question 17

What is time zero?

Answer 17

The booking in time for PED/CAU

For inpatients it is the time when red flag sepsis signs or observations noted

Question 18

Infants with red flag signs should have observations increased to..

Answer 18

Every 15-30 minutes

Question 19

Infants and children in amber flag category should have observations increased to every..

Answer 19

Hour with re assessment for red flag signs

Question 20

On the age <5 years paediatric sepsis screening and action tool, what red flag sepsis signs are there?

Answer 20

Appearance: any - appears I’ll to healthcare professional, looks mottled/ashen, cyanosis of skin, lips or tongue, non blanching rash

Breathing: any- grunting/apnoea, SpO2 <90% OA or increased O2 requirements over baseline
<1 RR > or equal to 60
1-2 RR > or equal to 50
3-4 RR > or equal to 40

Circulation: any - HR < 60
<1 HR > or equal to 160
1-2 HR > or equal to 150
3-4 HR > or equal to 140

Demeanour: any- no response to social cues, does not wake, if roused does not stay awake, weak high pitched or continuous cry

Exposure: any - temp <36
< 3 months temp >38

Question 21

What sepsis mimics are there?

Answer 21

Asthma, anaphylaxis, DKA, bronchiolitis

Question 22

What urgent investigations should be done?

Answer 22

FBC, urea and electrolytes, LFTs, CRP 
EDTA bottle for PCR
Blood sugar 
Clotting studies 
Blood gas 
Other microbiology samples - CSF, urine etc

Question 23

What should a blood gas be done for?

Answer 23

Lactate and glucose

Question 24

If lactate >2 mmol/L what fluids should be given?

Answer 24

20ml/kg of 0.9% sodium chloride max 500ml over 5-10 minutes and repeat if necessary

Question 25

What inotropic support should be considered?

Answer 25

Adrenaline infusion via peripheral IV or IO access

Question 26

If there is a moderate risk of sepsis, what should be done?

Answer 26

Paediatric amber flag sepsis tool

Question 27

What antibiotics are given in children less than 1 month?

Answer 27

Gentamicin Amoxicillin 50mg/kg/dose IV (12 hourly under 7 days old, 8 hourly over 7 days) Cefotaxime 50mg/kg/dose IV

Question 28

What antibiotics are prescribed in 1-3 month age?

Answer 28

Amoxicillin | Ceftriaxone

Question 29

What antibiotic is prescribed in over 3 month age?

Answer 29

Ceftriaxone

Question 30

What is prescribed for haematological /ontological sepsis?

Answer 30

Piperacillin-Tazobactam

Question 31

What is the definition of sepsis?

Answer 31

Life threatening organ dysfunction due to a dysregulated host response to infection

Question 32

Why can sepsis cause organ failure?

Answer 32

The cytokines produced as a result of the infection initiate thrombin production and inhibit fibrinolysis The coagulation cascade leads to micro vascular thrombosis and hence organ ischaemia

Question 33

In neonates, what is classified as early onset sepsis?

Answer 33

Less than 48 hours after birth