Sepsis

Question 1

Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. What system would you use to identify organ dysfunction and whats included?

When using this system, what is needed to diagnose sepsis?

Answer 1

SOFA score Sepsis-related organ failure assessment

Respiratory via PaO2/FiO2 for acute resp distress
Coag (platelets) for DIC
Liver (Serum bilirubin)
Cardio - MAP
CNS - GCS
Renal - Creatinine and urine output

Acute increase in SOFA score by 2 or more points

Question 2

Gram +ve and -ve organisms almost equally cause sepsis, although if you had to pick one say positive. What organ infections may lead to sepsis most frequently? (4)

Answer 2

Lung (pneumonia)
Abdominal (gut infection)
Skin (cellulitis)
Renal + GU (UTI, pyelonephritis)

Question 3

What is considered an altered mental status?

Answer 3

GCS <15

Question 4

What is considered hypotension as a positive indication for sepsis?
What is considered hypotension that requires fluid resus?
What would you give for resus?
What would you give for resus in a case of severe sepsis

Answer 4

sepsis = <100 mmHg
Hypotension = <90 mmHg or 40 below baseline
0.9% Saline at 30ml/kg
Albumin at 30ml/kg

Question 5

You are asked to see a patient and see the common symptoms of sepsis. What are they? What are the common blood test findings in this case?

You notice that the patient is deteriorating quite rapidly and there is no time to complete the SOFA score. What would you use and what are the relevant cutoffs to diagnose sepsis at the bedside?

Answer 5

Fever Tachypnea tachycardia, altered mental state, clammy/sweaty skin
Tests: increase in lactate, WCC (>12 or <4), CRP, Procalcitonin but reduced creatinine

qSOFA = HAT
Hypotension <100
Altered mental status GCS <15
Tachypnea >22

Question 6

How would you identify septic shock?

Answer 6

Persistent hypotension requiring vasopressors to maintain MAP >65
and/or Lactate >2

Question 7

What would you use to obtain serum lactate levels at the bedside?

Answer 7

VBG

Question 8

What is the MAP? How is it calculated?
How is it monitored?
What is the cutoff requiring vasopressors? What are the first, second, and 3rd line?

Answer 8

Mean arterial pressure obtained via DP +1/3 (SP - DP)
Monitored on the blood pressure monitor (it is in parenthesis like this)
MAP<65. Norepinephrine, Vasopressin, Epinephrine

Question 9

What is the role of vasopressors?
If vasopressors fail to control MAP, what would you administer and give an example

Answer 9

Vasoconstriction
Cardiac inotropes => Epinephrine, Norepinephrine, and Dopamine

Question 10

What are the 3 main pathophysiological features of sepsis?

Answer 10

Endothelium: Vasodilation, leukocyte adhesion => increased permeability and procoagulant state => widespread oedema
Coagulation activation: Microthrombi + DIC => DVT risk
Immune system dysfunction: Opportunistic infections + increased risk due to hospital stay

Question 11

Give the RFs for sepsis

Answer 11

Focus on patients predisposition to infection
1) Age <1 or >75
2) Immunocompromised: Chemo/cancer, diabetes, long term steroid use, immunosuppressant tx (transplant, RA, SLE…)
3) Breach of skin integrity: Surgery, wound, IV drug use, indwelling catheters
4) Pregnancy - 6 weeks post-partum

Question 12

Clinical features of sepsis are dependent on the source of the infection. e,g liver will have increased SBR and LFTs. What criteria is considered high risk according to the NICE Guidelines?

Answer 12

Moderate risk = between normal and high risk
History: evidence of altered mental state (moderate: collateral hx of change in behaviour)
Resp: RR>25
Cardio: HR >130
BP: <90 or 40 below normal
Urine output: Not passed in 18 hours or <0.5ml/kg/hr
Skin: Cyanosis, mottling, non-blanching rash (meningitis)

Question 13

A patient with cellulitis quickly begins to deteriorate.
What investigations would you carry out?
What management would you carry out?

Answer 13

Inv: Take 3 + 1
Blood gas
Blood culture
Bloods (FBC, U and E, CRP, Procalcitonin, LFTs, Creatinine, clotting screen)
Urine culture and dipstick

Management: Give 3 + 1
First: Source control: removal of indwelling catheter or infected tissue, drainage of abscess
Give O2 (start 40% FiO2)
IV fluids IV 0.9% saline at 30 ml/kg
IV antibiotics
Vasopressors indicated if MAP <65 (norepinephrine
FOR 5/5 (3): other considerations include VTE prophylaxis, Stress ulcer prophylaxis, nutritional help, glycemic control if diabetic, minimal sedation for early mobilization

Question 14

How are blood cultures taken?

Answer 14

Aerobic and anaerobic tubes!!!

Question 15

Can viral infections cause sepsis?
Can fungal infections cause sepsis?

Answer 15

Yes to both

Question 16

What is “Time zero”

Answer 16

Time of presentation => it is the time for triage at ED or first note made relating to sepsis

Question 17

Lactate levels are a predictor of mortality where clearance of lactate is associated with improved survival. What is the presence of elevated lactate an indication of? What level would it be considered high (septic shock)? At what level would be extreme?

Answer 17

Indicates tissue hypo perfusion
2
4

Question 18

What must be completed in the first hour of sepsis?

Answer 18

1. Measure lactate -> remeasure if >2 mmol/L
2. Obtain blood cultures before administering antibiotics
3. Begin IV resus of 30 ml/kg hartmann’s (esp if <90 systolic/40 below baseline or lactate ≥4mmol/L
4. Administer vasopressor if MAP<65 (Norepinephrine, Vasopressin, Epinephrine)
   All of these need frequent reassessment

Question 19

Quick! Hx information you would like to know from a patient when screening for risk of sepsis

Answer 19

Age (<1 or >75)
IV drug use
Pregnancy/recent pregnancy
Chemo/cancer, diabetes, long term steroid use, immunosuppressant tx (transplant, RA, SLE…)
Rashes, fever, recent illness