Sepsis

Question 1

What describes an extreme systemic response to an infection leading to hypotension, tissue damage, organ failure, and potentially death?

Answer 1

Sepsis.

Question 2

What triggers sepsis?

Answer 2

Another infection elsewhere in the body.

Question 3

What are the four infections most commonly linked to sepsis?

Answer 3

Pneumonia, urinary tract infections (most common in elderly patients), skin infections, gastrointestinal (GI) infections.

Question 4

What are the most common organisms causing sepsis?

Answer 4

Staphylococcus aureus, Escherichia coli (E. coli), certain strains of Streptococcus.

Question 5

Which patient populations are at increased risk for sepsis?

Answer 5

Adults aged 65 years or older, infants under one year, patients with chronic diseases (diabetes, kidney failure, cancer, lung disease), malnourished or immunosuppressed individuals.

Question 6

What are the key symptoms of sepsis?

Answer 6

Dyspnea, delirium, encephalopathy, hypotension, tachycardia, fever or hypothermia (worse prognosis than fever), cold, clammy skin, extreme pain, leukocytosis, and hypoglycemia (due to suppressed gluconeogenesis and increased consumption).

Question 7

How is sepsis diagnosed?

Answer 7

Clinical diagnosis based on symptoms. Cultures of catheter tips (urinary and IV), sputum, urine, blood.

Question 8

What is the key initial treatment for sepsis?

Answer 8

1) IV fluids, 2) Immediate parenteral antibiotics, and 3) manage shock

When sepsis is likely (even with no clear source), a bundle of care is recommended within the first 1-3 hours: 1) Appropriate fluid resuscitation: Patients with sepsis usually have concurrent hypovolemia due to third spacing. Volume expansion with isochloremic crystalloids (eg, lactated Ringer, Plasma-Lyte A) is recommended. Fluid boluses are given in increments of 0.5-1.0 L. After each bolus, hemodynamic status, including static (eg, mean arterial pressure [MAP]) and dynamic (eg, pulse pressure [surrogate for stroke volume]) markers of volume responsiveness, is reassessed. For patients susceptible to fluid overload (eg, chronic kidney disease, congestive heart failure), incremental volume loading is generally safe when monitored for pulmonary edema (eg, worsening oxygenation, dyspnea, crackles). 2) Early antibiotics and source control: Empiric broad-spectrum antibiotics, covering gram-negative and gram-positive bacteria, should be administered promptly. Each hour of delay is associated with a 5% to 8% increase in sepsis mortality. Infective sources should be quickly diagnosed (eg, blood cultures, body imaging) and controlled (eg, abscess drained). 3) Management of septic shock: Vasodilatory shock (refractory hypotension despite fluid boluses) with persistent lactic acidemia indicates circulatory failure, causing inadequate tissue perfusion. If hypotension persists after fluid loading, norepinephrine should be infused to maintain MAP >65 mmHg. If hypotension persists despite norepinephrine, a second vasopressor (typically vasopressin) is added, and “stress-dose” steroids (eg, hydrocortisone) are administered to support the adrenal response to extreme stress.

Question 9

Why is early antibiotic therapy crucial in sepsis?

Answer 9

Delays increase mortality by 8% per hour.

Question 10

What other treatments are commonly used after antibiotics?

Answer 10

Oxygen therapy, intravenous (IV) fluids, vasopressors, dialysis.

Question 11

What therapy is given in septic shock when the patient is refractory (remains hypotensive) to IV fluids and pressors?

Answer 11

Glucocorticoids are often administered to patients with septic shock who have refractory hypotension despite adequate fluid resuscitation and vasopressor therapy.

Question 12

A 72-year-old man with a history of diabetes presents with fever, tachycardia, dyspnea, and altered mental status. His blood pressure is 85/50 mmHg. Blood cultures grow E. coli. What is the most likely source of his infection?

A) Pneumonia
B) Skin infection
C) Urinary tract infection
D) Gastrointestinal infection

Answer 12

C) Urinary tract infection.

Question 13

Which of the following symptoms would you not expect in a patient with sepsis?

A) Hypothermia.
B) Tachycardia.
C) Hypertension.
D) Dyspnea.

Answer 13

C) Hypertension.

Question 14

A 1-month-old infant is diagnosed with sepsis. What is the most common pathogen likely to be involved?
A) Escherichia coli.
B) Group B Streptococcus.
C) Staphylococcus aureus.
D) Klebsiella pneumoniae

Answer 14

B) Group B Streptococcus.

Question 15

Which culture type provides the best yield for diagnosing sepsis?

A) Blood cultures.
B) Sputum cultures.
C) Urinary catheter tip cultures.
D) IV catheter tip cultures.

Answer 15

A) Blood cultures.

Question 16

A 65-year-old immunosuppressed woman develops sepsis. What initial treatment is the most critical to reduce her risk of death?

A) IV fluids.
B) Antibiotics.
C) Oxygen.
D) Vasopressors.

Answer 16

B) Antibiotics.

Question 17

A patient presents with fever, cold clammy skin, and hypotension. What clinical test would confirm the suspected diagnosis of sepsis?

A) Lactate levels.
B) Complete blood count.
C) Blood cultures.
D) Arterial blood gas.

Answer 17

C) Blood cultures.

Question 18

Which of the following patients is at the highest risk for developing sepsis?

A) A 35-year-old with well-controlled asthma.
B) A 2-month-old infant with a urinary tract infection.
C) A 40-year-old man with pneumonia.
D) A 70-year-old diabetic woman with skin cellulitis.

Answer 18

D) A 70-year-old diabetic woman with skin cellulitis.

Question 19

What additional treatment is indicated for a sepsis patient whose blood pressure remains low despite IV fluids?

A) Antibiotics.
B) Vasopressors.
C) Antipyretics.
D) Corticosteroids.

Answer 19

B) Vasopressors.

Question 20

A malnourished cancer patient develops sepsis after chemotherapy. Which of the following pathogens is the most likely cause?

A) Staphylococcus aureus.
B) Pseudomonas aeruginosa.
C) Escherichia coli.
D) Candida albicans.

Answer 20

A) Staphylococcus aureus.

Question 21

What is the first-line management for suspected sepsis?

Answer 21

First:
0.9% saline

Second:
Administer broad-spectrum antibiotics
(e.g., vancomycin + ceftriaxone).
Usually obtain microbiological cultures before antibiotics.

Third:
Norepinephrine

Question 22

What vital sign is most strongly associated with increased mortality in sepsis?

Answer 22

Temperature

Especially hypothermia.

Question 23

What is the most reliable global marker of tissue hypoperfusion in sepsis?

Answer 23

Serum lactate levels: Elevated in anaerobic metabolism due to hypoperfusion.

Question 24

What is the normal range for lactate, and when is it concerning in sepsis?

Answer 24

Normal lactate: <2 mmol/L.

Concerning: ≥4 mmol/L indicates severe sepsis or shock.

Question 25

What is the target lactate clearance in sepsis management?

Answer 25

≥10% reduction in lactate levels within 2-6 hours indicates improved tissue perfusion.

Question 26

A mid-aged female comes to the emergency department due to fever, confusion, and malaise beginning 24 hours ago. The patient has a history of rheumatoid arthritis. Current medications include methotrexate, low-dose prednisone, as well as indomethacin as needed. Temperature is 38.9 C (102 F), pulse is 109/min, blood pressure is 73/40 mm Hg, respirations are 24/min, and oxygen saturation is 92% on 6 L/min oxygen. Weight is 80 kg (176 lb). Physical examination shows an ill-appearing woman with dorsocervical and central fat deposition but slim extremities. Mucous membranes appear moist. Laboratory studies reveal a leukocyte count is elevated, serum creatinine of 1.7 mg/dL, and blood glucose level of 228 mg/dL. Chest x-ray is shown. Broad spectrum antibiotics are initiated. The patient remains hypotensive after rapid administration of 2.5 L crystalloid fluid and continuous infusions of norepinephrine. A second vasopressor agent is added. Which of the following is the most appropriate recommendation regarding glucocorticoid therapy for this patient?

Answer 26

This chronically immunosuppressed patient with rheumatoid arthritis has developed probable community-acquired pneumonia (fever, leukocytosis, multifocal airspace opacities on chest x-ray) complicated by septic shock (eg, refractory hypotension requiring vasopressors after volume resuscitation). When faced with physiological stress (eg, sepsis, surgery), the normal response is a boost in endogenous adrenal cortisol production. Cortisol supports peripheral vascular tone and cardiac contractility by increasing the expression and responsivity of adrenergic receptors, which is needed for catecholamine signaling (eg, sensitivity to norepinephrine). In some patients facing extreme stress, adrenal steroid production may not adequately meet the increased demand (ie, relative corticosteroid deficiency), which can lead to refractory hypotension and worsened shock. Preexisting hypofunction of the adrenal glands (eg, autoimmune adrenalitis) or the hypothalamic-pituitary axis (eg, suppression by chronic corticosteroid exposure) can aggravate this relative corticosteroid deficiency. Therefore, patients who are facing an acute physiological stressor and are on chronic corticosteroid therapy require **additional glucocorticoid supplementation** to meet the increased demand (ie, higher than usual home dosage). A standard "stress dose steroid" regimen for septic shock involves 200 mg/day of intravenous hydrocortisone. Although corticosteroids may increase the risk of developing infection, the risk of aggravating an existing infection in patients already receiving appropriate antibiotic therapy is low and outweighed by the benefits of supporting adrenal function. In fact, corticosteroid therapy may improve outcomes in patients with massive inflammation (high C-reactive protein) and pneumococcal pneumonia.