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[ ESA 3- Infection and Immunity > Sepsis > Flashcards

Sepsis Flashcards

1
Q

What factors should be considered when making a diagnosis of sepsis?

A 
Age
Physiological state
Pathological state
Social factors
Relative time
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2
Q

What needs to be established regarding pathological state in sepsis?

A

Any ongoing past medical history that could impact the diagnosis

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3
Q

Give two examples of ongoing medical history that could impact a diagnosis of sepsis

A

Diabetes

Cancer

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4
Q

What is the importance of social factors in a diagnosis of sepsis?

A

If they are in close contact with other people, could impact on potential source and potential for spread

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5
Q

What contributes to a diagnosis of sepsis?

A

History
Examination
Investigations

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6
Q

What is important when making a diagnosis of sepsis?

A

The process of diagnosis needs to be condensed into essential information, as a very rapid assessment needs to be made

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7
Q

What features will be seen on examination of a patient with sepsis?

A 
Pale
Clammy
Very high temperature
Increased pulse
BP may be normal, or may be raised
Raised respiratory rate
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8
Q

How is a clinical assessment made of a patient who looks like they may have sepsis?

A

Using an early warning score (EWS)

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9
Q

What is a healthy EWS score?

A

0

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10
Q

What is considered to be a high EWS score?

A

3+

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11
Q

What is the EWS based on?

A 
Basic observations; 
RR
HR
Temp
BP
Conscious and alert?
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12
Q

Give three examples of clinical features suggesting a source that could be considered when making a diagnosis of sepsis

A

Pneumonia
UTI
Meningitis

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13
Q

What are the clinical features of sepsis?

A

Neck stiffness

Non-blanching rash

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14
Q

What are the red flags in sepsis?

A

High RR
Low BP
Unresponsive

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15
Q

What does a low BP indicate in sepsis?

A

Heading towards septic shock

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16
Q

What is required if a patient has red flag sepsis?

A

Urgent action is required; inform senior doctor for review, and send for urgent investigations

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17
Q

What is the sepsis 6 bundle?

A 
Oxygen
Blood cultures
IV antibiotics
Fluid challenge
Lactate
Measure urine output
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18
Q

What timeline should the sepsis 6 bundle be performed on?

A

All needs to occur within a one hour timeline

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19
Q

What urgent investigations should be made with sepsis?

A 
Full blood count 
EDTA bottle for PCR
Blood sugar
Liver function tests
C-reactive protein 
Coagulation studies 
Blood gases
Other microbiology samples
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20
Q

What should be looked for in the full blood count of a sepsis patient?

A

Urea and electrolytes

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21
Q

What does the measurement of urea and electrolytes in a sepsis patient determine?

A

Renal function

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22
Q

What is C-reactive protein?

A

An acute phase reactant

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23
Q

What other microbiological samples should be taken in sepsis?

A

CSF

Urine

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24
Q

How can a diagnosis of sepsis be confirmed?

A

Blood culture
PCR of blood
Lumbar puncture

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25
Q

What must a blood culture investigating sepsis determine?

A

Antibiotic susceptibility

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26
Q

Why must a blood culture in sepsis determine susceptibility?

A

Because of antibiotic resistance

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27
Q

When should a lumbar puncture be done?

A

Only after checking contraindiciations

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28
Q

What investigations can be done subsequent to a lumbar puncture?

A

Microscopy and culture of cerebrospinal fluid
PCR of CSF
Glucose and protein estimation in biochemistry
Appearance
Gram stain

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29
Q

What should be assessed when looking at the appearance of a lumbar puncture sample?

A

Turbidity

Colour

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30
Q

How many cells should the CSF normally contain?

A

Virtually none

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31
Q

What colour should the CSF normally be?

A

Clear

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32
Q

Why is a gram stain performed following a lumbar puncture?

A

Most rapid way of determining likely diagnosis

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33
Q

How has the definition of sepsis changed?

A

Terms SIRs and severe sepsis are no longer used

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34
Q

How has the definition of sepsis not changed?

A

Process of recognition, and specifics of management not changed

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35
Q

What is sepsis?

A

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

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36
Q

What organs may be dysfunctioning in sepsis?

A

Kidney
Heart
Brain
Haemopoetic

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37
Q

What is meant by dysregulation of host response?

A

Overreaction of host to the insult of infection

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38
Q

What is septic shock?

A

Persisting hypotension requiring treatment to maintain blood pressure despite fluid resuscitation

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39
Q

What is the prognosis of septic shock?

A

Imminently fatal unless treated very quickly

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40
Q

What is required in the case of septic shock?

A

Transfer to ICU

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41
Q

What is bacteraemia?

A

Presence of bacteria in the blood, with or without clinical features

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42
Q

How severe is bacteraemia?

A

Can be asymptomatic, or may be very unwell

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43
Q

What does bacteraemia specifically require?

A

Demonstration

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44
Q

How is bacteraemia demonstrated?

A

Blood cultures

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45
Q

What is septicaemia?

A

An outdated clinical term meaning generalised sepsis

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46
Q

What is the pathogen in meningococcal meningitis sepsis?

A

Bacteria Neisseria meningitidies

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47
Q

What kind of bacteria is meningococcal meningitis?

A

Gram -ve dipolococcus

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48
Q

What are the main serogroups of Neisseria meningitis?

A

A
B
C
W-135

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49
Q

What does the serogroup of Neisseria meningitides depend on?

A

The polysaccharide capsular antigen

50
Q

What is the purpose of Neisseria meningitides polysaccharide capsular antigen?

A

Evades immune response by preventing phagocytosis

51
Q

What does the outer membrane of Neisseria meningitides act as?

A

An endotoxin

52
Q

How is meningococcal meningitis spread?

A

Direct contact with respiratory secretions

53
Q

What % of young adults may be carriers of meningococcal meningitis?

A

Up to 25%

54
Q

What is meant by being a carrier of meningococcal meningitis?

A

Colonised with no signs or symptoms of infections

55
Q

What does acquisition of meningococcal meningitis lead to?

A

Either clearance, carriage, or invasion

56
Q

What is the problem with young adults being carriers of meningococcal meningitis?

A

May spread to other people

57
Q

How can carriers of meningococcal meningitis spread the pathogen to other people?

A

By aerosols and nasopharyngeal secretions

58
Q

What can happen in a few people who are infected with meningococcal meningitis?

A

The infection can be rapidly progressive, invasive, and potentially fatal if not recognised and treated promptly

59
Q

How many cases of meningococcal meningitis are there per year in England?

A

~1000

60
Q

What serogroup are the cases of meningococcal meningitis in England?

A

Group B

61
Q

Give an example of where other serogroups of meningococcal meningitis predominate?

A

Meningitis belt across Africa is the group A strain

62
Q

What is the fatality rate of meningococcal meningitis?

A

~10%

63
Q

What is happening to the fatality rate of meningococcal meningitis?

A

It is improving over the years

64
Q

Why is the fatality rate of meningococcal meningitis improving over the years?

A

Getting better at recognising and managing

65
Q

How can meningococcal meningitis be prevented?

A

Vaccination

Antibiotic prophylaxis

66
Q

What are the vaccines available for meningococcal meningitis?

A

Meningococcal C conjugate vaccine
ACWY vaccine
Serogroup B vaccine

67
Q

How effective is the meningococcal C conjugate vaccine?

A

Very

68
Q

When was the meningococcal C conjugate vaccine introduced in the UK?

A

1999

69
Q

What did the introduction of the meningococcal C conjugate vaccine lead to?

A

A dramatic drop in cases

70
Q

Who is the ACWY vaccine for?

A

Originally for immunocompromised patients and travel protection, especially for middle east, but is now replacing the MenC vaccine

71
Q

Why is the ACWY vaccine replacing the MenC vaccine?

A

Due to the increase in W cases in the UK

72
Q

When was the serogroup B vaccine introduced in the UK?

A

Sep 2015

73
Q

Why was a meningitis serogroup B vaccine hard to develop?

A

It is a very different strain in terms of vaccination, and the B capsule is poorly immunogenic and similar to neural tissue

74
Q

What is the result of the meningitis serogroup B capsule being similar to neural tissue?

A

Potential side effects

75
Q

Why are potential side effects not acceptable in a meningitis vaccine?

A

As you are giving it to 10,000s of people against a rare disease

76
Q

How was the serogroup B vaccine developed?

A

After screening candidate subcapsular antigens from genome studies

77
Q

How many antigens does the current serogroup B vaccine have?

A

4

78
Q

When is the serogroup B vaccines given?

A

At 2, 4, and 12 months, and adults at increased risk

79
Q

What has there been massive debate over regarding the serogroup B vaccine?

A

Millions of pounds versus a small number of cases

80
Q

What is the result of the serogroup B vaccine introduction?

A

Beginning to see drop in number of cases

81
Q

What is meant by meningitis being a notifiable disease?

A

Person diagnosing, e.g. GP, has to inform local Health Protection Unit of PHE of any cases

82
Q

What happens once PHE has received notification of a meningitis case?

A

They decide what, if any, action to take

83
Q

What action may PHE take on receiving notification of a case of meningitis?

A

Close contacts are determined, and can be given antibiotic prophylaxis and considered for vaccination

84
Q

Why would close contacts of someone with meningitis be considered for antibiotic prophylaxis?

A

Break chain of transmission

85
Q

How does giving antibiotic prophylaxis to the close contacts of a person with meningitis break the chain of transmission?

A

Removes strain from carriers

Short term protection for those in close contact

86
Q

What is the inflammatory cascade intended to do?

A

Combat infectious stimulus

87
Q

How does the inflammatory cascade combat an infectious stimulus?

A

Confine infection to produce a local abscess

88
Q

What happens when endotoxins bind to macrophages?

A

They cause local and systemic effects

89
Q

What are the local effects of endotoxins binding to macrophages?

A

Cytokines are released

90
Q

What cytokines are released locally when endotoxins bind to macrophages?

A

Tissue necrosis factors and interleukins

91
Q

Give an example of a tissue necrosis factor

A

TNF-alpha

92
Q

Give an example of an interleukin

A

IL-1

93
Q

What do tissue necrosis factors and interleukins do when released locally?

A

Stimulates inflammatory response, promoting wound repair and recruits RE system

94
Q

What are the systemic effects of endotoxins binding to macrophages?

A

Cytokines are released into the circulation

95
Q

What is the result of cytokines being released into the circulation?

A

Stimulates growth factor, macrophages, and platelets

96
Q

What is the goal of releasing cytokines systemically?

A

Control of infection

97
Q

What is the result of the infection not being controlled in sepsis?

A

Cascades are activated to a degree that there is insult to host

98
Q

What do cytokines lead to in sepsis?

A

Activation of humoral cascades and the RE system, leading to circulatory insult

99
Q

What does circulatory insult include in sepsis?

A

Disseminated intravascular coagulation and organ injury

100
Q

What is the problem with disseminated intravascular coagulation in sepsis?

A

Because clotting is dysregulated, organs can loose their effective blood supply, and start to fail

101
Q

Why do cytokines cause problems with clotting?

A

They initiate the production of thrombin and thus promote coagulation
Inhibit fibrinolysis

102
Q

What happens if cytokines promote coagulation in small vessels?

A

It impairs circulation

103
Q

What does the coagulation cascade lead to in sepsis?

A

Microvascular thrombosis

104
Q

What does microvascular thrombosis lead to?

A

Organ ischaemia
Dysfunction
Failure

105
Q

What is microvascular injury a major cause of?

A

Shock and multiorgan failure

Progressive necrosis

106
Q

Why does microvascular injury lead to progressive necrosis?

A

Circulatory collapse means the supply to non-essential organs, such as hands and feet, is lost

107
Q

What is sometimes required to preserve life as a result of microvascular injury in sepsis?

A

All four limbs need to be amputated

108
Q

What are the specific treatments for sepsis?

A

Antimicrobials

Surgery

109
Q

What antimicrobial agent should be used in sepsis?

A

One likely to be active against the pathogens that cause meningitis in the age group
Must be agent that penetrates into the CSF

110
Q

Why is it important to consider the age group when looking to treat sepsis?

A

The causative organism is going to be different in neonates and the elderly

111
Q

What is the emperic antimicrobial choice in sepsis?

A

Ceftriaxone

112
Q

Why may surgery be required for sepsis?

A

Drainage

Debridement

113
Q

Why might surgical drainage be required in sepsis?

A

If large collection of pus

114
Q

Why might debridement be required in sepsis?

A

If lots of dead tissue, or if infected limb needs to be amputated

115
Q

What are the supportive treatments for sepsis?

A 
Symptom relief 
Physiological restoration 
Consider early referral to ITU
Sepsis six
Regular monitoring and reassessment
116
Q

How can the symptoms of sepsis be relieved?

A

Pain relief
Blood if anaemia
Prevent clotting

117
Q

When can life threatening complications of sepsis occur?

A

Immediately, or over next few hours/days

118
Q

What are the life threatening complications of sepsis?

A

Respiratory failure
Acute kidney injury
Raised intracranial pressure
Ischaemic necrosis of digits/hands/feet

119
Q

Can respiratory failure occur if a sepsis patient is ventilated?

A

Yes

120
Q

Why may sepsis lead to acute kidney injury?

A

Kidney is unable to excrete urea and creatinine

121
Q

What is the result of AKI in sepsis?

A

The patient is poisoned

[ ESA 3- Infection and Immunity (15 decks)

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