Sepsis

Question 1

general stats

Answer 1

123,000 cases in england every year

37,000 deaths

Question 2

what is SIRS

Answer 2

systemic inflammatory response syndrome
abnormal regulation of cytokines, endotoxins and acid metabolism
2 or more of the following:
temp <36, >38
heart rate >90bpm
RR >20 
WCC <4 or >12

suspect sepsis until proven otherwise

Question 3

presentations of sepsis

Answer 3

new onset confusion, drowsiness, unwell and cause unknown
abdo pain or distension, dysuria
headache with neck stiffness
endocarditis, line infection
cellulitis, wound infection
productive cough, chest pain

important in:
immunosuppressed/compromised
recent chemo/haem disorder
absolute neutrophil count likely or proven to be <1.0

Question 4

risk factors for the development of sepsis

Answer 4

<1, >75, very frail

impaired immunity:
illness/drugs (e.g. methotrexate)
chemo
DM, splenectomy, sickle cell
surgery or invasive procedure within last 6 weeks
breach of skin integrity
long term steroids
IVDU
indwelling catheters or lines

given birth or miscarriage within last 6 weeks

Question 5

qSOFA

quick sepsis related organ failure assessment

Answer 5

2 or more:
GCS <15
RR >/= 22
systolic BP> 100mmHh

Question 6

sepsis 6

Answer 6

IN
fluids
ABx
high flow oxygen
OUT
bloods (and cultures)
lactate
urine output

timeframe - ‘the golden hour’

Question 7

high risk criteria

Answer 7

objective evidence of new altered mental state
RR >25
new need for >40% FiO2 to maintain sats >92% (88% in known COPD)
sBP 90mmHg or less, or more than 40mmHg below normal
HR >130bpm
no urine in the last 18hrs
<0.5ml/kg/hr if catheterised
mottled or ashen skin
cyanosis of skin, lips, tongue
non-blanching rash

Question 8

moderate to high risk criteria

Answer 8

Hx from patient or relative of new altered mental state
acute deterioration of functional state
impaired immune system
trauma, surgery or invasive procedures within last 6 weeks
RR 21-24
sBP 91-100mmHg
HR 91-130bpm
pregnant women 100-130 bpm or new onset arryhthmia
no urine in past 12-18hrs
catheterised 0.5-1ml/kg/kr
tympanic temperatures <36
signs of potential infection including redness, swelling or discharge at surgical site or breakdown of wound

Question 9

low risk criteria

Answer 9

normal behaviour
no other high or moderate to high risk criteria met
no non blanching rash

Question 10

moderate to high risk factors

Answer 10

with lactate >2mmol/l or evidence of AKI, treat as high risk

lactate <2mmol/l and no AKI, repeat assessment hourly, senior review within 3hrs

Question 11

high risk factors

Answer 11

failure to respond:
sBP persistently <90mmHg
reduced levels of consciousness despite resus
RR >25 or a new need for mechanical ventilation
lactate not reduced by more than 20% of initial value within 1hr

lactate >4mmol/l or sBP <90mmHg, speak to critical care

Question 12

septic shock

Answer 12

sepsis imnduced tissue hypoperfusion persisting after resus with 30mls/kg IV isotonic crystalloid fluid
causing end organ dysfunction

Question 13

effects of septic shock

Answer 13

lungs: ARDS
PaO2 <3kPa, low sats

brain: encephalopathy
confusion, coma, agitation ischaemia, haemorrhage, DIC), volume overload

kidney: AKI
low urine output, electrolyte abnormal, volume overload

heart: failure
fluid overload, hypotension

Question 14

Px fluids for sepsis 6

Answer 14

be cautious of:
PMH - cardiac Hx
signs of overload

IV fluid resus:
crystalloids e.g. NaCl 0.9% or Hartmann’s (compound sodium lactate)

re-assess after IV fluid bolus
if no improvement, give 2nd bolus
if no improvement after 2nd bolus, alert consultant, must attend