Sepsis and septic shock

Question 1

Define sepsis

Answer 1

Systemic illness caused by microbial invasion of normally sterile parts of the body

Question 2

4 descriptions in traditional model of sepsis

Answer 2

SIRS
sepsis - SIRS and infection
severe sepsis - sepsis and end organ damage
septic shock - severe sepsis and hypotension

Question 3

4 SIRS criteria and how many are required to make a diagnosis?

Answer 3

temp >38 or <36
HR - >90
RR>20 or PaCO2 <32
WBC >12 000 or <4000 or >10% bands

Question 4

What from the traditional model of sepsis is no longer used and why?

Answer 4

severe sepsis - no prognostic indicators

Question 5

Septic shock definition

Answer 5

sepsis with refractory hypotension on vasopressors and lactate > 2

Question 6

List some causes of SIRS

Answer 6

pancreatitis
burns
trauma
sepsis

Question 7

qSOFA

Answer 7

hypotension systolic bp <100mmHg
altered mental status
tachypnea RR>22/min

Question 8

What does qSOFA tell us?

Answer 8

patients with suspected infection likely to have a prolonged ICU stay or die in hospital

Question 9

Main management of sepsis is?

Answer 9

SEPSIS 6

Question 10

The main 3 body’s defences (1 barrier +2 immune systems)

Answer 10

physical barrier - skin, mucosa, epithelial lining
innate immune system - IgA in GI trac, macrophages, dendritic cells
adaptive immune system - lymphocytes, Ig

Question 11

3 features patients with sepsis have consistent with immunosuppression?

Answer 11

loss of delayed hypersensitivity
inability to clear infection
predisposition to nosocomial infection

Question 12

Nosocomial?

Answer 12

hospital acquired

Question 13

Change in sepsis syndrome over time in terms of inflammatory and anti inflammatory

Answer 13

initial increase in inflammatory mediators

later a shift towards anti inflammatory immunosuppressive phase

Question 14

3 phases of sepsis syndrome

Answer 14

release of bacterial toxins
release of mediators
effects of specific excessive mediators

Question 15

Commonly released gram -ve bacterial toxins

Answer 15

LPS

Question 16

Commonly released gram positive bacterial toxins

Answer 16

MAMP (LTA) or super antigens

Question 17

Endotoxin - LPS

Answer 17

gram negative needs a binding protein to bind to macrophages via toll like receptors

Question 18

Endotoxin - LTA

Answer 18

gram positive do not need a binding protein

Question 19

Exotoxin

Answer 19

small amounts of gram positive super antigen lead to a large amount of mediators being released - cascade effect

Question 20

What can compensatory anti inflammatory mediators cause?

Answer 20

immunoparlysis

Question 21

Example of main pro inflammatory mediator

Answer 21

TNF alpha

Question 22

Example of main anti inflammatory mediator

Answer 22

IL IRA/4/10/13

Question 23

Brief description of the role of pro inflammatory mediators

Answer 23

complement and coagulation
hyperthermia
vasodilation and endothelial cell-leucocyte adhesion

Question 24

Brief description of the role of anti inflammatory mediators

Answer 24

Inhibit TNF alpha

inhibit coagulation and provide negative feedback

Question 25

Pro inflammatory > compensatory anti inflammatory

Answer 25

septic shock with multi organ failure

Question 26

Compensatory anti inflammatory > pro inflammatory

Answer 26

immunoparalysis with uncontrolled infection and multi organ failure

Question 27

Organ dysfunction in sepsis

Answer 27

brain - confusion, psychosis, altered consciousness blood - decrease platelets and c protein. Increase in D dimer and PT kidneys - oliguria, anuria, increase in creatinine Liver - jaundice, increase liver enzyme and PT, decrease bilirubin lungs - tachypnoea, sats <90% heart - tachycardia, hypotension

Question 28

6 general features of sepsis

Answer 28

``` fever >38 degrees hypothermia <36 degrees tachycardia tachypnoea altered mental status hyperglycaemia ```

Question 29

Who is hypothermia common in sepsis in?

Answer 29

elderly and young (and immunosuppressed)

Question 30

Inflammatory variables in sepsis

Answer 30

``` leucocytosis leucopenia high CRP high procalcitonin normal WCC with >10% immature forms ```

Question 31

Haemodynamic variables in sepsis

Answer 31

arterial hypotension | SvO2 >70%

Question 32

Organ dysfunction variables in sepsis

Answer 32

``` thrombocytopenia arterial hypoxaemia oliguria increase creatinine ileus ```

Question 33

Tissue perfusion variables in sepsis

Answer 33

high lactate | skin mottling and reduced capillary perfusion

Question 34

4 effects of the host on sepsis presentation

Answer 34

age co morbidities immunosuppression previous surgery

Question 35

How the organism can affect the sepsis presentation

Answer 35

gram +ve or -ve virulence factors bioburden

Question 36

How the environment can affect the presentation of sepsis

Answer 36

travel occupation hospitalisation

Question 37

SEPSIS 6 basis

Answer 37

Take 3 - blood cultures, blood lactate, urine output | Give 3 - oxygen, IV antibiotics, IV fluid challenge

Question 38

Use of blood cultures

Answer 38

microbiological diagnosis | spike in temp? take 2 sets

Question 39

Lactate use

Answer 39

marker of generalised hypoperfusion/severe sepsis/poorer prognosis

Question 40

What is low urine output a marker of?

Answer 40

renal dysfunction

Question 41

what antibiotics to use and what to consider?

Answer 41

working diagnosis and local policy | consider allergy, CI, interactions, previous MRSA

Question 42

Lactate type A

Answer 42

hypoperfusion

Question 43

Lactate type B

Answer 43

mitochondrial toxins, alcohol, malignancy, metabolism

Question 44

Why send a patient to HDU?

Answer 44

low bp responsive to fluids lactate >2 despite fluid resuscitation elevated creatinine, oliguria liver dysfunction

Question 45

Why send a patient to ITU?

Answer 45

Septic shock multi organ failure sedation, intubation, ventilation

Question 46

CURB 65

Answer 46

``` pneumonia confusion urea resp rate >30 bp low >65 ```