Sepsis and septic shock

Question 1

What is the definition of sepsis?

Answer 1

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

Question 2

What is the traditional model of sepsis?

Answer 2

SIRS -> sepsis -> severe sepsis -> septic shock

Question 3

What is sepsis a combination of?

Answer 3

SIRS + infection

Question 4

What is severe sepsis a combination of?

Answer 4

Sepsis + end organ damage

Question 5

What is septic shock a combination of?

Answer 5

Severe sepsis + hypotension

Question 6

What is a quickSOFA (qSOFA) score?

Answer 6

Abnormal mental status
RR >22/min (tachypnea)
Systolic BP <100mmHg (hypotension)

Question 7

What does a SOFA score >2 mean?

Answer 7

Overall mortality risk 10% in general hospital population with suspected infection

Question 8

At what SOFA score can organ dysfunction be identified as an acute change?

Answer 8

> 2

Question 9

For each hour’s delay in administering antibiotics in septic shock, what percentage does mortality increase by?

Answer 9

7.6%

Question 10

What are barriers the body has against sepsis?

Answer 10

Physical barrier
Innate immune system
Adaptive immune system

Question 11

What is the origin of sepsis?

Answer 11

Breach of integrity of host barrier - physical or immunological - organism enters via bloodstream

Question 12

Patients with sepsis have features consistent with immunosuppression, which are:

Answer 12

Loss of delayed hypersensitivity
Inability to clear infection
Predisposition to nosocomial infection

Question 13

What are the three phases in the pathogenesis of sepsis?

Answer 13

1. Release of bacterial toxins
2. Release of mediators
3. Effects of specific excessive mediators

Question 14

What are some commonly released toxins in the first stage of the pathogenesis of sepsis?

Answer 14

Gram neg: liopolysaccharide (LPS)
Gram pos:
Microbial-associated molecular pattern (MAMP)
Superantigens

Question 15

What are the two types of mediator roles in sepsis?

Answer 15

Pro-inflammatory mediators

Compensatory anti-inflammatory mediators

Question 16

What do pro-inflammatory mediators do?

Answer 16

Cause inflammatory responses that characterise sepsis

Question 17

What do compensatory anti-inflammatory mediators do?

Answer 17

Can cause immunoparalysis

Question 18

What happens when the balance between pro-inflammatory mediators and compensatory anti-inflammatory mediators shifts towards pro-inflammatory?

Answer 18

Septic shock with multi organ failure and death

Question 19

What happens when the balance between pro-inflammatory mediators and compensatory anti-inflammatory mediators shifts towards compensatory anti-inflammatory?

Answer 19

Immunoparalysis with uncontrolled infection and multi organ failure

Question 20

What are the general features of sepsis?

Answer 20

Fever >38'C
Hypothermia <36'C
Tachycardia >90bpm
Tachyponea >20/min
Altered mental status
Hyperglycaemia >8mmol/l in absence of diabetes

Question 21

How does a fever present in sepsis?

Answer 21

Chills
Rigors
Flushes
Cold sweats
Night sweats

Question 22

What is a FBC likely to show in sepsis?

Answer 22

Leucocytosis
Leucopenia
Normal WCC
High CRP
High procalcitonin

Question 23

What is leucocytosis?

Answer 23

Increase in number of white cells in blood

Question 24

What is leucopenia?

Answer 24

Reduction of number of white cells in blood

Question 25

What is the blood pressure likely to be in sepsis?

Answer 25

Arterial hypotension (systolic <90mmHg)

Question 26

What is the SvO2 likely to be in sepsis?

Answer 26

>70%

Question 27

What are other organ dysfunction signs of sepsis?

Answer 27

``` Arterial hypoxaemia Oliguria Creatinine increase Coagulation abnormalities Ileus Thrombocytopenia Hyperbilirubinaemia ```

Question 28

What is the tissue perfusion like in sepsis?

Answer 28

``` High lactate Skin mottling Reduced capillary perfusion Non-blanching rsh of skin Cyanosis ```

Question 29

What host effects can affect sepsis presentation?

Answer 29

Age Co-morbidities Immunosuppression Previous surgery

Question 30

What are the SEPSIS 6?

Answer 30

``` Oxygen Blood cultures Antibiotics IV fluid challenge Blood lactate Measure urine output ```

Question 31

Why blood cultures for SEPSIS 6?

Answer 31

Make microbiological diagnosis | Can repeat if rise in temp

Question 32

Why blood lactate in SEPSIS 6?

Answer 32

Marker generalised hypoperfusion/severe sepsis/poor prognosis

Question 33

Why measure urine output SEPSIS 6?

Answer 33

Low urine output = marker renal dysfunction

Question 34

What is type A lactic acidosis due to?

Answer 34

Hypoperfusion

Question 35

What is type B lactic acidosis due to?

Answer 35

Mitochondrial toxins Alcohol Malignancy Metabolism errors

Question 36

When should you consider HDU referral in sepsis?

Answer 36

``` Low BP response to fluids Lactate >2 Elevated creatinine Oliguria Liver dysfunction ```

Question 37

When should you consider ITU referral in sepsis?

Answer 37

Septic shock Multi-organ failure Sedation, intubation, ventilation

Question 38

If qSOFA above 2 what should you do?

Answer 38

Start SEPSIS 6

Question 39

What is the CURB65 score?

Answer 39

Pneumonia severity score

Question 40

What are the prognostic features in the CURB65 scoring system for pneumonia?

Answer 40

``` Confusion Raised blood urea nitrogen Raised RR Low BP Age 65+ ```

Question 41

What is a high risk CURB65 score?

Answer 41

3-5