Sepsis

Question 1

what are risk factors for early onset infection (<48h)

Answer 1

maternal pyrexia, chorioamninitis
maternal GBS +
Prior child with GBS
PROM

Question 2

How does bacterial spread in early onset infection occuyr

Answer 2

foetal lungs are in direct contact with infected amniotic fluid, causing pneumonia and septicaemia/bacteraemia

OR

foetus is infected via placenta following maternal infection (viral/listeria)

Question 3

How does early onset infection present in the newborn

Answer 3

resp distrss
apnoea
temp instavbility

vopmiting, poor feeeding, abdo distension, jaundice
neutropoenia
shock, irritability, seizures

Question 4

What are investigations for sepsis - to identify source of infection

Answer 4

Urine dip, MC&S 
FBC (neutropoenia), CRP
Blood culture 
CXR 
LP

Question 5

What antibiotics do you give for early onset infection

Answer 5

BENZYLPEN + GENT

Question 6

what antibiotic do you give for GBS

Answer 6

Benzylpen / ampicillin

Question 7

what are common causes of late onset infection > 48h

Answer 7

coag neg staph - Staph epidermidis
Gram +ve: S aureus, E faecalis
Gram -ve: Klebsiella, pseudomonas

Question 8

What is a suitable regimen for late onset infection

Answer 8

ampicillin + gent

Question 9

what antibiotics work against listeria

Answer 9

amoxicillin
co-trimoxazole

DO NOT GIVE TRIMETHOPRIM in pregnancy

Question 10

what is the most common cause of sepsis in children in UK

Answer 10

COAG NEG Staphylococci

Question 11

What are 4 key things to give in neonatal sepsis

Answer 11

1. Antibiotics, without delay
2. Fluids (as hypovolaemia likely, with circulating fluid lost in interstitium)
3. Inotropic support
4. If in DIC > give FFPor CPP or platelet transfusion

Question 12

What is the first thing you must assess if suspecting sepsis

Answer 12

Assess the HIGH RISK of severe illneess /death from sepsis:

• BEHAVIOOUR (no response to social cues, appears ioll, does not wake / cannot staya awake, weak high pitched cryting)
• HR: tachycardic OR <60bpm
• RR: tachpynoea, grunting, apnoea, O2<90
• mottled/ashen appearance
• central cyanotis s
• non blanching rash
• ages <3m with temp >38
• temp <36

Question 13

What shoouyld you do in community if signs of meningococcal disease

Answer 13

IM benzylpenicillin

Question 14

What are contraindications for an LP in a childl

Answer 14

signs of raised ICP (nausea, vomiting, papilloedema, bradycardia, raised BP)

• focal neurological signss
• shock
• purpura (indicates bleeding)

Question 15

what is Cushing’s reflex

Answer 15

Irregular, decreased respirations (caused by impaired brainstem function) > periods of apnoea
slow HR
Systolic HTN (widening pulse pressure)

Question 16

How does Cushings reflex occur

Answer 16

1. ICP begins to increase, it eventually becomes greater than the mean arterial pressure, which typically must be greater than the ICP in order for the brain tissue to be adequately oxygenated.
2. This difference in pressure causes a decrease in the cerebral perfusion pressure (CPP), or the amount of blood and oxygen the brain is receiving
3. This leads to the brain not receiving enough oxygen (also known as a brain ischemia).
4. To compensate for the lack of oxygen, the sympathetic nervous system is activated, causing an increase in systemic blood pressure and an initial increase in heart rate.
5. The increased blood pressure then signals the carotid and aortic baroreceptors to activate the parasympathetic nervous system, causing the heart rate to decrease.
6. As the pressure in the brain continues to rise, the brain stem may start to dysfunction, resulting in irregular respirations followed by periods where breathing ceases completely.

This progression is indicative of a worsening prognosis.

Question 17

What investigations must you do for sepsis, and with what aims in mind?

Answer 17

1. IDENTIFY SOURCE OF INFECTION

Urine dip, MC&S 
FBC (neutropoenia), CRP
Blood culture 
CXR 
LP

2. ASSESS PATIENT STATUS

VBG:

• blood glas (incl glucose and LACTATE)
• blood culture
• FBC, CRP
• urea and electrolytes
• creat

Question 18

what must you review wihtin 1h in sepsis

Answer 18

LACTATE

Question 19

what do different levels of lactate indicate in terms of risk

Answer 19

lactate >2mmol/L or AKI: HIGH RISK

lactate <2mmol/L : repeat assessment hourly and ensure clinician review

Question 20

How do you manage high risk sepsis

Answer 20

BROAD SPECTRUM ANTIBIOTICS at MAX DOSE without delay (according to trust guidelines)

Monitor child continously
Monitor mental stat with GCS/AVPU

Question 21

What do you do in sepsis if lactate >4mmol/L

Answer 21

immediate IV fluid bolus,

Refer for critical care review for central access and initiation of inotropes

Question 22

What do you do in sepsis if lactate 2-4

Answer 22

Immediate IV fluid bolus

Question 23

What do you do in sepsis if lactate <2

Answer 23

consider IV fluid

Question 24

What antibiotic do you give for meningococcal sepsis

Answer 24

IM benzylpen in community
IV ceftriaxone in hospital

( if <1m do NOT give ceftriaxone - cefotaxime instead)