Sepsis

Question 1

What is sepsis?

Answer 1

is caused when the body’s immune system becomes overactive in response to an infection, causing an exagerrated inflammation which causes body tissue damage

Question 2

Criteria for systemic inflammatory response syndrome (SIRS)?

Answer 2

1. HR>90
2. RR>20
3. T > 38 degrees or < 36 degrees celsius
4. Abnormal WBC count > 12,000 or < 4,000
5. Band cells > 10%
6. Low pCO2

Question 3

Sepsis and SIRS?

Answer 3

2 SIRS criteria + Infection

Question 4

Criteria for severe sepsis?

Answer 4

1. Hypotension
   - systolic BP less than or equal to 90 or MAP of less than or equal to 70.
2. End organ damage
3. Elevated lactic acidosis
4. Thrombocytopenia
   - Platelets of less than 80 thousand

Question 5

Septic shock?

Answer 5

• Severe sepsis and persistent signs of end organ dysfunction
• Mortality 50%

Question 6

Normal response to infection?

Answer 6

non-specific inflammatory response to local infection that happens in 3 phases

Question 7

3 phases of normal response to infection?

Answer 7

1. Vasodilation - increased blood flow to site, infusion of antibodies and cells to fight infection
2. Vessel permeability - antibodies and cells exit bloodstream and enter infected tissue
3. Once infection is controlled, tissue repairs itself

Question 8

Pathophysiology of sepsis?

Answer 8

1. Uncontrolled, exaggerated immune response
2. Endothelium damage, cell mediator activation, disruption of coagulation system homeostasis
3. Vasodilation and capillary permeability
4. Systemic inflammatory response
5. End-organ damage, death

Question 9

What is qSOFA?

Answer 9

quick sequential organ failure assessment score

Question 10

What is the scoring of qSOFA?

Answer 10

The quick SOFA (qSOFA) score, includes 1 point for each of 3 criteria
1. respiratory rate ≥ 22 breaths/min
2. altered mental status, or
3. systolic blood pressure (SBP) ≤ 100 mm Hg
- A qSOFA score ≥ 2 is suggestive of sepsis and warrants treatment instantly

Question 11

The infectious causes of sepsis?

Answer 11

1. bacteria
2. fungi
3. parasites
4. other

Question 12

SIRS triggers?

Answer 12

1. pancreatitis
2. burns
3. trauma
4. other

Question 13

Risk factors for sepsis?

Answer 13

1. Extremes of age (old and young)
2. Recent surgery, invasive procedure, illness, childbirth/pregnancy termination/miscarriage
3. Immunosuppression

Question 14

What extremes of age are risk factors for sepsis?

Answer 14

1. Can’t communicate, need careful assessment
2. Patients with developmental delay
3. Cerebral Palsy

Question 15

Diseases that increase the risk for sepsis?

Answer 15

1. Diabetes
2. Liver cirrhosis
3. Autoimmune diseases (lupus, rheumatoid arthritis)
4. HIV/AIDS
5. Para/quadriplegics
6. Sickle cell disease
7. Splenectomy patients
8. Compromised skin (chronic wounds, burns, ulcers

Question 16

Drugs that cause an increased risk for sepsis?

Answer 16

1. Chemotherapy
2. Post-organ transplant (bone marrow, solid organ)
3. Chronic steroid use
4. Recent antibiotic use
5. Indwelling catheters of any kind (dialysis, Foley, IV, etc)

Question 17

Signs and symptoms for sepsis?

Answer 17

1. Fever = most common (elderly and severely immunosuppressed patients may NOT mount a febrile response)
2. Flu-like symptoms
3. Chills/shaking (mistaken for seizure)
4. Nausea/vomiting
5. Mental status
6. changes/fatigue/lethargy

Question 18

Potential sources of infection?

Answer 18

1. Pneumonia
2. Skin infection – cellulitis, wounds
3. Infection after abdominal surgery
4. Urinary tract infection
5. IV drug use infections
6. Pressure sores

Question 19

Investigations in sepsis?

Answer 19

1. Culture
   - blood, urine, pus swab, sputum
2. Full blood count
3. Urea and creatinine& electrolytes
4. Lumber puncture
5. HIV tests, CD4 count, viral load
6. Radiological
   - CXR, USS, ECHO, CT, MRI
7. Serum lactate
8. Blood glucose

Question 20

Treatment of sepsis?

Answer 20

1. IV fluids, crystolloids, albumin,
2. Broad spectrum antibiotics within one hour of recognition until definitive culture results
3. Oxygen if ARDS or O2 stats below 92

Question 21

Inotropes treatment of sepsis?

Answer 21

1. epinephrine
2. vasopressin
3. Dopamine

Question 22

Supportive treatment of sepsis?

Answer 22

1. ICU care
   - ventilation, plone positioning in ARDS
2. Renal replacement for renal complications
3. Glucose control
4. Venous thromboembolic prophylaxis

Question 23

What is neutropenic sepsis?

Answer 23

Common in cancer patients as a consequence of chemotherapy or direct effect of malignancies on the bone marrow (suppression)
Note: Can also be a consequence of any other causes of severe neutropenia

Question 24

Definition of severe neutropenia?

Answer 24

Severe neutropenia is defined as an absolute neutrophil count of less than 0.5x10^9

Question 25

When does neutropenic sepsis occur?

Answer 25

Neutropenic sepsis commonly occurs 7-14 days after starting chemotherapy

Question 26

When to consider a neutropenic sepsis diagnosis?

Answer 26

in a patient on anti-cancer drugs with a neutrophil count of 0.5x10^9 with: 1. Temp 38 degrees celcius 2. signs and symptoms of sepsis

Question 27

Pathogen that causes neutropenic sepsis?

Answer 27

1. Coagulase-negative 2. gram positive cocci are the commonest cause - particularly staphylococcus epidermidis Note: this is usually due to use of indwelling lines

Question 28

Prophylaxis for a neutropenic patient?

Answer 28

Fluoloquinolones

Question 29

Treatment of neutropenic sepsis?

Answer 29

Antibiotics must be started empirically and immediately - do not wait for FBC results! 1. Piperacirin with tazobactam (Tazocin) a broad spectrum antibiotic combination. 2. Vancomycin can also be added if a patient has central venous lines 3. meropenem with or without vancomycin - if still febrile and unwell after 48 hours of initial antibiotics

Question 30

What do you do if you have no response after 4-6 days of treatment of neutropenic sepsis?

Answer 30

If no response after 4-6 days investigate for fungal sepsis and treat accordingly - Consider G-CSF (granulocyte colony stimulating factor).