Sepsis

Question 1

Define infection

Answer 1

The invasion of normally sterile host tissues by microorganisms

• Any infection can give way to sepsis but not all infections lead to sepsis

Question 2

Define sepsis

Answer 2

Life threatening organ dysfunction due to a dysregulated host immune response

Definite or likely infection + one red flag

Question 3

Define septic shock

Answer 3

Septic patient remaining hypotensive even though fluids have been given

A subset of sepsis in which particularly profoud circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality

Persisting hypotension - requires vasopressors (press on vessels) to keep MAP above 65

+ lactate >2 despite adequate fluid resuscitation

Question 4

Epidemiology of sepsis

Answer 4

1/5 deaths worldwide are caused by sepsis

150,000 people in the UK have sepsis every year

20-30% mortality from sepsis

50% people with septic shock die

1 person dies every 4hrs from sepsis in UK

£1.5billion cost to NHS per year

Question 5

What are the most common infections that cause sepsis in the UK?

Answer 5

• Pneumonia: strep pneumonia = 35%
• UTI: E.coli = 25%
• Intra-abdominal infections: gram negative & anaerobes = 11%

Skin & soft tissue: staph aureus = 11%

Question 6

How is sepsis clinically assessed?

Answer 6

NEWS2 = 5+

NEWS2 = 3 in any one parameter

Any red flags?

Signs of infection?

Question 7

Sepsis red flags

Answer 7

1. New/ altered mental state
2. Resp rate >25
3. Systolic BP <90 or 20% less than normal
4. Sats <94% (not COPD)
5. >40% oxygen needed to maintain sats
6. Oliguria/ anuria/ AKI/ no urine for 8-12hrs
7. Lactate >2mmol/L
8. Coagulopathy/ rash/ mottled/ ashen/ cyanotic
9. HR >130bpm
10. Chemo within last 2-3 weeks

**If any one of the above is present and an infection is the suspected cause - escalate**

Question 8

Sepsis physiology

Answer 8

Question 9

Explain the pathophysiology of sepsis related to the lungs

Question 10

Important to remember about communicating sepsis as a differential

Answer 10

SEPSIS IS NOT A DIAGNOSIS - IT HAS TO BE ‘SEPSIS SECONDARY TO…’

Question 11

What are the sepsis 6?

Answer 11

Bloods Urine Fluids Antibiotics Lactate Oxygen

The 6 things done to manage sepsis

1. Give oxygen: keep sats >94%
2. Cultures
3. Antibiotics
4. Fluids
5. Lactate level
6. Urine output

Question 12

Discuss giving oxygen in sepsis

Answer 12

Aim: maintain sats >94%

*Unless the patient has T2 hypercapnic respiratory failure

Question 13

Cultures in sepsis

Answer 13

At least 1 set, ideally 2

10mls blood in each bottle

• Allows for targetted antibiotic therapy

Question 14

Anibiotics in sepsis

Answer 14

GIVE WITHIN FIRST HOUR

Use trust antibiotic guidelines to pick the appropriate antibiotic - very broad spectrum given until cultre results available

Question 15

IV fluids in sepsis

Answer 15

Optimises oxygen delivery to tissues

>16yrs: use crystalloids that contain sodium in the range 130–154 mmol/litre with a bolus of 500 ml over less than 15 minutes

If hypotensive or lactate >2mmol/L give IV fluid bolus injection up to 30mls/kg fluid over first 1-2hrs

If, despite fluids, BP and lactate do not improve, consider referral to ICU

Question 16

Lactate in sepsis

Answer 16

Lactate rises becase lack of oxygen = anaerobic respiration = lactate production

High lactate = poor prognosis

*Sepsis is not the only cause of a raised lactate*

Question 17

Urine output in sepsis

Answer 17

Urine output reflects cardiac output - we can’t measure CO on the ward so this is the way to do it

Patient doesn’t need to have a catheter

Minumun of 0.5mls urine/kg/hr e.g. 35mls in 70kg human

Fall in urine production may be the first sign that CO is falling, even if B is normal

Question 18

Rsik factors for sepsis

Answer 18

Very young (<1yr)/ very old (>75yrs)

Immunocompromised: cancer, DM, splenectomy, steroids, immunosuppressant drugs

Recent surgery

Breach of skin integrity: cuts/ burns/ blisters

IV drug use

Indwelling lines/ catheters

Question 19

Why do we measure urine output in sepsis?

Answer 19

It is a marker of cardiac output via kidney function

Question 20

What is your responsibility in cases of suspected sepsis

Answer 20

1. Do sepsis 6 (BUFALO) within 1hr
2. Escalate to reg/ consultant
3. Regularly review patient
4. Refer to ICU if no improvement

Question 21

What is post-sepsis syndrome?

Answer 21

Subtle symptoms that occur following sepsis

• Sadness/ anxiety
• Dysphagia
• Weakness
• Clouded thinking
• Insomnia
• Poor memory
• Poor concentration
• Fatigue

Question 22

Compliations of sepsis

Answer 22

Death

Loss of fingers/ toes/ limbs due to dry gangrene

Impact on life and ability to work

Post-sepsis syndrome

Question 23

Finding the source of infection in sepsis

Answer 23

• PMH: immunosuppression
• Vaccinations: travel immunisation
• Recent hospital stay: SSI/ indwelling devices
• Contacts: family/ friends/ co workers
• Pets: psittacosis, campylobacter
• Travel: location, food, sexual contacts, Legionnaires
• Occupation: farmers, animal handlers, healthcare worker (GI infections/TB/blood borne), sewage (leptospirosis)
• Food: shellfish (Hep A), poultry (campylobacter/ salmonella)
• Leisure activities: tick bites (Lyme disease), swimming, canoeing (leptospirosis)
• Blood borne: IVDU/ tattoos
• Sexual history

Question 24

Risk assessment - NICE sepsis guidance

Answer 24

If sepsis is suspected the risk of severe illness is stratified

Behaviour and history: not waking, continuous cry, appears ill, carer concerned, impaired immune system

Breathing: grunting, apnoea, low sats, nasal flaring, crackles in chest, needing 40% oxygen to maintain sats >94%

Circulation: > <60bpm, cap refill 3+ seconds, cold peripheries, leg pain

Skin

Temperature

Urine

Question 25

Risk factors for sepsis

Answer 25

Age \>65yrs Immunocompromised Any skin breaches e.g. lines, surgery, haemodialysis, IV drug use Pregnant Alcoholic

Question 26

Are sepsis rates affected by season?

Answer 26

Yes - 1.4x more likely in winter

Question 27

Aetiology of sepsis

Answer 27

62% = gram negative e.g. pseudomonas spp. end e.coli 47% gram positive e.g. staph aureus 19% fungal \*Causative agent not always found

Question 28

Investigations in sepsis

Answer 28

**Cultures:** take bloods before antibiotics atrted - but don't delay antibiotic administration as a result If a line infection is suspected, remove the line and culture the tip **Serum lactate**: marker of stress and worse prognosis, high lactate = hypoperfusion **Urine output:** measure hourly - low output suggests AKI and low CO **FBC:** thrombocytopenia of non-haemorrhagic origin can occur in sepsis U&E: renal function **LFTs:** end organ dysfunction (esp. raised bilirubin) **Baseline ECG** to rule out differentials, also arrhythmias often seen in older people with sepsis **CRP:** sensitive but not specific for sepsis

Question 29

Differentials for sepsis

Answer 29

Depends on what you think sepsis is secondary too - Non-infectious inflammatory response - MI - Acute pancreatitis - Massive PE - Malignant yperthermia - Drug induced fever and coma

Question 30

What is APACHE 2 scoring system?

Answer 30

Used to establish illness severity in ICU and predict risk of deaht 25+ = high risk of death

Question 31

Management of sepsis

Answer 31

General - Establish venous access early to allow for IV antibiotics and fluids to be given Antibiotics: broad spec within 1hr Fluids: 500mL crystalloid over \<15mins and repeat if clinically indicated but don't exceed 30mL/ kg i.e. 2L Oxygen: sats \>94% or 88-92 if T2RF Measure urine output hourly BUFALO mnemonic Consider continuous monitoring or at least every 30 mins

Question 32

Antibiotic choice in sepsis

Answer 32

Surviving sepsis campaign suggests 2 antibiotics of different classes aimed at the most likely bacterial pathogen for the intial management

Question 33

Fluid resus in sepsis

Answer 33

Seems to be a marginal benefit using balanced crystalloid over normal saline \*Colloids no longer used in emergency med in the UK

Question 34

Most common site of infection leading to sepsis?

Answer 34

Resp tract

Question 35

Which antibiotics are used if meningococcal sepsis is suspected?

Answer 35

Hospital: IV ceftriaxone Community: benzyl penicillin

Question 36

How much crystalloid is given in sepsis before giving a vasopressor?

Answer 36

2-3L

Question 37

Examples of vasopressors

Answer 37

* Norepinephrine * Epinephrine * Vasopressin (Vasostrict) * Dopamine * Phenylephrine * Dobutamine

Question 38

What is the qSOFA score?

Answer 38

quick Sequential Organ Failure Assessment A way to assess for sepsis Consider sepsis and commence treatment if any one or more of the following present: RR \>22 Systolic BP \<100 Altered mental status (lower GCS than normal)

Question 39

What is neutropenic sepsis?

Answer 39

Systemic radio or chemotherapy can cause bone marrow suppression and limit the ability to respond to infection Patients with neutropenic sepsis can rapidly deteriorate without warning so ensure they receive immediate treatment Suspect in patients with signs of illness and a neutrophil count of \<0.5 x 10\*9/L