Sepsis (A&E)

Question 1

Define sepsis.

Answer 1

Life-threatening organ dysfunction caused by a dysregulated host response to an infection

Question 2

What is septic shock?

Answer 2

Persistent hypotension requiring vasopressors to maintain mean arterial pressure >65mmHg AND serum lactate >2mmol/L (>18mg/dL)

Question 3

When do we suspect sepsis?

Answer 3

Suspect sepsis based on acute deterioration in patient in whom there is evidence of infection

Question 4

What are the common microbial causes of sepsis? (3)

Answer 4

• S. aureus
• Pseudomonas sp.
• E. coli

Question 5

Describe the pathophysiology of sepsis.

Answer 5

• immune system activation resulting in cellular and humoral responses (cytokines, IL1, IL6, NO, proteases, ROS, complement system)
• endothelial activation (tissue oedema), pro-coagulative state
• vasodilation, increased capillary permeability (decrease in circulative volume) –> tissue dysfunction due to decreased oxygen delivery

Question 6

What is the SEPSIS 6?

Answer 6

Within 1h of the risk being recognised, TAKE:

• two sets of blood cultures
• serum lactate on a blood gas
• hourly urine output

Within 1h of the risk being recognised, GIVE:

• IV broad-spectrum Abx (after blood cultures)
• IV fluids if evidence of bacterial infection
• oxygen if any sign of circulatory insufficiency

Question 7

How does sepsis present? (11)

Answer 7

• signs associated with specific infection e.g. cough, dysuria, abdominal pain
• NEWS2: 5+
• temperature - high or low +/- rigors
• tachypnoea
• hypotension
• tachycardia
• altered mental state
• low O2 sats
• oliguria
• poor CRT, mottling, ashen appearance
• cyanosis

Question 8

What is measured in the NEWS score for sepsis? (6)

Answer 8

• breathing rate: tachypnoea
• temperature: pyrexia
• O2: low oxygen
• BP: hypotension
• HR: tachycardia
• mental status: altered

Question 9

What are the risk factors for sepsis? (10)

Answer 9

• age >65
• immunocompromised
• indwelling lines or catheters
• recent surgery
• haemodialysis
• DM
• IVDU
• breached skin integrity
• alcohol dependence
• pregnancy

Question 10

What are the first-line investigations for sepsis? (8)

Answer 10

• TAKE 3: 2x blood cultures, serum lactate, hourly urine output
• FBC, U&Es, serum glucose, CRP, LFTs
• ABG/VBG
• procalcitonin (guides Abx therapy)
• clotting screen
• ECG
• urinalysis
• troponin (raised in chest-source of sepsis due to V/Q mismatch secondary to sepsis –> myocardial ischaemia)

Question 11

What are some differential diagnoses for sepsis? (10)

Answer 11

• neutropenic sepsis
• non-infectious causes of SIRS (post-op, trauma, burns, transplant, hyperthyroidism, Addisonian crisis etc)
• MI
• pericarditis
• myocarditis
• acute pancreatitis
• massive PE
• leukaemia (fever, leukocytosis, anaemia, tachycardia, multi-organ dysfunction, dyspnoea)
• malignant hyperthermia (>41.1C + muscle rigidity following anaesthetics)
• drug-induced fever and coma

Question 12

What is neutropenic sepsis? (3)

Answer 12

• high temperature + neutrophil count <0.5x10^9
• in patients receiving cytotoxic chemotherapy
• prophylaxis with fluoroquinolone can be offered

Question 13

What acronym can be used to remember the investigations and management of sepsis?

Answer 13

SEPSIS 6 - OAFBLU:
Give:

• O2 - aim for 94-96%
• broad-spectrum IV Abx
• IV Fluids - 500ml crystalloid fluid (NaCl or Hartmann’s)

Take:

• Blood cultures - immediately, before Abx started
• serum Lactate - severity of sepsis, metabolic acidosis with raised lactate = potential sepsis
• Urine output hourly

Question 14

What else can we give for sepsis management, outside of the SEPSIS 6?

Answer 14

Vasopressor (noradrenaline) + inotrope (dobutamine/adrenaline) + corticosteroid (hydrocortisone sodium succinate)

Question 15

What is the empirical antibiotic of choice for neutropenic sepsis?

Answer 15

Piperacillin with tazobactam (Tazocin)

Question 16

What are some complications of sepsis? (8)

Answer 16

• renal dysfunction
• hypotension
• ARDS
• multiple organ system failure
• myocardial dysfunction and failure
• hepatic encephalopathy
• DIC
• neurological sequelae (focal deficits)

Question 17

Describe the prognosis of sepsis.

Answer 17

Sepsis is present in many hospitalisations that culminate in death