Sepsis and Septic Shock Overview

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Questions and Answers

According to the CDC, approximately how many adults in the United States develop sepsis annually?

270,000

1.7 million (correct)

3.4 million

500,000

Which type of infection is most commonly associated with the progression of sepsis?

Gram-positive bacterial infections (correct)

Gram-negative bacterial infections

Fungal infections

Viral infections

Which of the following is NOT identified as a factor contributing to the increasing incidence of sepsis?

Decreasing use of invasive procedures (correct)

Increased antimicrobial resistance

Aging population

Increased use of immunosuppressive medications

According to the Sepsis 3 definition, what is the hallmark of sepsis?

Life-threatening organ dysfunction caused by a dysregulated host response to infection Signup and view all the answers

What condition is characterized by profound circulatory and metabolic abnormalities, greatly increasing mortality?

Septic shock Signup and view all the answers

Which of the following is a hematological disorder associated with enhanced coagulation and is a possible complication of severe sepsis?

Disseminated intravascular coagulopathy (DIC) Signup and view all the answers

What is the immediate immune response activated upon pathogen invasion?

Innate immune response Signup and view all the answers

Which of the following is a late manifestation of septic shock, indicating prolonged poor tissue perfusion?

Hypotension, tachycardia, and hyperventilation Signup and view all the answers

In the progression of MODS, which organ system is typically the first to show signs of dysfunction?

Lungs Signup and view all the answers

What is a late indicator of progressive sepsis related to clotting that indicates the development of Disseminated Intravascular Coagulation (DIC)?

Excessive bleeding from puncture sites Signup and view all the answers

What is the significance of elevated venous oxygen saturation (SvO2) and ScvO2 levels in the later stages of sepsis?

They reflect a maldistribution of blood flow and are not indicative of recovery. Signup and view all the answers

Which of these laboratory findings is NOT associated with the progression to Disseminated Intravascular Coagulation (DIC) in sepsis?

Elevated antithrombin III levels Signup and view all the answers

What is the primary mechanism that leads to the systemic vasodilation observed in sepsis?

Excessive release of pro-inflammatory cytokines damaging endothelial cells. Signup and view all the answers

In the later stages of septic shock (cold shock), what best describes the change in venous oxygen levels?

Increased due to maldistribution of blood flow. Signup and view all the answers

Which of the following best describes the state of blood volume during septic shock?

Normal blood volume, but a state of relative hypovolemia. Signup and view all the answers

What is the role of antithrombin III in the coagulation cascade?

Deactivates thrombin. Signup and view all the answers

Which of the following best contributes to the pro-inflammatory effect seen in sepsis?

Endotoxins released by gram-negative bacteria and exotoxins released by gram-positive bacteria. Signup and view all the answers

What is the primary goal of the Surviving Sepsis campaign?

To standardize care and reduce sepsis-related mortality through evidence-based practice. Signup and view all the answers

In early or 'warm' sepsis, what assessment findings would be most expected?

Bounding pulse, warm, flushed skin, and tachycardia. Signup and view all the answers

Which is the most accurate description of protein C's role in the coagulation process?

To modulate the production of thrombin and promote fibrinolysis. Signup and view all the answers

What is the commonality of tools like NEWS, MEWS and SOFA in sepsis assessment?

They assess various clinical parameters to determine the severity of the illness and predict mortality. Signup and view all the answers

According to the latest guidelines, within what timeframe should a patient needing a higher level of care be admitted to the ICU?

Within 6 hours Signup and view all the answers

Which of these practices constitutes a first-line therapy for preventing infections in a healthcare setting?

Limiting the use of invasive procedures Signup and view all the answers

Within the 'Surviving Sepsis Campaign' bundle of care, what is the recommended initial intravenous fluid for resuscitation?

Lactated Ringer's solution at 30 mL/kg Signup and view all the answers

Which vasopressor is recommended as the first-line choice by the Surviving Sepsis campaign to maintain the appropriate mean arterial pressure in patients with sepsis?

Norepinephrine Signup and view all the answers

According to the provided information, when should antibiotics be administered in relation to suspected sepsis?

Within 1 hour of identification of sepsis Signup and view all the answers

Which medication is LEAST likely to be implicated in masking a patient's response to pain or discomfort during withdrawal of support?

Proton pump inhibitors (PPIs) Signup and view all the answers

When are corticosteroids typically recommended in the treatment of sepsis according to the Surviving Sepsis guidelines?

Only if the patient has not responded to fluid and vasopressor therapy Signup and view all the answers

What is the PRIMARY mechanism by which stress ulcers develop in critically ill patients?

Impaired mucosal protection from increased bile salts and toxins Signup and view all the answers

Which hemodynamic parameter is preferred for monitoring responsiveness to therapy by the Surviving Sepsis campaign?

Central venous pressure (CVP) with ScvO2 Signup and view all the answers

What is the most common initial clinical manifestation when clots lodge in the microvasculature during the thrombotic phase of DIC?

Cyanosis and ischemia in the extremities Signup and view all the answers

Which dynamic measure is recommended to assess fluid responsiveness by the provided content?

Passive leg raise maneuver with echocardiography Signup and view all the answers

Which laboratory finding is LEAST likely to be present during the bleeding phase of DIC?

Increased platelet count Signup and view all the answers

What should be a primary consideration when discussions regarding withdrawal of life support are initiated with patients or their families?

The patient’s preferences and values Signup and view all the answers

Which of the following is considered a primary risk factor for clinically significant stress ulcer bleeding?

Mechanical ventilation Signup and view all the answers

When transitioning from active intervention to palliative care during the withdrawal of life support, it is crucial to emphasize:

That care and pain management will continue Signup and view all the answers

What is the PRIMARY treatment for a patient experiencing bleeding from a stress ulcer?

Fluid resuscitation, acid suppression, and blood transfusions if needed Signup and view all the answers

Which of the following is NOT a common cause of Disseminated Intravascular Coagulopathy?

Hyperthyroidism Signup and view all the answers

What is the PRIMARY objective of an ethics consultation in cases of conflict during withdrawal of support?

To facilitate discussion and potential resolution Signup and view all the answers

What is the expected outcome when fibrinolysis attempts to break down clots during the bleeding phase of DIC?

Increased circulating fibrin degradation products that impair thrombin activity Signup and view all the answers

In addition to treating the underlying cause, which supportive treatment method is LEAST likely to be used in managing DIC?

Routine anticoagulation Signup and view all the answers

Study Notes

Sepsis/Septic Shock: Epidemiology

Incidence of sepsis in the US: ~1.7 million adults annually; ~270,000 deaths annually
Increasing incidence attributed to factors like:
- Increased invasive procedures and monitoring
- Growing aging population
- Rise in chemotherapy/immunosuppressive use
- Growing antimicrobial resistance
Mortality is decreasing due to improved treatment
Gram-positive infections more common but gram-negative still substantial
Fungal infections increasing but still less frequent than bacterial infections

Sepsis/Septic Shock: Definitions and Pathophysiology

Sepsis 3 definition: life-threatening organ dysfunction caused by a deregulated host response to infection.
Septic shock: circulatory and metabolic abnormalities, substantially increasing mortality.
Potential complications: DIC (disseminated intravascular coagulopathy), MODS (multiple organ dysfunction syndrome)
Pathophysiology: initial immune response activation (innate immunity)
- Mobilization of macrophages & neutrophils
- Pro-inflammatory cytokine activation
- Complement activation
- Coagulation activation (fibrin mesh for localization)
Sepsis results from an amplified and uncontrolled systemic inflammatory response
Normal deactivation process impaired, leading to excessive pro-inflammatory cytokines
Inflammatory damage to blood vessels, vasodilation, and increased permeability
Contributing factors: endotoxins and exotoxins from invading organisms (gram-negative & gram-positive)
Coagulation cascade dysfunction: significant fibrin deposition, impaired fibrinolysis (breakdown of clots), decreased protein C and antithrombin III levels
Microvascular clots, reduced blood flow and organ dysfunction

Sepsis/Septic Shock: Clinical Manifestations

Early (hyperdynamic/warm): tachycardia, bounding pulses, warm flushed skin, fever, potentially normal blood pressure (compensatory response).
Early signs of decreased organ perfusion (confusion, decreased urine output).
Increased cardiac output (as long as adequate fluid resuscitation).
Low filling pressures (CVP, PAOP).
Systemic vascular resistance (SVR) is low due to vasodilation.
Late (hypodynamic/cold): cool, pale skin, weak/thready pulses, hypothermia, persistent tachycardia,
Low blood pressure.
Severe end-organ hypoperfusion (lethargy/coma, anuria).
Decreased cardiac output.
Variable filling pressures (dependent on fluid resuscitation).
SVR may remain low or increase with compensation & drug therapy.
Low venous oxygen levels (reflecting inadequate tissue oxygen delivery)

Sepsis/Septic Shock: Interprofessional Management

Surviving Sepsis campaign: standardized care to reduce sepsis mortality.
Diagnosis: general indicators of infection (fever, WBC count changes in BP/RR/HR), specific infection signs, lab tests (CBC, metabolic panels, cultures), imaging (radiographs, CT, MRI)
Severity assessment: NEWS, MEWS, SOFA scores
ICU admission within 6 hours for those needing it

Sepsis/Septic Shock: Medical Management

Prevention first: hand hygiene, aseptic technique, and minimizing invasive procedures.
Bundle of care (1 hour): fluid resuscitation, blood work (lactate, blood cultures), antibiotics (after cultures)
Fluid resuscitation: balanced crystalloid solution, 30 mL/kg over 3 hours
Vasopressors: norepinephrine as first line if fluids are insufficient
Antibiotics: within 1 hour of diagnosis, guided by cultures
Corticosteroids: low-dose only in non-responsive patients to fluid & vasopressors

Sepsis/Septic Shock: Ongoing Monitoring

Frequent vital signs, peripheral perfusion, and mental status checks.
Cultures and blood testing (WBC, lactate).
Hemodynamic monitoring (CVP/PAOP, SvO2/ScvO2); PA catheter use is not standard.
Cardiac response evaluation (echocardiography after passive leg raise) .
Capillary refill time monitoring

Sepsis/Septic Shock: Withdrawal of Life Support

Patient/family discussion fundamental for withdrawal decisions.
Using “withdrawal of support” instead of “withdrawal of care” to reduce anxiety.
DNR order.
Gradual or immediate discontinuation of ventilation, with comfort measures.
Pain and sedation management driven by patient response, not a schedule
Discontinuing non-comfort interventions

Sepsis/Septic Shock: Complication - Stress Ulcers

Common in ICU patients, risk factors include: Mechanical ventilation, coagulopathy, shock, sepsis, major trauma, and head injury.
Prophylaxis: enteral PPIs or H2 blockers, IV options for those unable to take enteral drugs

Sepsis/Septic Shock: Complication - Disseminated Intravascular Coagulopathy (DIC)

Enhanced coagulation from procoagulant release during the inflammatory response of sepsis.
Two phases: thrombotic (clotting) and bleeding, often occurring simultaneously.
Thrombotic phase leads to microvascular clots, ischemia, and necrosis.
Bleeding phase caused by impaired fibrinolysis and excessive fibrin degradation products.
Diagnosis through clinical symptoms and lab tests (decreased fibrinogen, increased fibrin degradation products, D-dimer, decreased platelets, prolonged PT/aPTT, decreased antithrombin III)
Management: focus on treating underlying sepsis, hypotentions, hypoxemia, and metabolic acidosis. Fluid support, blood products, and clotting factors may be required.

Sepsis/Septic Shock: Complication - Multiple Organ Dysfunction Syndrome (MODS)

Multifaceted cause:
- Accelerated apoptosis (programmed cell death)
- Widespread vascular endothelium damage
- Microvascular dysfunction
- Enhanced coagulation
- Hypermetabolism
- Mitochondrial toxicity
Progression typically starts in lungs, then renal, hepatic, and GI systems.
High mortality rates, especially when 3+ organ systems are affected.

Sepsis/Septic Shock: Nursing Management

Assessment: neurological status, vital signs, hemodynamic readings, urine output, skin, bleeding.
Nursing Diagnoses: altered tissue perfusion, excessive clotting, bleeding.
Interventions: hand hygiene, oxygen, fluid replacement, monitoring lactate, labs (cultures, ABGs, coagulation studies).
Administer antibiotics after cultures.
Vasopressors for inadequate blood pressure
Oral care, nutrition, supportive care, turning to prevent complications.
Teaching: sepsis prevention, importance of hand hygiene, patient comfort

Sepsis/Septic Shock: Evaluating Outcomes

Early recognition & swift treatment (antibiotics, fluids)
Maintaining cardiac output
Monitor hemodynamics, frequent labs
Supportive care to prevent complications.
Evaluating response in blood pressure, cardiac output, and tissue perfusion.

Sepsis/Septic Shock: Delirium Management (Box 14.1)

Delirium: altered consciousness, impaired focus and memory.
Common in ICU
Management: -Orientation aids -Cognitive stimulation -Sleep-wake cycle support -Minimize restraints -Avoid problematic medications (benzodiazepines, opiates, antihistamines)

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Description

This quiz covers the epidemiology, definitions, and pathophysiology associated with sepsis and septic shock. Learn about the increasing incidence, contributing factors, and the latest definitions from Sepsis 3. Additionally, explore complications and the immune response mechanisms involved in these critical conditions.