Sepsis and SIRS Quiz

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Questions and Answers

Which organ is primarily affected by acute tubular necrosis?

Lung

Kidney (correct)

Liver

Heart

What is a common complication associated with the gastrointestinal tract in severe sepsis?

Pulmonary edema

Increased cardiac output

Cholestasis (correct)

Rhabdomyolysis

What stage of SIRS involves the recruitment of inflammatory cells and an acute phase response?

Stage 1

Stage 2 (correct)

Stage 3

Stage 4

Which condition is associated with altered organ perfusion in septic shock?

Hypotension Signup and view all the answers

What is a significant risk factor for developing bacterial translocation in the context of severe sepsis?

Stress ulcer Signup and view all the answers

During which stage of sepsis does oxygen metabolism become uncoupled?

Level IV Signup and view all the answers

Which of the following statements is true regarding septic shock mortality rates?

Mortality rates approach 35% Signup and view all the answers

What hemodynamic alteration characterizes 'cold shock' in septic patients?

Low cardiac output Signup and view all the answers

What is the primary difference between sepsis and systemic inflammatory response syndrome (SIRS)?

Sepsis occurs only with confirmed infection while SIRS can be due to various clinical insults. Signup and view all the answers

Which of the following correctly describes septic shock?

A sustained drop in blood pressure despite adequate fluid resuscitation. Signup and view all the answers

Which criteria are included in the SIRS definition?

Temperature over 38 degrees Celsius or tachycardia above 90 beats per minute. Signup and view all the answers

What underlying condition contributes to the risk of developing severe sepsis?

Renal or liver failure. Signup and view all the answers

Which of the following statements accurately describes Multiple Organ Dysfunction Syndrome (MODS)?

Altered organ function prevents homeostasis and requires intervention. Signup and view all the answers

What is the primary trigger for administering intravenous fluids in the treatment of sepsis-induced hypotension?

To replace losses and exceed maintenance volumes Signup and view all the answers

What is the recommended mean arterial pressure goal during initial resuscitation for septic patients?

65 mmHg Signup and view all the answers

What does stress hyperglycemia predominantly diminish in critically ill patients?

Neutrophil and macrophage effectiveness Signup and view all the answers

Which of the following treatments is shown to improve refractory hypotension in patients who do not respond to initial therapies?

Fludrocortisone with hydrocortisone Signup and view all the answers

During the management of acute respiratory distress syndrome (ARDS) caused by severe sepsis, which intervention is vital?

Providing supplemental oxygenation Signup and view all the answers

What is the mortality range typically associated with septic shock?

50% - 60% Signup and view all the answers

What is the primary purpose of tight glycemic control in critically ill patients?

To maintain serum glucose levels between 80 and 110 mg/dl Signup and view all the answers

Which type of medication is classified under failed therapies for septic patients?

Corticosteroids—high-dose methylprednisolone Signup and view all the answers

What is a key factor in differentiating severe sepsis from noninfectious systemic inflammatory response syndrome (SIRS)?

Measurement of procalcitonin Signup and view all the answers

Which of the following treatments should be initiated as soon as cultures are drawn in sepsis management?

Antibiotics Signup and view all the answers

What consequence is associated with a delay in administering antibiotics during hypotension in severe sepsis?

Survival rates decrease Signup and view all the answers

Which of the following best describes the final common pathway of severe sepsis?

Microvascular thrombosis Signup and view all the answers

What is the significance of obtaining blood cultures in the management of sepsis?

To inform empirical antibiotic therapy choices Signup and view all the answers

What supports a favorable outcome in severe sepsis management?

Early aggressive fluid resuscitation Signup and view all the answers

What role does source control play in the treatment of severe sepsis?

It emphasizes surgical intervention when necessary Signup and view all the answers

Which of the following is NOT typically part of the initial laboratory investigations for sepsis?

Thyroid function tests Signup and view all the answers

Study Notes

Sepsis/SIRS and MOF

Sepsis is defined as a systemic inflammatory response to an infection.
SIRS (Systemic Inflammatory Response Syndrome) is the body's response to severe clinical insults, including infection, inflammation, and stress.
SIRS is characterized by two or more of the following: body temperature greater than 38 degrees Celsius or less than 36 degrees Celsius, heart rate over 90 beats per minute, respiratory rate over 20 breaths per minute or partial pressure of carbon dioxide (PaCO2) less than 32 mm Hg, and white blood cell count greater than 12,000/cu mm or less than 4,000/cu mm.
Infection is a microbial phenomenon characterized by an inflammatory response to microorganisms or invasion of normally sterile host tissue by those organisms.
Bacteremia is the presence of viable bacteria in the blood.
The relationship between sepsis and SIRS is that SIRS is a broader category (a systemic inflammatory response), whereas sepsis is a specific condition of SIRS in response to an infection.

Objectives

The definitions of Sepsis and the Sepsis Syndromes.
The factors that precipitate and perpetuate the Sepsis Cascade.
The pathogenesis of Multiple Organ Dysfunction in Sepsis.
Treatment options in Sepsis.

Levels of Clinical Infection

Level I: Locally Controlled
Level II: Locally Controlled, Leukocytosis
Level III: Systemic Hyperdynamic Response
Level IV: Oxygen metabolism becomes uncoupled
Level V: Shock, Organ Failure

Stages in the Development of SIRS (Bone, 1996)

Stage 1: Local environment produces cytokines in response to injury/infection.
Stage 2: Small amounts of cytokines are released into the circulation.
Recruitment of inflammatory cells
Acute Phase Response, kept in check by anti-inflammatory mediators (IL-10, PGE2, antibodies, cytokine receptor antagonists.)
Stage 3: Failure to control inflammatory cascade – loss of capillary integrity, stimulation of nitric oxide (NO) production, maldistribution of microvascular blood flow, and organ injury and dysfunction.

High Risk Patients for Sepsis and Dying

Middle-aged, elderly individuals are at high risk.
Post-operative and post-trauma patients are at high risk.
Post-splenectomy patients are at high risk.
Transplant recipients are at high risk.
Immunocompromised patients are at high risk (e.g., alcoholics/malnourished, those with predisposing genes).
Delayed antibiotic administration is a high risk factor.
comorbidities such as AIDS, renal/liver failure, and neoplasms raise risk.

Clinical Signs of Sepsis

Fever
Leukocytosis
Tachypnea
Tachycardia
Reduced vascular tone
Organ dysfunction

Clinical Signs of Septic Shock

Hemodynamic Alterations
- Hyperdynamic State (“Warm Shock”)
  - tachycardia
  - elevated or normal cardiac output
  - decreased systemic vascular resistance
- Hypodynamic State (“Cold Shock”)
  - Low cardiac output
Myocardial Depression
Altered Vasculature
Altered Organ Perfusion
Imbalance of O2 delivery and Consumption
Metabolic (Lactic) Acidosis

Organ System Involvement

Circulation: Hypotension, increased microvascular permeability, shock
Lung: Pulmonary Edema, hypoxemia, Acute Respiratory Distress Syndrome (ARDS)
Hematologic: Disseminated Intravascular Coagulation (DIC), coagulopathy
GI tract: Stress ulcer, translocation of bacteria, liver failure, gastroparesis, ileus, cholestasis
Kidney: Acute tubular necrosis, renal failure
Nervous System: Encephalopathy
Skeletal Muscle: Rhabdomyolysis
Endocrine: Adrenal insufficiency

Sources of Sepsis (International Cohort Study) in Severe Sepsis and Septic Shock

Respiratory (66, 53)
Abdomen (9, 20)
Bacteremia (14, 16)
Urinary (11, 11)
Multiple (not listed)
Overall Mortality rate: 35%

Treatment of Sepsis

Antibiotics: Initiate immediately when cultures are drawn. Severe sepsis requires broad-spectrum antibiotics. Empiric antifungal drugs for neutropenic patients, patients with DM or having chronic steroid use
Early Aggressive Fluid Resuscitation
Inotropes (Dopamine, vasopressin, norepinephrine) for BP support
Source Control: Early recognition, surgical intervention if indicated, Aggressive supportive care in intensive care units
Steroid therapy (if adrenal insufficiency)
Activated protein C
Ventilatory strategies
Glycemic control
Newer therapies

Identifying a Septic Focus

History
Physical Examination
Imaging
Cultures (Blood, Urine, Sputum, Abscess)

Investigations

Basic: WBC, Platelets, Coagulation studies, Renal function, Glucose, Albumin, LFT, ABG
Specific? Source: Urine, CXR, Blood Cultures, Biopsy

Differentiating Sepsis from Noninfectious SIRS

Procalcitonin
C-reactive protein (CRP)
IL-6
Protein complement C3a
Leptin (not yet readily available for clinical practice)

Treatment of Hypotension

Intravenous fluids (crystalloids vs. colloids): more than maintenance needs, replace fluid losses
Goals of initial resuscitation
Central venous pressure 8-12 mmHg
Mean arterial pressure 65 mmHg
Urine output .5 ml/kg/hr
Pulmonary capillary wedge pressure exceeds 18 mmHg

Steroids

Improved refractory hypotension
Reduced Mortality by 10%
50mg hydrocortisone IV 6 hours.

Stress Hyperglycemia

Decreased insulin release
Increased release of hormones that counter insulin
Increased insulin resistance
Hyperglycemia reduces ability of neutrophils and macrophages to combat infection

Tight Glycemic Control

Continuous Insulin Infusion
Maintain serum glucose 80-110 mg/dL
Decreased mortality, less renal failure

Failed Therapies

High dose methylprednisolone
Anti-endotoxin antibodies
TNF antagonists (soluble TNF receptor)
Ibuprofen

Mortality

Sepsis: 30-50%
Septic Shock: 50-60%

Key Take Home Points

Recognize Sepsis early and determine severity.
Early Antibiotics are critical to resolution of shock.
Resuscitate severe Sepsis and septic shock
Early Goal Directed Therapy

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Test your knowledge on sepsis and systemic inflammatory response syndrome (SIRS) with this comprehensive quiz. Covering critical concepts such as organ involvement, complications, and hemodynamic changes, this quiz is essential for understanding severe sepsis and its implications. Challenge yourself with questions designed for medical students and healthcare professionals.