Sepsis Overview and Management

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Questions and Answers

Which of the following is NOT a common sign of late sepsis?

Thready pulses

Stupor/coma

Pale mucous membranes

Increased heart rate (correct)

What is the primary treatment approach for managing hypotension in sepsis?

Fluid resuscitation followed by pharmacologic management if needed (correct)

Administering high doses of vitamin C

Performing surgical intervention

Immediate dialysis

Which of the following treatments is a part of antimicrobial therapy for sepsis?

Hormone replacement therapy

Broad spectrum antibiotics (correct)

Antiviral drugs

Cholesterol-lowering medication

Which physiological alteration is commonly associated with sepsis progression to multiple organ dysfunction syndrome (MODS)?

Decreased blood perfusion to organs Signup and view all the answers

In cases of refractory hypotension, which medication is often the first choice for pharmacological management?

Norepinephrine Signup and view all the answers

Monitoring in sepsis involves evaluating which of the following parameters?

Urine output, blood gases, and ECG Signup and view all the answers

Which treatment strategy can be employed for source control in a sepsis patient?

Debridement or surgical repair Signup and view all the answers

What is the approximate mortality rate for septic shock?

<blockquote> 50% </blockquote> Signup and view all the answers

What is the main difference between sepsis and septic shock?

Sepsis involves a dysregulated host response without profound abnormalities, while septic shock involves significant circulatory and metabolic abnormalities. Signup and view all the answers

Which of the following is a clinical sign of early sepsis?

Red mucous membranes Signup and view all the answers

What characterizes cryptic shock in a patient with sepsis?

Decreased microcirculatory perfusion with normal hemodynamic values. Signup and view all the answers

What are the disrupted homeostatic mechanisms in sepsis?

Vasomotor tone and microvascular blood flow are altered. Signup and view all the answers

Which statement about SIRS criteria is true?

There are different thresholds for heart rate in dogs, cats, and horses. Signup and view all the answers

Which organism is least likely to cause sepsis?

Giardia protozoa Signup and view all the answers

What is the purpose of the Sequential Organ Failure Assessment (SOFA) score?

To evaluate organ dysfunction in patients with sepsis. Signup and view all the answers

Which cytokine is associated with the inflammatory response in sepsis?

TNF-a Signup and view all the answers

Which condition is likely associated with the development of sepsis?

Traumatic reticulopericarditis Signup and view all the answers

Which of the following best describes the interaction between inflammation and coagulation in sepsis?

Pro-inflammatory cytokines promote a pro-coagulant state. Signup and view all the answers

What is a characteristic of Multiple Organ Dysfunction Syndrome (MODS) related to sepsis?

It involves the failure of multiple organ systems following SIRS. Signup and view all the answers

Which treatment is commonly employed in managing sepsis?

Antibiotic therapy tailored to identified pathogens. Signup and view all the answers

What does the presence of microthrombi in sepsis indicate?

A pro-coagulant state and potential organ dysfunction. Signup and view all the answers

How does mitochondrial function relate to cytopathic hypoxia in sepsis?

Decreased mitochondrial function leads to poor oxygen utilization. Signup and view all the answers

Which mechanism is associated with the loss of vascular resistance in early sepsis?

Vasodilation mediated by cytokines producing nitric oxide. Signup and view all the answers

Study Notes

Sepsis Overview

Sepsis is a life-threatening condition caused by a dysregulated host response to infection.
Septic shock is a subset of sepsis where circulatory and cellular/metabolic abnormalities significantly increase mortality. A pressor requirement is often necessary.
Sepsis is distinct from bacteremia. Bacteremia is the presence of bacteria in the bloodstream whereas sepsis involves an inflammatory response to those bacteria.

Objectives

Define sepsis and septic shock
Identify and describe homeostatic mechanisms disrupted in sepsis.
Explain cryptic shock and cytopathic hypoxia.
Detail how inflammation and coagulation interact and contribute to sepsis.
Outline clinical signs and basic treatment for sepsis.

Terminology

Systemic Inflammatory Response Syndrome (SIRS) is characterized by a systemic response to infection or trauma indicated by elevated heart rate, respiratory rate, temperature, and white blood cell count (WBC).
Multiple Organ Dysfunction Syndrome (MODS) is a condition in which multiple organs are affected due to an abnormal functioning associated with SIRS.

SIRS Criteria

Criteria for diagnosing SIRS vary between species (e.g., dog, cat, and horse).
Specific values for heart rate, respiratory rate, temperature, and leukogram are presented in a table for each species.

Current Definitions

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.
Organ dysfunction is assessed using the Sequential (or Sepsis-related) Organ Failure Assessment (SOFA) score (a score of 2 or greater). MEWS/NEWS scores (or 2 or more SIRS criteria) can also be used.

SOFA Score

The SOFA score is a table listing different organ systems (respiration, coagulation, liver, cardiovascular, CNS, and renal) with severity grades 0–4 based on specific measurements for each system. These scores are used to assess organ system dysfunction in sepsis.

Current Definition: Septic Shock

Septic shock is a subset of sepsis where underlying circulatory and cellular/metabolic abnormalities substantially increase mortality. Treating shock often requires intravenous fluid resuscitation and pressor agents (such as norepinephrine).

Organisms of Sepsis

Gram-negative bacteria, gram-positive bacteria, aerobes/anaerobes, fungi, and protozoa are among the pathogens that can cause sepsis.

Conditions Associated with Sepsis

Several conditions can lead to sepsis
- Thoracic, abdominal and cutaneous conditions, and injuries are presented, including tissue injury, hypotension, ischemia, especially in the gastrointestinal tract, and immune compromise.

Infection and Host Responses

Pathogens (e.g., lipotechoic acid, peptidoglycan, bacterial DNA, exotoxins, fungal cell walls, flagellin) trigger the immune system.
Proinflammatory cytokines (TNF-α, IL-1, IL-6, IL-8, IFN-γ) are released, activating inflammation and coagulation processes.
Simultaneously, anti-inflammatory cytokines (TGF-β, IL-4, IL-10, IL-13) are released, opposing the inflammatory response.
- The balance between these pro- and anti-inflammatory cytokines can impact the severity of the host's response.

Disrupted Homeostatic Mechanisms

Vasomotor tone, inflammatory and coagulation cascades, and microvascular changes are major disrupted mechanisms in sepsis.
- Reduced vasomotor tone with systemic vasodilation is a hallmark of sepsis. Microvascular changes include endothelial dysfunction, reduced microvascular blood flow, and mitochondrial dysfunction.
- Cryptic shock occurs when microcirculatory perfusion is decreased despite normal hemodynamic values.
- Cytopathic hypoxia occurs when the mitochondria are unable to utilized oxygen leading to increased apoptosis and cell death.

Microvascular Changes

Loss of vascular muscle autoregulation, microthrombi formation, leukocyte activation, changes in RBC (red blood cell) rheologic properties, endothelial cell dysfunction, disruption of the endothelial glycocalyx, and changes in capillary permeability.

Cryptic Shock

A condition characterized by decreased microcirculatory perfusion despite normal blood pressure. These changes are due to vasodilation, microthrombi formation, and edema.

Cytopathology

Mitochondrial dysfunction due to sepsis, resulting in insufficient oxygen utilization by cells

Clinical Signs of Sepsis

Early sepsis may present with red mucous membranes, increased heart rate, brisk capillary refill time, and bounding pulses.
Late sepsis may manifest as thready pulses, prolonged capillary refill time, pale/muddy mucous membranes, hypothermia, hypoglycemia, stupor/coma, and organ failure.
Cats frequently present differently than dogs. Cats often exhibit pale mucous membranes, bradycardia, hypothermia, and abdominal pain in the context of sepsis.

Progression to MODS/MOFS

Cardiovascular, respiratory, gastrointestinal, renal, liver, brain, and coagulation systems could be affected by the progression of sepsis to multiple organ dysfunction syndrome (MODS).

General Treatment for Sepsis

Fluids, pressors/inotropes and broad-spectrum antimicrobial therapy.
Treat the underlying source (cause) of the infection.
Support organ system function to combat complications.

Fluid Resuscitation and Management of Hypotension

First, aggressively resuscitate with fluids.
Use crystalloids and/or synthetic colloids, followed by plasma based on coagulation abnormalities.

Refractory Hypotension

If hypotension persists after adequate fluid resuscitation, use pharmacologic agents (e.g., norepinephrine, vasopressin, dopamine, or dobutamine).

Antimicrobial Therapy

Obtain cultures if possible.
Empiric therapy tailored to the specific site of infection; broader spectrum may be used until culture results are available. Consider 4-quadrant coverage.

Additional Medical Therapy

Supplementation of electrolytes/glucose, and nutrition support.
Blood product support.
Management of pain, and respiratory issues.
Maintain appropriate body temperature, hydration and overall care of the patient including bandages and catheter support.

Monitoring

Monitor for decompensation, and recognize and address early signs of sepsis.
Monitor vital signs (temperature, heart rate, respiratory rate, and respiration effort), mucous membrane color, capillary refill time, urine output, urine specific gravity, mentation, EKG, blood pressure, pulse oximetry, blood gases, CBC, chemistry panel, coagulation profile, and blood glucose. Early recognition and treatment are essential for positive outcomes.

Prognosis

A substantial risk of mortality (over 50%) can be associated with sepsis. Many comorbidities/organ failures related to sepsis contribute to this risk.

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Description

This quiz covers the critical aspects of sepsis, including its definition, associated terms like septic shock, and the homeostatic mechanisms disrupted by this condition. You will also learn about the interplay between inflammation and coagulation, as well as the clinical signs and basic treatment options for sepsis.