Lecture 3.1 - Sepsis

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Questions and Answers

What is the primary indicator of severity and underlying pathophysiology in response to fluids?

Cardiac output

Urinary output (correct)

Oxygen demand

Blood pressure

What is the primary goal of fluid therapy in sepsis?

To reduce cardiac output

To correct absolute and relative hypovolaemia (correct)

To decrease blood pressure

To increase oxygen demand

What is the relationship between cardiac output and oxygen delivery?

Oxygen delivery is independent of cardiac output

Oxygen delivery is dependent on cardiac output but not directly proportional

Oxygen delivery is inversely proportional to cardiac output

Oxygen delivery is directly proportional to cardiac output (correct)

What is the primary reason for monitoring urinary output in sepsis?

To monitor fluid therapy Signup and view all the answers

What is the preferred first-line fluid for resuscitation in sepsis?

Crystalloids Signup and view all the answers

What is the primary factor affecting stroke volume?

Preload and afterload Signup and view all the answers

What is the recommended approach to prescribing antibiotics in sepsis?

Use existing local antimicrobial guidance Signup and view all the answers

What is the primary consideration when delivering antibiotics in sepsis?

The speed of delivery of antibiotics Signup and view all the answers

What is the primary function of the hepatic reticuloendothelial system in relation to sepsis?

To act as a first line of defence in clearing bacteria and their products Signup and view all the answers

Which of the following patient groups is at high risk of developing sepsis?

Women who have given birth or had a termination of pregnancy or miscarriage in the last 6 weeks Signup and view all the answers

What is the primary purpose of using a structured set of observations/early warning score in sepsis assessment?

To stratify risk and identify patients who require immediate intervention Signup and view all the answers

What is the primary reason for assessing the frequency of urination in the past 18 hours in a sepsis patient?

To assess for signs of organ dysfunction and sepsis progression Signup and view all the answers

What is the primary goal of the NEWS2 scoring system in sepsis management?

To stratify risk and identify patients who require escalation of care Signup and view all the answers

What is the primary indicator of sepsis progression?

Narrative of progressive organ failure Signup and view all the answers

What is the primary reason for examining the skin in sepsis patients?

To look for signs of skin breach or infection Signup and view all the answers

What is the primary purpose of senior review in sepsis management?

To reassess the patient's risk of sepsis and identify any gaps in care Signup and view all the answers

What is the primary purpose of the Sepsis 6 bundle?

To restore the circulation, assess risk, monitor the effect of treatment, and switch off the infective trigger Signup and view all the answers

What is the recommended oxygen therapy target saturation for adults at risk of hypercapnic respiratory failure?

88-92% Signup and view all the answers

What is the recommended action for a patient who has a red flag sepsis?

Inform senior doctor for review and send urgent investigations Signup and view all the answers

What is the primary reason for measuring lactate levels in sepsis?

To assess the severity of sepsis and guide treatment Signup and view all the answers

What is the role of senior review in sepsis management?

To provide multidisciplinary input and fast-track decision-making Signup and view all the answers

What is the recommended NEWS2 score for red flag sepsis?

A score of 7 or above Signup and view all the answers

What is the initial oxygen therapy recommended for a patient who is shocked or critically ill?

A non-rebreathe face mask with reservoir bag at 15 l/min Signup and view all the answers

What is the primary reason for including blood cultures in the sepsis six bundle?

To identify the source of infection Signup and view all the answers

Study Notes

Septic Shock and Ileus

Septic shock can cause ileus, which is delayed by the use of narcotics and sedatives.

Hepatic and Renal Dysfunction

The hepatic reticuloendothelial system is the first line of defense against bacteria and their products, and liver dysfunction leads to a spillover of these products into the systemic circulation.
Acute kidney injury (AKI) is associated with: • Systemic hypotension • Cytokines (e.g. TNF) • Activation of inflammatory cells, which indirectly and directly contribute to renal tubular injury

Sepsis Risk Groups

Extremes of age
Impaired immune systems due to illness or drugs (e.g. chemotherapy)
Recent surgery or other invasive procedures
Breach of skin integrity (e.g. cuts, burns, blisters, or skin infections)
IVDU
Indwelling lines or catheters
Women who are pregnant, have given birth, or had a termination of pregnancy or miscarriage in the last 6 weeks
Neonates

Clinical Assessment

Assess people with suspected infection to identify: • Possible source of infection • Factors that increase the risk of sepsis • Any indicators of clinical concern (e.g. new onset abnormalities of behavior, circulation, or respiration)
Use a structured set of observations/early warning score to assess people in a face-to-face setting to stratify risk
Assess: • Temperature • Heart rate • Respiratory rate • Blood pressure • Level of consciousness • Oxygen saturation
Ask the person, parent, or carer about frequency of urination in the past 18 hours

Examination

Pale
Temperature 36°C, pulse 110/min, BP 90/70 mmHg
Respiratory rate 30/min
Widespread purpuric (non-blanching) rash
Mentally alert, Glasgow Coma Scale 15

NEWS2 Scoring System

Sepsis is defined as: • Aggregate NEWS2 score of 7 or above • OR a patient with a lower NEWS2 score (5 or 6) but also with:
- Lactate > 2 mmol/L
- Chemotherapy in the last 6 weeks
- Other organ failure evident (e.g. AKI)
- Patient looks extremely unwell
- Patient is actively deteriorating

Sepsis 6 Bundle

Sepsis 6 works to minimize the increased mortality risk by: • Restoring the circulation • Assessing risk • Monitoring the effect of treatment • Switching off the infective trigger
The sepsis 6 bundle should be delivered as quickly as possible, but for the sickest patients with red flag sepsis always within the first hour following recognition of sepsis

Oxygen Therapy

Imbalance between oxygen demand and supply
If the patient is shocked or critically ill, the initial oxygen therapy is a reservoir mask at 15 L/min
Adults: • Target oxygen saturation of 94-98% • 88-92% for those at risk of hypercapnic respiratory failure
Children: • Give oxygen if SpO2 < 92%

Bloods and Cultures

Glucose: • Stress response causes gluconeogenesis, glycogenolysis, and insulin resistance • Increases risk of secondary infection
FBC: • WCC:
- Trend
- Differential
- Aetiology • Plt:
- Acute phase increase then sign of progressing organ dysfunction • Hb:
- Helpful to maximize oxygenation

Lactate

In sepsis and other pathological conditions, lactate is a marker of anaerobic respiration
A raised arterial lactate is usually due to one of four types of problems: • Insufficient oxygen delivery due to circulatory failure (the ‘macro circulation’) • Insufficient oxygen delivery due to microcirculation (the capillary beds are not working properly) • Inability of the tissue to use oxygen (e.g. mitochondrial dysfunction) • Excessive oxygen demand (e.g. tonic-clonic seizures, or excessive exercise)
Therefore, response to fluids gives an indication of severity and underlying pathophysiology

Antibiotic and Suitable Control

Ensure mechanisms are in place to deliver antibiotics fast
Take microbiological samples before prescribing an antimicrobial (where possible)
For all people with suspected sepsis where the source of infection is clear, use existing local antimicrobial guidance
If not clear, use broad-spectrum antibiotics
Revise according to results
Think about the source: abscess, obstruction

IV Fluids

O2 delivery = O2 content of blood x cardiac output
Cardiac output = stroke volume x heart rate
The stroke volume is dependent on: • Preload • Afterload
The aims of fluid therapy are: • To correct absolute and relative hypovolemia • To bring the patient's pulse, blood pressure, mental state, lactate, and urine output within target • To do this judiciously, and to avoid pushing the patient into overload
Crystalloids are the preferred first-line fluid for resuscitation
Monitor: • UO:
- In early stages, this is key
- Easy to measure/ask about
- The urine output is an excellent window on the circulation

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Description

This quiz covers the effects of septic shock on the body, including the development of ileus, delayed enteral feeding, and hepatic and renal dysfunction. Learn about the impact of liver dysfunction and acute kidney injury on the body's response to septic shock.