Sepsis and shock Flashcards
Define:
a) sepsis
b) septic shock
c) cryptic shock
a) Life-threatening organ dysfunction caused by a dysregulated host response to infection
- Requires two things: infection + organ dysfunction
b) Sepsis + refractory hypotension, i.e.
- requiring vasopressors to maintain MAP > 65
- and lactate > 2 despite adequate volume resuscitation
c) Raised lactate in the presence of a normal BP
Common sources of infection
Chest, abdo, line, UTU, MSK, CNS, skin
Signs of organ dysfunction
- Hypotension (SBP < 90, MAP < 65)
- Hypoperfusion (lactate > 2)
- Hypoxia
- Brain: Confusion, reduced GCS
- Renal: oliguria, creatinine rise
- Marrow: low platelets, raised INR/APTT
Septic shock: management
Sepsis = BUFALO (within 1 hour)
- Blood cultures
- Urine output
- Fluid resus (IV NaCl 0.9% - 500 ml over < 15 mins)
- Antibiotics (IV)
- Lactate
- Oxygen
Septic SHOCK - will require vasopressors +/- inotropes
Shock
a) Define
b) How it leads to cell death
c) Types (plumbing: fluid, pump, pipes)
d) Mortality of septic shock
a) Circulatory failure leading to tissue hypoperfusion
b) Leads to cellular hypoxia and energy deficit, which leads to anaerobic respiration, lactic acidosis and eventually cell death
c) Fluid (hypovolaemic, haemorrhagic), pump (cardiogenic, obstructive), pipes (septic, anaphylactic, distributive - neurogenic, endocrine)
d) 50%
Cardiogenic shock.
a) What is it?
b) Causes
c) Management
a) Pump failure
b) Ischaemic (post-MI), arrhythmic
c) Inotropes +/- fluid
Obstructive shock.
a) What is it?
b) Causes
c) Management
a) Physical obstruction of the great vessels
b) Tension pneumothorax, massive PE, tamponade
c) Relieve obstruction:
- chest drain
- thrombectomy/ fibinolysis
- pericardiocentesis
Neurogenic shock.
a) What is it?
b) Causes
c) Management
a) Loss of vascular sympathetic tone
b) Spinal cord injury, TBI
c) Fluids and vasopressors
Hypovolaemic shock.
a) What is it?
b) Causes
c) Management
d) Concealed bleeding - 4 areas
a) Low circulating volume leading to shock
b) Haemorrhage, dehydration, fluid losses
c) - Volume replacement: fluids, blood, etc.
- Arrest the bleeding: TxA, vitamin K/PTC, FFP, etc.
d) - Intra-thoracic
- Intra-abdominal
- Long bones
- Pelvis
Anaphylactic shock.
a) What is it?
b) Causes
c) Management
a) Circulatory disturbance due to systemic IgE mediated hypersensitivity reaction
b) Allergies - drugs (eg. penicillin), nuts, latex, bee stings, etc.
c) - Adrenaline IM 500 mcg (1: 1000)
- IV fluid challenge (NaCl 0.9% 500 ml)
- Chlorphenamine IV/IM 10 mg
- Hydrocortisone IV/IM 200 mg
Clinical signs of shock
Obs:
- Tachycardia
- Hypotension (late) - or reduction from normal
- Tachypnoea
- Reduced pulse pressure
- Reduced urine output
Clinical:
- Confused/reduced GCS
- Clammy
- Reduced CRT/ cool peripheries
68 year old male, admitted with back pain and collapse of sudden onset
a) Diagnosis
b) Management
a) Aortic aneurysm (thoracic/abdominal) UPO
b) A-E approach, crossmatch blood, call vascular surgery
NEWS2.
a) Normal ranges
b) Low clinical risk (total score) and action
c) Medium risk (individual and total scores) and action
d) High risk (total score) and action
e) Patients with a NEWS score of ___ or more (medium-high risk) with signs and symptoms of infection should be assessed for red flags signs of sepsis
f) In what patient groups is NEWS not reliable in?
a) - RR: 12 - 20
- SpO2: 96% or more* (88% or more in T2RF on air)
- HR: 51 - 90
- SBP: 111 - 219
- Temp: 36.1 - 38.0
- ACVPU: alert (A)
- If on oxygen, score an additional 2 points
- N.B: administered oxygen is a drug with a therapeutic range, in most patients 94 - 98%, in patients at risk of T2RF 88 - 92%
b) - Low clinical risk: aggregate score 1-4
Action:
- prompt nursing review (may escalate)
- minimum 4-6 hourly observations
c) - Low to medium clinical risk: Score of 3 in any individual parameter
- Medium clinical risk: aggregate score 5-6
Action:
- urgent medical review (may escalate)
- minimum 1-hourly observations
d) High clinical risk: aggregate score 7 or more
Action:
- emergency critical care review*
- continuous observations
- should have critical care skills, including airway management
e) 5 or more
f) - Spinal cord injury (due to autonomic fluctuations of pulse and BP)
RED FLAG signs of sepsis*
a) Give the signs using an A-E approach
b) Management if any ONE of these is present
*Red flags correspond to red scores on the NEWS2 charts (plus additional features)
Airway and breathing:
- Oxygen requirement to maintain SpO2 >/= 92%
- RR >/= 25
Circulation:
- SBP = 90 mmHg (or drop of >40 mmHg)
- HR >/= 130 bpm
- Lactate > 2mmol/L
- Urine output < 0.5 ml/kg/hr (or anuric for 18 hours)
Disability:
- Altered mental state
Everything else:
- Recent chemotherapy
- Immunosuppression in children
- Skin - ashen, mottled, cyanosed, non-blanching rash
b) In the presence of any ONE red flag sign:
- Initiate Sepsis 6 bundle (BUFALO)
- Seek immediate critical care outreach review
c)
Amber flags* of sepsis
a) Give the amber flags using an A-E approach
b) Management if any ONE of these is present
c) In which patients should sepsis 6 be initiated immediately in the presence of an amber flag?
*Amber flags correspond to amber scores on NEWS2 charts (plus additional features)
a) Airway and breathing:
- Respiratory rate 21-24 breaths per minute
Circulation:
- Systolic blood pressure 91-100 mmHg
- Heart rate 91-130 or new dysrhythmia
Disability:
- Relative(s) concerned about mental status
- Acute deterioration in functional ability
Everything else:
- Temperature < 36°C
- Clinical signs of wound infection
- Immunosuppressed adults (other than recent chemo - this is a red flag)
- Trauma/surgery/procedure in the last eight weeks
b) If any ONE of these is present:
- Send bloods - FBC, CRP, U+Es, clotting
- Escalate for clinical review within one hour
- Consider the need for antimicrobials
c) Patients with AKI
