QuestionSBA
QuestionChoice
The patient will need to be admitted and will receive at least 48 hours of intravenous antibiotics, however, this is not the best option - it does not address the need for other items within the sepsis 6, including taking blood cultures and giving fluids
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Admit patient to complete a minimum of 48 hours of intravenous antibiotics
QuestionChoice
Giving beta-blockers to lower the heart rate would be unhelpful here acutely - it would not address the cause of the tachycardia which is ultimately sepsis from severe infection. In some circumstances infection can trigger tachyarrhythmias which do require rate control, however nothing in the stem suggests that this has occurred
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d
Give beta-blockers to help control his tachycardia
QuestionChoice
Young patients often do receive significant volumes of fluid resuscitation quickly when unwell, however, this is not the single best answer here. This option does not address the need for other items within the sepsis 6, including taking blood cultures and giving intravenous antibiotics
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e
Give 1 litre of 0.9% sodium chloride over 1 hour and then return to reassess the patient
QuestionChoice
This patient is clearly very unwell and triggering as potentially septic within all of his observation parameters - he requires inpatient admission, intravenous antibiotics and careful monitoring during this stage of his illness. Additionally, it's important to be aware that young patients can tend to underscore on the CURB-65 model for assessing CAP severity - in these circumstances, it is important to also look at any oxygen demand and consider co-morbidities when assessing their risk of deterioration
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b
Discharge home to complete a course of oral antibiotics
QuestionChoice
This patient has a diagnosis of community acquired pneumonia (CAP) from his history and chest x-ray. Respiratory rate of >20 breaths per minute, heart rate of >90 beats per minute, low oxygen saturations and hypotension are all markers of sepsis, and this patient's presentation should prompt immediate action with "sepsis 6". The sepsis 6 involves taking **blood cultures** and a blood gas for a **lactate** measurement, giving **oxygen** and **intravenous antibiotics and fluids**, as well as careful monitoring of **fluid input/output** (usually with a catheter) all within 1 hour of recognition of sepsis. This is evidence-based and shown to improve mortality
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a
Perform the "sepsis 6" within the next 1 hour
QuestionComment
But his CURB-65 is 0 = outpatient care??
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Man is septic 

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Hypertension Migraine
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Did you look at his Obs Acute Botox???????????
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Intravenous Prone
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Acute Botox
QuestionComment
what is that on his XR
23815
QuestionComment
right middle lobe consolidation indicative of CAP
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Biopsy Gland
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Relapse Kinase
Concept
Chapter
# Summary
 
Sepsis is a syndrome characterised by life-threatening organ dysfunction that occurs due to a dysregulated response to infection. Key signs and symptoms include fever, altered mental state, tachycardia, hypotension and dehydration, as well as localising signs of infection. The "Sepsis Six" bundle is used to guide care in the first hour following recognition of sepsis; this involves taking blood tests including cultures, a blood gas to measure lactate and monitoring urine output, and giving oxygen, IV broad-spectrum antibiotics and IV fluids.
 
# Definition

The terminology used to describe sepsis has changed, with terms like "severe sepsis" and SIRS (systemic inflammatory response syndrome) no longer in use.

**Sepsis** is defined as a syndrome of life-threatening organ dysfunction due to a dysregulated host response to infection.

**Septic shock** is another term used to describe some patients with sepsis who are at greater risk of death. To be classified as having septic shock, patients need to be persistently hypotensive, requiring vasopressors to maintain a mean arterial pressure of 65 mmHg or more **and** have a lactate of over 2 mmol/L despite adequate fluid resuscitation.  

# Epidemiology

- Due to variations in coding and definitions, statistics related to admissions to hospital with sepsis tend to be inconsistent
- Approximately 200,000 people are admitted to hospital with sepsis per year
- Approximately 20% of these (40,000 per year) require intensive care admission
- Mortality is also approximately 20%, with deaths estimated at up to 48,000 per year in the UK
- Men are more commonly affected than women
- Patients at the extremes of age (infants under a year and people aged over 75) are more at risk

# Aetiology

- The commonest sources of infection are respiratory, genitourinary, renal and gastrointestinal 
- Most causative pathogens are bacteria, although fungal, parasitic and viral infections can also lead to sepsis
- The commonest organisms identified are Staphylococcus aureus, Escherichia coli and Pseudomonas species
- In 50% of sepsis cases, no causative pathogen is identified 

**Risk factors** for sepsis include:

- Pregnancy
- Recent miscarriage or abortion
- Frailty
- Immunocompromise due to chronic comorbidities e.g. HIV, diabetes, sickle cell disease
- Immunosuppression secondary to medications e.g. chemotherapy, steroids
- Recent surgery or trauma
- Skin breaks or infections
- Drug or alcohol misuse
- Indwelling lines or catheters

# Signs and Symptoms

Symptoms include:

- General malaise
- Fevers, sweats or chills
- Localising signs of infection e.g. rashes, dysuria
- Decreased urine output
- Confusion
- Breathlessness
- Nausea and vomiting
- Myalgia
 
On examination, signs include:
 
- Tachycardia
- Hypotension
- Pyrexia or hypothermia
- Dehydration e.g. dry mucous membranes
- Altered mental state including delirium
- Irritability
- Respiratory distress e.g. tachypnoea, accessory muscle usage
- Cyanosis and hypoxia
- Delayed capillary refill time
- Cool extremities
- Skin appears mottled or ashen

# Differential Diagnosis

- **Acute alcohol withdrawal** causes altered mental state, tachycardia and sweating; patients are usually tremulous and may have withdrawal seizures if severe
- **Acute haemorrhage** may cause hypovolaemic shock with signs of shock including tachycardia, hypotension, delayed capillary refill and cool extremities; differentiated by signs of bleeding which may be overt or more subtle (e.g. abdominal pain)
- **Diabetic ketoacidosis** causes malaise, tachypnoea (with Kussmaul breathing), dehydration and confusion; metabolic acidosis may be seen in both but in diabetic ketoacidosis glucose will be very high
- **Pulmonary embolism** may cause tachycardia, hypotension, respiratory distress and a low-grade fever; may have haemoptysis and pleuritic chest pain (which could also be seen in sepsis secondary to pneumonia) - CTPA can be used to differentiate if unclear
- **Thyrotoxicosis** produces similar symptoms of confusion and fevers and signs of tachycardia; thyroid function testing shows high T4 and suppressed TSH
- **Drug reactions** e.g. neuroleptic malignant syndrome - shares features of fever, confusion, labile blood pressure and sweating; differentiated by a recent history of antipsychotic use, no localising signs of infection

# Investigations 

The **Sepsis Six** involves taking three key measures (as well as giving three key treatments):

- **Blood cultures** ideally prior to antibiotic administration
- **Lactate** (i.e. a blood gas - venous or arterial)
- **Urine output** (which may involve inserting a urinary catheter)

Other **bedside tests** should include:

- **Capillary blood glucose** as hypo or hyperglycaemia may contribute to confusion
- **Urine pregnancy test** in women of childbearing age
- **Urine dip** and send for **MC&S** looking for evidence of urinary tract infection
- **ECG** as in any acutely unwell patient, looking for arrhythmias and ischaemic changes

**Blood tests** should include:

- **FBC** and **CRP** for inflammatory markers
- **U&Es** looking for evidence of acute kidney injury
- **LFTs** as a baseline prior to giving antibiotics, may be deranged in sepsis
- **Coagulation screen** as this may be deranged in sepsis

**Imaging** should include:

- **Chest X-ray** as part of a septic screen

Other investigations should be targeted at a suspected underlying cause, e.g. respiratory or wound swabs, other imaging e.g. a CT abdomen or echocardiogram or special tests e.g. lumbar puncture when stable.

# Management 
 
The three things that should be given as part of the **Sepsis Six** are:

- IV fluid resuscitation (usually a 500ml bolus over 15 minutes initially)
- Supplementary oxygen to target saturations of 94-98% (88-92% if at risk of type 2 respiratory failure)
- Broad-spectrum IV antibiotics (as per local guidelines)

Other **conservative** management considerations involve:

- Close monitoring of observations, fluid balance, clinical condition and bloods including serial lactate measurement
- Early escalation for senior review and inform intensive care as may require interventions such as inotropes or vasopressors

Other **medical** management involves:

- Modify antibiotic therapy if a source of infection is identified or microbiological results become available
- Further IV fluids may be required however this should be done with careful fluid balance monitoring

**Surgical** management involves:

- Source control, e.g. draining abscesses or debriding infected tissue
- Infected devices may need to be removed
 
# Complications

- **Multi-organ failure** including renal failure, heart failure, acute respiratory distress syndrome and cholestasis
- **Coagulopathy** including disseminated intravascular coagulation
- **Delirium** which may be associated with long-term cognitive impairment e.g. difficulty concentrating and memory loss
- **Mental health impacts** including anxiety, depression and post-traumatic stress disorder
- **Secondary infections** which are often hospital-acquired
- **Polyneuropathy** i.e. critical illness polyneuropathy, characterised by generalised weakness and sensory loss
- **Death**

# Prognosis

- Overall mortality has been estimated at around 20-30%
- This increases to 64% in patients aged over 85 years
- Patients with septic shock also have higher mortality (40-60%) 
- Risk of death in survivors remains raised after recovery (15% of sepsis survivors die within a year of discharge, with 6-8% more dying each year for the following 5 years) 

# NICE Guidelines

[NICE - Sepsis: recognition, diagnosis and early management](https://www.nice.org.uk/guidance/ng51)

[NICE CKS - Sepsis](https://cks.nice.org.uk/topics/sepsis/)

# References 
 
[UK Sepsis Trust](https://sepsistrust.org/)

[Patient UK - Sepsis](https://patient.info/doctor/sepsis-septicaemia-pro)
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Topic
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Emergency Medicine
A 31-year-old man presents to the Emergency Department with shortness of breath, fever and a cough productive of green sputum. This has been worsening over the course of 3 days, however, today he has been feeling very weak and faint, so decided to seek medical attention. His observations are as follows:

Respiratory rate 24 breaths per minute, oxygen saturations 95% on 2 litres of oxygen by nasal cannula, heart rate 123 beats per minute, blood pressure 91/63 and temperature 38.4. His Glasgow Coma Score (GCS) is 15.

His chest x-ray is displayed below:

[lightgallery]

What is the most appropriate next step in the management of this patient?
a