Sepsis

Question 1

What is sepsis?

Answer 1

• it is a condition triggered by an infection
• in an attempt to overcome the infection our bodies release a battery of chemicals and hormones causing inflammation and send white blood cells to fight the invading organisms
• thought of as the body’s severe response to an infection rather than a severe infection
• microorganisms are usually but not exclusively bacteria

Question 2

Define sepsis

Answer 2

• condition triggered by an infection

Question 3

Define SIRS

Answer 3

• systemic inflammatory response syndrome

Question 4

Define septic shock

Answer 4

• sepsis induced hypotension (<90 mmHg or a reduction of 40 mmHg)

Question 5

Define severe sepsis

Answer 5

• sepsis associated with acute organ dysfunction

Question 6

Define septicaemia

Answer 6

• the presence in the blood of large numbers of bacteria and their toxins

Question 7

Define MODS

Answer 7

• multiple organ dysfunction syndrome

Question 8

Describe the continuum of illness due to infection

Answer 8

Bacteremia —> Septicaemia —> Sepsis —> Severe Sepsis —> severe sepsis with septic shock —> MODS —> death

Question 9

Describe the pathophysiology of sepsis

Answer 9

• the following chemicals are thought to cause the ‘damage’
• endotoxins —> lipoproteins contained within gram - neg organisms
• exotoxins —> products of microorganisms - harmful to host
• host - mediators —> cytokines including tumour necrosis factor, interleukin 1,6,8 and myocardial depression factor

Question 10

What are the effects of systemic infection?

Answer 10

• inappropriate fluid shift and vasodilation compromising tissue perfusion
• impaired tissue oxygenation, hypoxia, acidosis (disturbed pH, may be characterised by vomiting, tachypnoea, drowsiness), hypotension and hypovolaemia
• at cell level, reduced oxygenation and perfusion ends to falling adenosine triphosphate (ATP) levels and loss of cell membrane integrity
• despite the body compensating by increasing cardiac output, this rise fails to meet metabolic demands or to compensate for the decreased ventricular pre-load leading to end organ subperfusion and failure

Question 11

What are the effects of sepsis?

Answer 11

• bacteria enter blood and trigger complex immunologic reactions
• vasodilation occurs and fluid leaks from blood vessels into surrounding tissue
• leaking vessels impair the body’s ability to pump blood (containing vital nutrients) to surrounding tissues and organs
• decreased blood flow to organs results in poor nutrient exchange and tissue swelling
• shock
• MODS
  —> kidney failure - kidneys shut down
  —> respiratory failure - alveoli collapse and fill with fluid
  —> osteomyelitis - infection in bone causes deterioration
  —> brain damage - brain swells and is deprived of oxygen

Question 12

What are some of the pre-disposing factors for pregnancy?

Answer 12

• initial insults - trauma
• poor infection control policy
• staffing levels
• length of stay
• invasive equipment
• resident populations of microorganisms
• inappropriate antibiotic therapy
• poor nutritional status

Question 13

What are some of the risk factors for sepsis?

Answer 13

• c/s
• perineal trauma
• catheterisation
• PROM
• prolonged labour
• obesity
• diabetes
• impaired immunity
• anaemia
• retained products

Question 14

What are some of the common symptoms of sepsis in the puerperium?

Answer 14

• fever, rigours
• diarrhoea or vomiting - may indicate exotoxin production
• breast engorgement/ redness/ rash
• abdominal/ pelvic pain and tenderness

Question 15

What are the signs and symptoms of sepsis?

Answer 15

• tenderness
• wound infection - spreading cellulitis or discharge
• offensive vaginal discharge
• productive cough
• urinary symptoms
• delay in uterine involution
• general - non specific sign such as lethargy, reduced appetite

Question 16

What is the sepsis 6?

Answer 16

• administer high flow oxygen
• take blood cultures
• give broad spectrum antibiotics
• give intravenous fluid challenges
• measure serum lactate and haemoglobin
• measure hourly urine output

Question 17

What is genital tract sepsis?

Answer 17

• genital tract infection can be acquired during pregnancy, labour, the puerperium is after surgery
• main causative organism is GAS (group A streptococcus pyogenes)
• sepsis in early pregnancy is associated with miscarriage, PROM and chorioamnionitis
• infection in the 3rd trimester may present with a short history of flu-like symptoms, tachycardia and an abnormal CTG - may lead to emergency c/s
• increased risk of atonic uterus, major haemorrhage, cardiac arrest, ARDS, fetal infection and asphyxia, maternal and/or neonatal death

Question 18

What are some of the early signs and symptoms of GAS sepsis?

Answer 18

• vomiting
• diarrhoea
• abdominal pain
• lymphangitis
• tachycardia
• increased respiratory rate
• pyrexia

Question 19

What is puerperal sepsis?

Answer 19

• it is defined by WHO as an infection of the genital tract occurring at any time between the rupture of membranes or labour and the 42nd day postpartum in which two or more of the following are present
  —> pelvic pain
  —> oral temp >38.5
  —> abnormal vaginal discharge
  —> abnormal smell/foul odour of discharge
  —> delay in the rate of reduction of the size of the uterus

Question 20

What investigations should take place if sepsis is suspected in pregnancy?

Answer 20

• Bloods - culture, FBC, u+e’s, lft’s, coags, Crp arterial blood gases and lactate
• high and low vaginal swabs
• MSU
• throat swab

Question 21

What is the role of the midwife in managing sepsis in pregnancy?

Answer 21

• antenatal education to raise awareness of signs and seriousness of infection
• personal and perineal hygiene
• avoiding unnecessary contact with potentially ill children
• if a mother reports symptoms of feeling unwell, especially a sore throat
  —

Question 22

What is the role of the midwife in managing sepsis in the postnatal period?

Answer 22

• prevention —> all the advice as in the antenatal period but emphasise washing hands before and after using the toilet in home and in hospital
• detection —> thorough systemic postnatal examination of all mothers
  —> vigilant observations
• action —> medical aid sort and midwife must not leave woman
  —> reassure, ambulance
• when in hospital take perineal and rectal swabs, culture breast milk