PANCE Blueprint Infectious Disease (6%)

Sepsis/systemic inflammatory response syndrome

Patient will present as → a patient with severe pancreatitis is experiencing new-onset changes in mental status. Vitals are: BP 70/50 mm Hg, HR 132/min, RR 24/min, temp 103°F, sat 94%. Laboratory values reveal a WBC count of 28,000 and a serum lactate level of 17.3 mmol/L (normal: 0.5–2.2 mmol/L).

What are the components of the qSOFA (Quick SOFA) Score for Sepsis?

Quick SOFA – Use to predict mortality, NOT to diagnose sepsis

  • New or worsened mentation
  • Respiratory rate greater than or equal to 22/min
  • Systolic blood pressure less than or equal to 100 mmHg

Sepsis is a toxic inflammatory condition arising from the spread of microbes, especially bacteria or their toxins, from a focus of infection. Ttriggers a systemic inflammatory response syndrome (SIRS) in the body in response to toxins.

Systemic inflammatory response syndrome (SIRS) requires at least 2 of the 4 following criteria be met (no longer used, important to be aware of)

  • Body temperature less than 36 deg C or greater than 38 deg C
  • HR > 90 bpm
  • Respiratory rate greater than 20/min
  • WBC count less than 4,000 or greater than 12,000 OR greater than 10% bands

Quick SOFA - a new guideline for predicting mortality that has replaced SIRS

  • New or worsened mentation
  • Respiratory rate greater than or equal to 22/min
  • Systolic blood pressure less than or equal to 100 mmHg

Gram-positive shock results from exotoxins leading to fluid loss - common etiologies are staph and strep

Gram-negative shock is caused by endotoxin by bacteria - such as E. Coli, Klebsiella, Proteus, Pseudomanas

Group associations:

  • Neonates: Group B Strep, E. coli, Klebsiella
  • Children: H. influenzae, pneumococcus, meningococcus
  • Adults: Gram positive cocci, aerobic bacilli, anaerobes
  • IV drug: users S. aureus
  • Asplenic patients: Pneumococcus, H. influenzae, meningococcus
  • Line associated infections: Skin flora (e.g., coagulase negative staph)

Laboratory findings include

  • Respiratory alkalosis with a metabolic acidosis 
  • Neutropenia or neutrophilia with increased bands
  • Thrombocytopenia occurs in 50% of the cases
  • Coagulation studies and possible a DIC panel

Any neonate with a temperature of 100.4 deg F or higher should receive a full work-up:

  • Blood and urine culture, UA, CBC, LP

Identify and remove the cause of infection - patients often require ICU admission

  • IV fluids/pressors to support blood pressure (may be best initial step depending on the case)
  • Empiric antibiotics
  • Send blood cultures
  • Remove all existing catheters, IV lines, central lines, culture
Sepsis is a systemic inflammatory response to an infection and it is classified as severe sepsis when organ dysfunction is involved. Septic shock is the occurrence of sepsis with hypotension despite adequate fluid resuscitation. In response several pathological mechanisms occur in the body including excessive vasodilation, increased microvascular permeability, excessive cellular activation, and increased coagulation. This results in maldistribution of blood leading to inadequate tissue perfusion and subsequently tissue hypoxia.

Sepsis and Septic Shock Picmonic

Sepsis is a systemic infection that triggers a systemic inflammatory response syndrome (SIRS) in the body in response to toxins. The initiating event may result from an infection, major surgery, trauma, burns, or acute pancreatitis. Common symptoms include a fever, hypotension from systemic vasodilation, an increase in white blood cell count, change in LOC, tachycardia and tachypnea. Some patients may also present with significant edema due to fluid shift, along with elevated blood glucose levels. Factors placing the patient at increased risk for developing this condition include increased aged, immunosuppressed individuals, and prolonged hospitalization.

Sepsis Assessment Picmonic

DIC is a secondary disease that results from the abnormal widespread over-activation of the coagulation cascade (either the intrinsic or extrinsic pathway). This results in thrombi formation in the microcirculation and subsequent tissue hypoxia and infarction and microangiopathic hemolytic anemia.

DIC Picmonic

Shock is a condition characterized by decreased tissue perfusion and impaired cellular metabolism. The four main types of shock classified by either the functional impairment or the site of origin and are known as hypovolemic, cardiogenic, obstructive, and distributive. More than one type of shock can be present at the same time.

Types of Shock Picmonic

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