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Septicaemia

Septicaemia Portfolio

Student Name:

Student Number:

PARA201 S1, 2020

Septicaemia

Definition

Clinical Features

Aetiology

Classifications (if applicable)

Pathophysiology

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Septicaemia is the event in which bacteria enters the bloodstream from elsewhere in the body i.e. lungs or skin. The infection travels through the blood to multiple spots around the body causing a major immune response referring to sepsis (O'Connell & Cafasso, 2018). Septicaemia has a number of clinical features that depend on how long the patient has been infected for. First phase features of a septic patient include Tachycardia (>130 beats per minute), Tachypnoea (20 breathes per minute), fever and an alteration in mental state (Glasgow Coma Scale < 15) (MacGill, 2017). A septic patient’s condition can deteriorate rapidly leading to signs of septic shock. Features of septic shock include severe Hypotension and Hypoxaemia (Hotchkiss et al., 2016). The very distinctive features of septicaemia include; Oliguria which is limited or decreased urine output as a result of renal failure, Lactaemia describing the high levels of lactate in the blood as a result of anaerobic respiration and extreme Leukocytosis indicating a large spike in white blood cell count (Legrand & Payen, 2011). In 2017 the Australian Sepsis Network recorded the number of Septicaemia cases in Australia and around the world. They recorded 55,000 cases which led to the death of 8700 people in Australia whilst globally there were 49 million cases with 11 million deaths (Australian Sepsis Network, 2017). Any person can be diagnosed with septicaemia, however, children, older adults or people with serious medical conditions/injuries are at a higher risk of septicaemia (National Institute of General Medical Sciences, 2019).Any form of infection can cause infiltration of bacteria in the blood however Pneumonia, Infection to the digestive system and Infection to the urinary system are the most common causes of Sepsis (Berwick et al 2008). People who do not have a fully functioning and effective immune system such as infants, the elderly and immunocompromised patients are most at risk (National Institute of General Medical Sciences, 2020). Septicaemia is usually obtained through a past inflammatory response a result from wounds, injuries and burns. People who have invasive devices such as gastronomy buttons or catheters also are at risk of septicaemia (National Institute of General Medical Sciences, 2020). Septicaemia is classified in terms severity. There are three stages of septicaemia; sepsis, severe sepsis and septic shock (Ryding, 2017). First stage sepsis involves the ignition of a simple immune response presenting as mass increase in white blood cell count and a presentation of febrile body temperatures. Severe sepsis involves organ dysfunction as a result of hypoperfusion and hypotension (Ryding, 2017). Increased lactate levels in the blood, decreased Urine output, Abnormal heart activity and limitations to respiratory pattern occur. Septic shock occurs as a result of untreated sepsis. This presents severe hypotension and hypoxia and as a result organ damage and cirrhosis can occur increasing pressure on the heart and lungs potentially leading to cardiac arrest. Septicaemia occurs when a foreign bacterial antigen enters the bodies blood stream as a result of a traumatic haemorrhage, Burns or a previous infection (O'Connell & Cafasso, 2018). The bodies response usually begins with a second line non- specific immune response. A Macrophage refers to a type of leukocyte (White Blood cell) that engulfs/Phagocytoses all microbes that passes into the bodies tissues (Austin Community College (ACC), 2005). The cell membrane of the macrophage opens up and engulfs the microbe into an envelope (Harris, 2016). Lysosomes infiltrate the vesicle made by the Macrophage and acidify the microbe thus destroying it (Laing, 2017). The remnants of the destroyed microbe are brought to the surface of the macrophage via a protein complex specifically known as class two major histocompatibility complex (Lumen, 2020). When the antigen is presented only then can an immune cell interact with the destroyed microbe. Helper – T Lymphocytes attach themselves to MHC to decide if this microbe is “self” or “nonself” (ACC, 2005). The Helper – T Lymphocytes will then secrete Interleukin 2 which is a type of cytokine signalling molecule (Thèze, 1998). The cytokine signal is used to proliferate the action of Cytotoxic T cells and B cells. By this stage an all-out immune response is activated targeting antigen the macrophage has presented. Student Number:

PARA201 S1, 2020

Septicaemia

An immune response triggers inflammation to the site of infection. Inflammation is the bodies response to an infection. Its role is to encourage repair and prevent further infection (The Editors of Encyclopaedia Britannica, 2019). An inflammation response is triggered by a number of mediators including; Cytokines, Histamines, Bradykinin, Prostagalndins and Leukotrienes (Branco, Yoshikawa, Pietrobon & Sato, 2018). These mediators all take control of blood flow by regulating dilation, constriction and pressure. An inflammation response is when the site becomes red, swollen, hot, painful or there is a loss of function as a result of the inflammatory mediators (Retamal, Bennett, Pelegrin & Fernandez, 2016). A familiar type of Prostaglandin known as thromboxane plays a role in constriction on muscles as well has platelet coagulation. The point of these mediators is to encourage excess blood flow to the target site so that white blood cells can easily flood in. (William & Shiel, 2018). The risks of Septicaemia is a complete body inflammation that becomes so severe that body loses its primary functions. Septicaemia occurs when a bacterial infection invades the blood stream (O'Connell & Cafasso, 2018). Vasodilation as a result of inflammation gives bacteria free range within the circulatory system. Bacteria are known for the ability to reproduce at extreme rates (Lewis et al., 2010). There population can double within 4 – 20 minutes which causes a rapid and unconventional immune response. As the bacteria flows throughout the circulatory system the immune system kicks in and inflammation occurs all around the body in order to encourage white bloods cells to destroy the foreign microbes (Institute for Quality and Efficiency in Health Care (IQEHC, 2006). Patients with septicaemia at this stage begin to experience hypotension as a result of extreme vasodilation. Inflammation stimulates the sympathetic nervous system which causes tachycardia and tachypnoea to deal with the bodies stress (Kalil, A., & Pinsky, M., 2019). The hallmarks of the exaggerated inflammation causes a number of coagulation cascades encouraging severe clotting risks, Vasodilation which can disrupt cardiac activity, Endothelial leakage of the capillaries and a dysfunction in the exchange of gases between membranes (Pongratz, G., & Straub, R., 2014). White blood cells release lytic enzymes to fight the bacteria in the blood (Mannarino, I., 2014). These enzymes end up damaging areas of the vessel walls. This causes a number of problems such as severe blooding clotting and fluid leakage. Permeability increases causing large amounts of fluid to enter the cells limiting the amount of oxygen that can travel into the cell (Mannarino, I., 2014). Vessels begin to repair using coagulation of fibrin and platelets to block the wounds. This damage has a major effect on the lungs and can lead to Acute Respiratory Distress Syndrome which limits the lungs ability to take in oxygen (Allen, S., 2018). As a result of decreased Systemic Vascular Resistance and decreased blood pressure the heart is forced to increase its rate in an attempt to increase cardiac output (Matthay, Aldrich & Gotts, 2020). In severe cases the vessels can become so damaged that the heart becomes paralysed. The demand for oxygen becomes to great that cell death occurs, and organ dysfunction becomes imminent. Most Patients who die from sepsis die as a result of organ failure and blood clotting, both of which are caused by the bodies effort to eliminate the foreign particle. Under NSW and QLD ambulance guidelines (2020) recognition of risk factors and symptoms Evaluation and of the sepsis is priority. Paramedics must decide the severity of the symptoms. As stated Risk assessment under the NSW ambulance protocols “Sepsis is a life-threatening condition and one of the leading causes of death in hospital patients worldwide”. It is critical that the level of severity is recorded so that time critical decisions can be made, and the hospital can be notified of the patient’s condition before arrival to the hospital. Queensland Ambulance (2020) state that a high-risk patient has a respiratory rate of greater than 25 breathes per minute, Diastolic blood pressure less than 90mmHg, Altered mental status, Febrile body temp and a tachycardic heart rate greater than 130 beats per minute. Patients with these qualities are considered ‘sick’ and ‘Time critical’ and need urgent treatment. Student Name:

Student Number:

PARA201 S1, 2020

Septicaemia

Differential Diagnosis

Treatment

Sepsis is defined as a Systemic Infection Response Syndrome. Conditions that could mimic sepsis must have very similar symptoms of sepsis including; Fever, Hypotension, Tachycardia and Tachypnoea (MacGill, 2017). The most critical conditions that mimic sepsis are Pulmonary Embolism, Pancreatitis and Hypovolaemia (Long & Koyfman, 2016). They all share very similar symptoms, however, must be ruled out, as they require different treatments. For example, if a paramedic diagnosed the patient as septic and gave IV fluid to a patient experiencing a pulmonary embolism, more pressure would be put on the clot and further tissue damage and possibility of death would increase dramatically. If diagnosis is not correct a patient can be put at further risk. For any adult septicaemic patient, the following interventions must be considered; Oxygen deliver, Antipyretics, IV/IO access and IV/IO Fluids. Sepsis patients require a high a level of supplemental oxygen (Polat et al., 2017) Oxygen is to be delivered through a Non-Rebreather mask (NRBM) or through a Bag Valve Mask provided that the patient requires a positive pressure ventilation. Oxygen is to be delivered 15 L/min maintaining an oxygen saturation level of 94% - 98% (MIMSonline, 2020). Antipyretics can be used to alter the effects of fever (Aronoff & Neilson, 2001). Most common Antipyretics used by paramedics include Paracetamol and Ibuprofen. Paramedics can give 200-400mg Per Orally to a patient and 500mg- 1g of Paracetamol per orally (MIMSonline, 2020). A patient with sepsis who is hypotensive, and hypo perfused should be given compound sodium lactate intravenously. 500ml bag is raised above the attachment. The fluid is given intravenously in dosage size of 20mL/kg (New South Wales Ambulance Service, 2020). Epinephrine when fluid resuscitation is not so effective in high risk patients can also be used (Mackenzie et al., 1991). CCP administer this drug by injecting 1mg of 1:1000 adrenaline 500ml of Sodium Chloride 9% through a smart site burette set. The infusion is given through IV cannulation (MIMSomline, 2020).

Ceftriaxone can be given to treat severe bacterial infection under certain states (Multum, 2019). It’s given either Intramuscularly at 1000mg diluted with 3.5ml of Lignocaine 1%, administered in upper lateral thigh or Intravenously at 1000mg diluted with 10ml of water administer slowly over 2 minutes (MIMSonline, 2020). As stated in New South Wales (NSW) clinical practice guidelines (CPG) (2020) there is a CPG Variations strong focus on fast recognition of sepsis risk factors and symptoms, early resuscitation via fluids and antibiotics and transport to the hospital. NSW outline to importance for a clear IMIST-AMBO Handover making sure to properly outline that the patient has signs suggesting sepsis (New South Wales Ambulance Service, 2020) The QLD CPG advises the paramedic to assess the severity of the sepsis and depending on the degree will allocate how fast the patient is transported to hospital. QLD CPG considers all treatment options that NSW do however for a high-risk patient, QLD paramedics consider the use of Epinephrine depending on how effect fluid resuscitation is (Clinical Quality & Patient Safety Unit, QAS, 2020) The Victorian (VIC) CPG only have procedures for meningococcal septicaemia rather specifically for sepsis. They allocated sepsis in a high-risk category for oxygen therapy however it does not mention how a typical sepsis patient presents. Victoria is similar to NSW CPG however they can give Ceftriaxone either IM or IV. This is to target the bacterial infection straight away (Victorian Ambulance Service, 2020).

Student Name:

Student Number:

PARA201 S1, 2020

Septicaemia References Allen, S. (2018). What is Acute Respiratory Distress Syndrome. Retrieved from https://www.healthline.com/health/acute-respiratory-distress-syndrome

Aronoff, D., & Neilson, E. (2001). Antipyretics: mechanisms of action and clinical use in fever suppression. The American Journal Of Medicine, 111(4), 304-315. doi: 10.1016/s0002-9343(01)00834-8

Austine Community College (2005) Immune System. Retrieved from https://www.austincc.edu/apreview/EmphasisItems/Inflammatoryresponse.html

Bewick, T., Simmonds, M., Chikhani, M., Meyer, J., & Lim, W. (2008). Pneumonia in the context of severe sepsis: a significant diagnostic problem. European Respiratory Journal, 32(5), 1417-1418. doi: 10.1183/09031936.00104808

Branco, A., Yoshikawa, F., Pietrobon, A., & Sato, M. (2018). Role of Histamine in Modulating the Immune Response and Inflammation. Mediators Of Inflammation, 2018, 1-10. doi: 10.1155/2018/9524075

Clinical Quality & Patient Safety Unit, QAS (2020). Medical/Sepsis. Retrieved from

https://www.ambulance.qld.gov.au/docs/clinical/cpg/CPG_Sepsis.pdf

Harris, J. (2016). Phagocytosis. Retrieved from https://www.immunology.org/public-information/bitesized-immunology/systemsand-processes/phagocytosis.

Hotchkiss, R., Moldawer, L., Opal, S., Reinhart, K., Turnbull, I., & Vincent, J. (2016). Sepsis and septic shock. Nature Reviews Disease Primers, 2(1). doi: 10.1038/nrdp.2016.45

Institute for Quality and Efficiency in Health Care, (2006). What is Inflammation?. Cologne. Informedheatlh.org

Kalil, A., & Pinsky, M. (2019). How do Tachycardia and Tachypnoea manifest in sepsis/septic shock?. Retrieved from https://www.medscape.com/answers/168402-27362/how-do-tachycardia-and-tachypnea-manifest-in-sepsisseptic-shock

Laing, K. (2017). Immune response to bacteria. Retrieved from https://www.immunology.org/public-information/bitesizedimmunology/pathogens-and-disease/immune-responses-viruses Student Name:

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PARA201 S1, 2020

Septicaemia Legrand, M., & Payen, D. (2011). Understanding urine output in critically ill patients. Annals Of Intensive Care, 1(1). doi: 10.1186/2110-5820-1-13

Lewis, N., Hixson, K., Conrad, T., Lerman, J., Charusanti, P., & Polpitiya, A. et al. (2010). Omic data from evolved E. coli are consistent with computed optimal growth from genome ‐scale models. Molecular Systems Biology, 6(1), 390. doi: 10.1038/msb.2010.47

Long, B., & Koyfman, A. (2016). Sepsis Mimics. Retrieved from https://epmonthly.com/article/sepsis-mimics/

Lumen. (2020). Antigen Presenting Cells. Retrieved from https://courses.lumenlearning.com/wm-biology2/chapter/t-and-b-lymphocytes/

MacGill, M. (2017). Septicemia: Risk factors, symptoms, treatment, prevention, and outlook. Retrieved 29 March 2020, from https://www.medicalnewstoday.com/articles/311589#symptoms

Mackenzie, S., Kapadia, F., Nimmo, G., Armstrong, I., & Grant, I. (1991). Adrenaline in treatment of septic shock: Effects on haemodynamics and oxygen transport. Intensive Care Medicine, 17(1), 36-39. doi: 10.1007/bf01708407

Mannarino, I. (2014, November). Septic shock - pathophysiology and symptoms | NCLEX-RN | Khan Academy [video file]. Retrieved from https://www.youtube.com/watch?v=-bt-H5VQl5E. Matthay, M., Aldrich, J., & Gotts, J. (2020). Treatment for severe acute respiratory distress syndrome from COVID-19. The Lancet Respiratory Medicine. doi: 10.1016/s2213-2600(20)30127-2

MIMSonline. (2020). Adrenaline-Link Injection BP. Retrieved from https://www-mimsonline-comau.ezproxy2.acu.edu.au/Search/AbbrPI.aspx?ModuleName=Product %20Info&searchKeyword=epinephrine&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=89700001_2

MIMSonline. (2020). Air Liquide Australia Limited Medical Oxygen. Retrieved from https://www-mimsonline-comau.ezproxy2.acu.edu.au/Search/AbbrPI.aspx?ModuleName=Product %20Info&searchKeyword=oxygen&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=129510001_2

Student Name:

Student Number:

PARA201 S1, 2020

Septicaemia MIMSonline. (2020). Antipyretics. Retrieved from https://www-mimsonline-comau.ezproxy2.acu.edu.au/Search/AbbrPI.aspx?ModuleName=Product %20Info&searchKeyword=panamax&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=3950001_2

MIMSonline. (2020) Ceftriaxone. Retrieved from https://www-mimsonline-comau.ezproxy2.acu.edu.au/Search/AbbrPI.aspx?ModuleName=Product %20Info&searchKeyword=Ceftriaxone&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=95340001_2

Multum, C. (2019). Ceftriaxone. Retrieved from https://www.drugs.com/mtm/ceftriaxone-injection.html

National Institute of General Medical Sciences. (2020). Sepsis. Retrieved from https://www.nigms.nih.gov/education/factsheets/Pages/sepsis.aspx

National Institute of General Medical Sciences. (2019). SEPSIS. Bethesda, Maryland.

New South Wales Ambulance Service. (2020). Protocols and Pharmacology. Retrieved from http://www.ambo.com.au/download/protocol_2011.pdf

O'Connell, K., & Cafasso, J. (2018). Septicemia. Retrieved 29 March 2020, from https://www.healthline.com/health/septicemia Retamal, M., Bennett, M., Pelegrin, P., & Fernandez, R. (2016). Ion Channels in Inflammatory Processes: What Is Known and What Is Next?. Mediators Of Inflammation, 2016, 1-1. doi: 10.1155/2016/6245731

Polat, G., Ugan, R. A., Cadirci, E., & Halici, Z. (2017). Sepsis and Septic Shock: Current Treatment Strategies and New Approaches. The Eurasian journal of medicine, 49(1), 53–58. https://doi.org/10.5152/eurasianjmed.2017.17062

Pongratz, G., & Straub, R. H. (2014). The sympathetic nervous response in inflammation. Arthritis research & therapy, 16(6), 504. https://doi.org/10.1186/s13075-014-0504-2

Ryding, S. (2017). The Stages of Sepsis. Retrieved 31 March 2020, from https://www.news-medical.net/health/The-Stages-ofSepsis.aspx

The Editors of Encyclopedia Britannica. (2019). Inflammation. Retrieved from https://www.britannica.com/science/inflammation. Student Name:

Student Number:

PARA201 S1, 2020

Septicaemia Thèze, J. (1998). Interleukin 2. Retrieved from https://www.sciencedirect.com/topics/neuroscience/interleukin-2

Victorian Ambulance Service. (2020). Meningococcal septicaemia. Retrieved from https://www.ambulance.vic.gov.au/wpcontent/uploads/2019/11/avcpg_small-min.pdf

William, C., & Shiel, J. (2018). Medical definition of Prostaglandin. Retrieved from https://www.medicinenet.com/script/main/art.asp?articlekey=16461

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