The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes336
EMQ1502
SBA2115
Do you realy want to delete this discussion?
Forum >>

Essay 300 - Sepsis

Posted by Namia F.

 

A.The initial managment of severe sepsis should be rapid prompt IV broad spectrum antibiotic whithin 1 hour of the presentation, after taking the appropriate investigations ( blood culture, FBC, serum lactate, U & E, CLOTTING SCREEN , liver functions, MSU , SWABS ).Multidisciplinary care team with involvement of infectious disease, ITU physcians. Antibiotic should cover Group A streptoccoi, aneorobes and common organism ( IV clindamycin , and Iv Gentamycin ,  as the patient is critically ill with metronidazole added if suspected aneorobes ) if MRSA is suspected 3 doses of IV teicoplanin or Linezolid should be added.The Antibiotics can be modified after resuts of swabs and culture.Strict monitoring of the patient ideally in ITU , with monitoring of pulse , BP, PO2, JVP, CVP and fluid input and output .If serum lactate ismore than 4mmol/l initial fluid crstalloid or colloid 20ml/ kgm should be given , with possible vassopressors like epinephrine or ionotropes like dobutamine to maintain MAP more than 65 mmhg. If still hypotensive despite the initial fkuid therapy, aggressive fluid replacement to maintain CVP more than 8 mmhg with consultation of intensivist. Correction of electrolyte disturbances, and blood transfusion if anaemia detected. Coagulopathy to be treated with fsh frozen plasma. Steroids IV dexamethasone may be needed in refractory shock.Treatment of the cause after thourough assesment of the patient and stabiliztion and removing the source of infection. Assesment of the patient risk for possible thromboprophylaxis with LMWH To prevent VTE .

B.The measure tos reduce infection at elective CS can be preoperative like identification of risk factors like obesity, detection and treatment of antenatal anaemia with iron suplemetation, MSU samples for detection of UTI with adequate tretment before operation. Intraoperatively, measure should be strict adherence to nfection control neasure of all OT staff, with strict adherence to scrubbing and stilizatio technique, prophylactic IV antibiotics ( 1st. Geration cephalosporin ) At the time of skin incision, meticulous surgical techniques like avoiding exteiorization of the uterus, good haemostasis, decreasing trauma to the tissue.Avoiding routine insertion of wound drains. The education of the patient about general personal hygience to decrease risk of peurperal infection .Advise about washing hand before and after toilet or neonatal diper care. Education of mother about symptoms and signs of sepsis, to attend to medical facility rapidly if offensive lochia, feeling unwell or having fever after eelivery.

 

 

 

 

 

 

 

 

 

sepsis essay 300 Posted by hoba K.

A 35 healthy year old woman presents to the assessment unit 4 days after an elective caesarean section because she is feeling increasingly unwell. Her temperature = 38.9C, pulse = 138 / min, BP = 75/58 mmHg.

(a)    Discuss your initial acute management [14 marks].

This patient management should be under a MDT care consisting of consultant obstetrician, consultant anaesthetist, specialist midwife, microbiologist, laboratory specialist and ITU specialist. The first step is to assess Airway, Breathing and Circulation, if there is evidence of cardiovascular compromise immediate resuscitation and transferral to ITU should be done. If no evidence of cardiovascular compromise I will start reviewing her history regarding the pregnancy  as prolonged rupture of fetal membranes before delivery which increases the risk of endometritis, recurrent UTI or asymptomatic bacterurea. I will ask about abdominal pain which generalised might be due peritonitis, lower abdominal and pelvic pain due to endometritis, loin and suprapubic pain due to pyelonephritis. I will ask about wound pain, discharge or bleeding. I will ask about breast feeding and the prescence of breast pain, nipple discharge could be due to mastitis. I will ask about offensive vaginal discharge due to endometritis, more than average vaginal bleeding can denote retained products of conception as a source of sepsis. I will examine her generally for BMI, repeat blood pressure, pulse, tempreture and respiratory rate. Abdominal examination for generalised tenderness, rigidity and guarding due to endometritis and peritonitis, subinvolution of uterus could be due to endometritis or retained products of conception, loin tenderness due to acute pyelonephritis, wound examination for swelling, erythema, induration, tenderness, discharge and bleeding. Pelvic examination for discharge, bleeding, uterine and adenexal tenderness. Resuscitation, Investigations, monitoring and treatment should go hand in hand. Blood samples taken for FBC, ALT, Bilirubin, U & E, serum Lactate, CRP as baseline markers and part of sepsis screen. coagulation profile for possibility of DIC complicating sepsis. Blood for group and save. Blood for culture, HVS, wound swab, throat swab, MSU for culture and sensitivity.broad spectrum IV antibiotics should be started within 1 hour of recognition of sepsis. Cefuroxime and metronidazole can be used initially ( or as unit protocol after discussion with microbiologists) until results of antibiotics sensitivity are obtained.IV fluid resuscitation ( 2 L crystalloids + colloids) to maintain blood pressure above 90 mmHg. If blood pressure remains below 90 mmHg or lactate above 4 mmol/L vasopressors should be added to fluids to maintain CVP above 8 mmHg or central venous O2 saturation above 70 %.transfering the patient to ITU should be considered. consider transfusion of blood and blood products as indicated. Continuous monitoring of blood pressure, pulse, temp, O2 saturation, RR, urine output via a foley’s catheter and conscious level.  Thromboprophylaxis should be considered if no risk of bleeding.

 

(b)   Discuss the steps that should be taken to reduce the risk of infection in healthy women undergoing elective caesarean section [6 marks]

Sepsis is the main cause of death in the last CEMACE report. Incidence can be reduced by recognition of high risk groups and providing treatment or prophylaxis as appropriate. Examples of These include patients with prolonged rupture of membranes before delivery, recurrent UTI and asymptomatic bacterurea. All pregnant ladies scheduled for elective caesarean section should be screened for MRSA before the procedure and treatment provided for positive cases. The role of prophylactic IV antibiotics at the time of anaesthesia is well established in reducing the risk of sepsis. Strict following of aseptic techniques during scrubbing of surgical team should be done and routinely audited. The use of disposable draping reduces the risk of infection. Meticulous surgical techniques with ensuring haemostasis and closure of dead spaces reduce surgical site infection. Health care professionals should be able to recognise early symptoms and signs of infection and act accordingly. Regular skill drills should be conducted in all units to maintain optimum recognition and management of septic patients. All units should have clear guidelines and protocols regarding management of septic patients and antibiotic prophylaxis in certain cases. 

Posted by Angeldust S.

(A)

This woman has severe sepsis and if untreated can lead to increased morbidity and mortality up to 20-40%. Early recognition and treatment is key. Initial acute management includes resuscitation. She needs to be managed under a multidisciplinary tream of obstetrician, anaesthetst, senior midwife and microbiologist. Airway needs to be checked for patency and assessed for need for intubation. Pulse oximetry is attached for oxygen satuation. HIgh flow oxygen 10-15L/min is administered via fae mask. 2 large bore 14G venous lines are inserted for fluid resuscitation with intravenous crystalloids and colloids up to 2.5L as this patient is in circulatory shock. If rarefactory to fluid expansion, consideration needs to be given for dopamine infucion. Bloods are taken for FBC for white cell count, CRP for infection marker, renal and liver panel to assess for multiorgan failure, coagulation profile for DIVC and group and cross match. Arterial blood gas is taken to asses degree of hypoxia and lactate levels as <4 is significant for tissue hypoperfusion.blood cultures are taken for bacteraemia. Broad spectrum IV antibiotics should be started after cultures are taken and within one hour of presentation in congruence with surviving sepsis guidelines. The patient should be transferred to high dependency unit for close monitoring under MEOWs chart to identify early deterioation. Indwelling catheter, central venous line should be inserted for fluid monitoring. Thromboprophylaxis with LMWH and graduated compression stockings should be started as sepsis is a risk factor for VTE. 

Assess the conscious level of the patient and aim to take a history for duration of fever, localising symptoms e.g. dysuria, upper respiratory tract infection, breast pain and engorgement. Ask for foul smelling lochia to exclude endometriotitis and passage of tissue and vaginal bleeding for retained products of conception, which is less likely after a caesarean section. A history of abdominal distension and vomiting is asked to exclude bowel injury. Breathless, lower abdominal, calf and thigh pain is asked to exclude VTE as well as previous personal history and family history of VTE to assess risk. Her intra-operative notes are reviewed for any complicated caesarean section. A systemic examiantion is carried out to localise the source of sepsis. Abdominal examination for distension, massess signifiying haematoma, absence of bowel sounds suggestive of peritonism. Wound inspection is carried out to look for pus and wound breakdown. Pelvic examination for uterine and adnexal tenderess for pelvic infection. Speculum examination for foul smelling discharge, expelled products of conception. Breast examination for mastitis and engorgement, and lower limb examiantion for calf tenderness for DVT. Cardiorespiratory examination to rule out pneumonia. 

Additional investigations include vaginal swabs for infection, cultures from brastmilk and wound if any, urine cultures for mid-stream urine. Decision for imaging may include US Pelvis for retained POC, haematoma formation and CT AP for abscess and bowel injury. Treatment of the condition with depend on cause. Collaboration with microbiologist for optimum antibiotic regime is vital.

(B)

Pre-operative identifcation of MRSA carriers and treatment prior to Caesarean secion helps to reduce infection from MRSA commensals. Handwashing and proper scrubbng techniques is crucial to optimise hand hygience. PAtient should be advised to clean the body with cholohexidine day before surgery and advise against plucking of pubic hair to avoid folliculitis.

Intra-operatively broad spectrum antibiotics is given before knife-to-skin as this has been shown to decease wound infection. Meticulous surgical haemostasis is crucial to prevent formation of wound haematoma. Surgery to be done by skilled surgeon to minimise operating time and handlin. Need to ensure swab, needle and instrument count correct before closure as retained foreign body is a nidus for infection.

POst-oepratively, early ambualtion and removal of indwelling catheter helps to reduce urinary infection. Teach the woman on perineal hygeiene and handwashing before changing pads as the commonest cause of postnatal sepsis is genital tract sepsis. Education of family members to limit contact and practise contact precautions (wearing of mask, hand hygeiene) when having sore throat or URTI to minimise spread of Group A streptococcus. Written information is provided for the woman and family members and regular audits should be conducted on wound infection/sepsis post-caesarean section to identify potential sources of problem. Unit protocols should be in place for antibiotics use during caesarean section and compliance maintained. 

Sepsis Posted by Sarah S.

 a)       This is an obstetric emergency; I will summon help initially from the available staff and alert obstetric consultant and anesthetist. I will set 2 large bore cannula and draw blood for Full blood count,CRP,ESR, lactate levels and culture. I will start resuscitating her with IV fluids in a minimum 20kg/ml of crystalloids or equivalent. I will adminster broad spectrum  iv antibiotics within 1 hour of suspecting severe sepsis. A combination of pipercillin and tazobectum or carbopenum and clindamycin would be giving the broadest range of coverage. If MRSA is suspected, clindamycin may be added  vancomycin or teicoplanin till sensitivity is known. It is better to involve the microbiologist at an early stage as we need guidance to those medication that are suitable for breastfeeding mothers,and also help type of antibiotics if initial treatment is not showing response. 10-15l of Oxygen should be delivered through face mask. Urinary catheter should be inserted to monitor urine output. Alert the the intensive care unit team as we may need to nurse patient there if not responding to resuscitative measures. The patient’s vital signs including blood pressure, pulse rate, temperature and respiratory rate should be recorded in the modified early obstetric warning score charts. Vasopressors are given for hypotension not responding to the initial fluid resuscitation to maintain mean arterial pressure above 65mmhg. Central line of monitoring may be needed as these patients are more prone to develop pulmonary edema. If despite the fluid resuscitation the patient remains hypotensive and serum lactate levels of 4mmol/l or more (a sign of tissue hypoperfusion) or showing any evidence of multiorgan failure, she should be transferred to intensive care unit. Once the patient is stable full history taking and examination done to look for the source of sepsis. Other investigations like chest xrays, USG pelvis/abdomen/CT scan abdomen to be carried out as the clinically indicated. Then the treatment should be directed to the causative if found. The neonate should also be examined by pediatrician and treated especially if mother is noted to have invasive GAS infection. The family members should updated about the current condition of the mother.

b)       She is advised to maintain general hygiene. If she had any procedures in the antenatal period like amniocentesis to warn her about possible small risk of infection and report if unwell. As per NICE guidelines all women undergoing caesarean section, a single dose of a prophylactic broad spectrum antibiotics such as ampicillin or first generation cephalosrorin be offered. The doctor and the staff  should adhere to hygiene, frequent hand washing and aseptic precaution in order to minimize the risk of infection. intraoperativeley hemostasis should be secured well as blood is known good culture media for infection. The hospital should follow the standard protocol for sterilizing the surgical instruments and field. Postpartum also advice the patient to keep the hygiene and frequent hand washing, advice of wound care provided.  She should also be advised to stay away from any contagious infection in the family(eg GAS infection). information leaflet is given to the patient about general measures to prevent the infection and when to seek advise.

Posted by abeer E.

this is a case of acute sepsis , i will examine her and identify the cause of sepsis ,first examine site of skin incision (red,hot or any discharge)examine breast for engoragment swelling and tenderness be aware that staph.aureuse may cause necrotising fasciitis and it cause sever deep pain .iwill seeif theres any abnormal lochia(abnormal smell or color )to exclude endometritis .Iwlii ask about UTI symptos (burning sensation with micturation ,urgency or frequency) i will see if ther is any signs of respiratory tract infection . also i will examamine site of injection or canula and site of epidural in jection as it may be arare cause of sepsis postoperative.after that I need to take blood culture and other swap and culture according to the cause i suspect (vaginal swap, sputum, urinary ..) I have to start broad spectrum antibiotics as soon as posible with in one hour of presentation without the need to wait for culture result.also I will start IV fluid ,I will give her antipyretics 

and Iwill send blood sample for  (CPC , LFT , RFT.)  urine analysis .Also  I may need to do imaging like chest x ray  f iI suspect respiratory infection . Ultrasound pelvis If I suspect endometritis. finally I will make risk assessment to my patient regarding the need for thrompoprophylaxis and consider give if multiple rish factorspresent.

b)To reduce infection in healthy woman andergo elective CS , I will Identify risk facors( properative , Intraoperative , And postoperative ) and try to avoid it for preoperative Identify and treat any source of infection befor operation like (UTI , respiratory tract infection ,...)Intraoperatively  I will make sure of appllying full aseptic technique during operation give one dose prophylactic antibiotics afer skin incision ,make sure that all equipments sterlalised before using it . Regarding postoperatively I will make sure that site of wound clean and if there is catheter or drain remove in aseptic condition.