Sepsis and Septic Shock — MCQs
Refractory Septic shock is defined as?
Best solution to be used in hypovolemic shock is:
All the following are criteria for SIRS, except
A 70-year-old man develops pneumonia and septicemia, and subsequently experiences renal failure with a blood pressure of 70/50 mmHg. Which drug should be used to maintain blood pressure?
What is the main goal of fluid resuscitation in a child with septic shock?
A patient with a fever presents with a heart rate of 120 beats per minute and a respiratory rate of 30 breaths per minute. What does this indicate?
Most common cause of death in diphtheria is due to
A young lady complains of sore throat for 3 days along with fever and headache. On examination, she was severely dehydrated, her BP was found to be 90/ 50 mm Hg and on the distal aspect of the cuff, small red spots were noted. What could be the most probable etiological agent responsible for causing these symptoms -
Following pathogenetic mechanisms operate in septic shock except -
A 64-year-old woman presents to the emergency room with flank pain and fever, accompanied by dysuria for the past three days. Blood and urine cultures are obtained, and she is started on intravenous ciprofloxacin. Six hours after admission, she becomes tachycardic and her blood pressure drops. Her intravenous fluid is normal saline at a rate of 100 mL/h. Her current vital signs are blood pressure of 79/43 mm Hg, heart rate of 128 beats per minute, respiratory rate of 26 breaths per minute, and a temperature of 39.2°C (102.5°F). She appears drowsy yet uncomfortable. Her extremities are warm with trace edema. What is the best next course of action?
Sepsis and Septic Shock Indian Medical PG Practice Questions and MCQs
Question 1: Refractory Septic shock is defined as?
- A. Shock requiring mechanical ventilation and inotropic support
- B. Shock with lactate levels >4 mmol/L despite treatment
- C. Shock that does not respond to initial fluid bolus within 1 hour
- D. Shock persisting despite adequate fluid resuscitation and vasopressor support (Correct Answer)
Explanation: ***Shock persisting despite adequate fluid resuscitation and vasopressor support*** - This is the **standard definition** of refractory septic shock according to current **Surviving Sepsis Campaign Guidelines** and critical care literature. - It specifically refers to the failure of **both fluid resuscitation and vasopressor therapy** to restore adequate mean arterial pressure and tissue perfusion. *Shock that does not respond to initial fluid bolus within 1 hour* - This describes **early non-response** to fluid therapy, which is concerning but not the complete definition of refractory shock. - Refractory shock requires failure of **comprehensive standard therapy** (fluids AND vasopressors), not just initial fluid bolus failure. *Shock requiring mechanical ventilation and inotropic support* - This describes a patient in **severe septic shock** with multi-organ support but does not define its **refractory nature**. - The need for these interventions indicates **organ dysfunction** and severity, not necessarily refractoriness to standard resuscitation efforts. *Shock with lactate levels >4 mmol/L despite treatment* - **Elevated lactate** indicates tissue hypoperfusion and ongoing shock, but it is a **severity marker**, not the definition of refractoriness. - High lactate levels can occur even in shock that is **responsive to standard therapy** and doesn't specifically indicate failure of resuscitation efforts.
Question 2: Best solution to be used in hypovolemic shock is:
- A. Ringer's Lactate solution. (Correct Answer)
- B. Darrow's solution.
- C. 5% dextrose.
- D. 0.9% Nacl.
Explanation: ***Ringer's Lactate solution*** - This **isotonic crystalloid solution** is commonly used in hypovolemic shock because its electrolyte composition is similar to that of human plasma. [2] - The **lactate** component is metabolized by the liver to bicarbonate, which helps to buffer acidosis often associated with shock. [2] *Darrow's solution* - Darrow's solution is a **hypertonic solution** containing high concentrations of potassium, primarily used for severe dehydration and significant potassium deficits, not initial fluid resuscitation in hypovolemic shock. - Its high potassium content can be dangerous in patients with **renal impairment** or who are already hyperkalemic. *5% dextrose* - **5% dextrose in water (D5W)** is an initially isotonic solution, but the dextrose is quickly metabolized, making it effectively a hypotonic solution. [2] - It is primarily used to provide **free water** and is not effective for volume expansion in hypovolemic shock as it does not stay in the intravascular space. [2] *0.9% Nacl* - **0.9% normal saline** is an isotonic crystalloid often used for volume resuscitation but has a higher chloride content than plasma, which can lead to **hyperchloremic metabolic acidosis** with large volumes. [1], [2] - While it expands the intravascular space, Ringer's Lactate is often preferred in situations of significant blood loss or acidosis due to its more balanced electrolyte profile and buffering capacity. [2]
Question 3: All the following are criteria for SIRS, except
- A. Heart rate >90/min
- B. Systolic blood pressure <90 mmHg (Correct Answer)
- C. Respiratory rate >20 bpm
- D. Temperature >38 degree Celsius or <36 degree Celsius
Explanation: ***Systolic blood pressure <90 mmHg*** - This criterion is associated with **septic shock** or **hypotension**, indicating organ dysfunction, which is a more severe stage beyond **SIRS**. - While low blood pressure can be seen in severe infections, it is not a direct diagnostic criterion for **SIRS** itself. *Heart rate >90/min* - An elevated **heart rate** (tachycardia) is a common physiological response to systemic stress and inflammation. - This criterion fulfills one of the four clinical parameters to diagnose **SIRS**. *Respiratory rate >20 bpm* - An increased **respiratory rate** (tachypnea) reflects the body's attempt to compensate for metabolic acidosis or increased oxygen demand during a systemic inflammatory response. - This criterion is one of the four clinical parameters used to diagnose **SIRS**. *Temperature >38 degree Celsius or <36 degree Celsius* - Both **fever** (>38°C) and **hypothermia** (<36°C) are indicators of a systemic inflammatory response, as the body's thermoregulation is affected [1]. - This criterion is one of the four principal parameters used to diagnose **SIRS** [1].
Question 4: A 70-year-old man develops pneumonia and septicemia, and subsequently experiences renal failure with a blood pressure of 70/50 mmHg. Which drug should be used to maintain blood pressure?
- A. Adrenaline
- B. Ephedrine
- C. Phenylephrine
- D. Norepinephrine (Correct Answer)
Explanation: ***Norepinephrine*** - **Norepinephrine** is the first-line vasopressor recommended for treating **septic shock** with hypotension unresponsive to fluid resuscitation, as it potently increases **mean arterial pressure** without excessive tachycardia. - It primarily acts on **alpha-1 adrenergic receptors** to cause vasoconstriction, thereby increasing systemic vascular resistance and blood pressure, which is crucial in stabilizing a patient with **sepsis and renal failure**. *Adrenaline* - **Adrenaline (epinephrine)** is a potent vasopressor but is generally reserved for septic shock unresponsive to norepinephrine or in cases of **cardiac arrest** due to its potential for increased arrhythmias and splanchnic vasoconstriction. - While it raises blood pressure, its broader **beta-adrenergic effects** can lead to undesirable side effects such as tachycardia and increased myocardial oxygen demand. *Ephedrine* - **Ephedrine** is an indirect sympathomimetic that releases stored norepinephrine, providing both alpha and beta effects, but its use in severe septic shock is limited by its **weaker and less predictable pressor effect** compared to direct-acting catecholamines. - It has a slower onset and longer duration of action, making it less suitable for rapid titration and precise blood pressure control in an acute, unstable condition like **septic shock**. *Phenylephrine* - **Phenylephrine** is a pure alpha-1 agonist that causes significant vasoconstriction and increases blood pressure, but its use in septic shock is generally discouraged due to its potential to cause **reflex bradycardia** and a higher risk of reducing **cardiac output**. - While it effectively raises blood pressure, its lack of direct inotropic effects and potential for reducing perfusion to vital organs make it a less optimal choice compared to norepinephrine in **septicemia-induced hypotension**.
Question 5: What is the main goal of fluid resuscitation in a child with septic shock?
- A. Increase urine output
- B. Reduce heart rate
- C. Decrease fever
- D. Restore blood pressure (Correct Answer)
Explanation: ***Restore blood pressure*** - In septic shock, **vasodilation** and extravasation of fluids lead to decreased **effective circulating volume** and profound **hypotension**. - Aggressive fluid resuscitation is critical to restore adequate **mean arterial pressure** and improve **organ perfusion**. *Increase urine output* - While increased urine output is a positive sign of improved renal perfusion, it is a **consequence** of successful resuscitation rather than the primary goal. - The main focus is on addressing the circulatory dysfunction that leads to **oliguria** in the first place. *Reduce heart rate* - A **high heart rate** (tachycardia) in septic shock is a compensatory mechanism to maintain **cardiac output** in the face of reduced preload and systemic vascular resistance. - Reducing heart rate directly is not the primary goal of fluid resuscitation and may even be harmful if **cardiac output** is already compromised. *Decrease fever* - Fever is a systemic inflammatory response to infection and is typically managed with **antipyretics**, not primarily with fluid resuscitation. - While fluids can help prevent complications of hyperthermia like dehydration, the main goal in shock is **hemodynamic stabilization**.
Question 6: A patient with a fever presents with a heart rate of 120 beats per minute and a respiratory rate of 30 breaths per minute. What does this indicate?
- A. Tachypnea due to anxiety
- B. Early sepsis (Correct Answer)
- C. Expected response to fever
- D. Normal physiological response to fever
Explanation: ***Early sepsis*** - A heart rate of 120 bpm (**tachycardia**) and a respiratory rate of 30 bpm (**tachypnea**) in the setting of fever meet the criteria for **Systemic Inflammatory Response Syndrome (SIRS)**, which can indicate early sepsis. - Sepsis is defined by life-threatening organ dysfunction caused by a dysregulated host response to infection, and these vital sign abnormalities are key indicators. *Tachypnea due to anxiety* - While anxiety can cause tachypnea and tachycardia, the presence of **fever** suggests an underlying infectious or inflammatory process rather than isolated anxiety. - Relying solely on anxiety as the cause without considering other indicators can lead to delayed diagnosis and treatment of serious conditions. *Expected response to fever* - While a moderate increase in heart rate and respiratory rate is expected with fever (e.g., 8-10 bpm increase per degree Celsius of fever), a heart rate of **120 bpm** and especially a respiratory rate of **30 bpm** are disproportionately elevated and exceed a typical physiological response. - These elevated vital signs signal a more significant physiological stress or dysregulation beyond a simple febrile response. *Normal physiological response to fever* - A "normal" physiological response to fever would involve a mild-to-moderate elevation in heart rate and respiratory rate; however, a heart rate of **120 bpm** and a respiratory rate of **30 bpm** are considered *abnormal* for a typical febrile response. - These values are sufficiently high to raise concern for **SIRS** or early sepsis, requiring further investigation.
Question 7: Most common cause of death in diphtheria is due to
- A. Airway obstruction
- B. Septic shock
- C. Toxic cardiomyopathy (Correct Answer)
- D. Descending polyneuropathy (rare)
Explanation: ***Toxic cardiomyopathy*** - Diphtheria toxin primarily targets and damages the **myocardium**, leading to heart failure, arrhythmias, and ultimately death. - Myocardial damage can occur even in mild cases and is the most frequent cause of **fatality** in both treated and untreated diphtheria. *Airway obstruction* - While significant **pharyngeal and laryngeal pseudomembrane formation** can cause severe respiratory distress and obstruction, it is not the most common cause of death overall. - Prompt medical intervention, such as **tracheostomy** or antitoxin administration, can often alleviate acute airway issues. *Septic shock* - Diphtheria itself is a **toxin-mediated disease**, not typically characterized by overwhelming bacterial sepsis leading to septic shock as the primary cause of death. - While secondary infections can occur, direct **toxin-induced organ damage** is the main concern. *Descending polyneuropathy (rare)* - **Neurological complications**, such as polyneuropathy, can occur later in the course of diphtheria due to toxin effects. - However, these are generally less common and less immediately life-threatening than **cardiac complications**, and rarely the direct cause of death.
Question 8: A young lady complains of sore throat for 3 days along with fever and headache. On examination, she was severely dehydrated, her BP was found to be 90/ 50 mm Hg and on the distal aspect of the cuff, small red spots were noted. What could be the most probable etiological agent responsible for causing these symptoms -
- A. Brucella suis
- B. Neisseria meningitidis (Correct Answer)
- C. Brucella abortus
- D. Staphylococcus aureus
Explanation: Neisseria meningitidis - The combination of sore throat, fever, headache, severe dehydration, hypotension, and petechiae (small red spots from broken capillaries, often seen with bleeding diathesis) is highly suggestive of meningococcemia [1]. - Neisseria meningitidis can cause fulminant sepsis and meningitis, leading to rapid progression of symptoms including DIC and widespread petechial rashes due to vasculitis [2]. Brucella suis - Brucellosis typically presents as an insidious illness with undulating fever, arthralgia, and organomegaly, not sudden onset severe symptoms with dehydration and petechiae. - While it can be severe, it does not commonly manifest with the acute, dramatic hemorrhagic signs seen in this patient. Brucella abortus - Similar to Brucella suis, Brucella abortus causes brucellosis, which is a chronic or subacute infection. - The clinical picture of acute onset, severe dehydration, hypotension, and petechiae points away from brucellosis. Staphylococcus aureus - Staphylococcus aureus can cause various infections, including sepsis, but a sore throat and the specific presentation of petechiae with hypotension following an apparent upper respiratory tract infection are less characteristic [3]. - While S. aureus can produce toxins leading to toxic shock syndrome, meningococcal sepsis is a more direct fit for the rapid onset and hemorrhagic signs.
Question 9: Following pathogenetic mechanisms operate in septic shock except -
- A. Direct toxic endothelial injury
- B. Veno constriction
- C. Increased peripheral vascular resistance (Correct Answer)
- D. Activation of complement
Explanation: Following pathogenetic mechanisms operate in septic shock except - ***Increased peripheral vascular resistance*** - Septic shock is characterized by profound **vasodilation** and a subsequent **decrease in systemic vascular resistance (SVR)**, leading to hypoperfusion. - The body's compensatory mechanisms attempt to increase cardiac output rather than constrict peripheral vessels, making increased PVR an unlikely finding in established septic shock. [1] *Direct toxic endothelial injury* - **Bacterial products** (e.g., endotoxins from Gram-negative bacteria) and inflammatory mediators directly damage the **endothelium**, leading to capillary leak and microvascular dysfunction. - This endothelial damage contributes significantly to the widespread organ damage seen in sepsis. *Veno constriction* - While initial compensatory mechanisms might involve elements of vasoconstriction to maintain blood pressure, the hallmark of septic shock is widespread **vasodilation**, which includes both arterial and venous beds. - Early, fleeting venoconstriction is overshadowed by the profound venodilation and loss of venous tone that ultimately contributes to reduced preload and distributive shock. *Activation of complement* - The innate immune response in sepsis triggers the **complement cascade**, leading to the generation of potent inflammatory mediators. - Complement activation contributes to endothelial damage, leukocyte recruitment, and further amplification of the systemic inflammatory response.
Question 10: A 64-year-old woman presents to the emergency room with flank pain and fever, accompanied by dysuria for the past three days. Blood and urine cultures are obtained, and she is started on intravenous ciprofloxacin. Six hours after admission, she becomes tachycardic and her blood pressure drops. Her intravenous fluid is normal saline at a rate of 100 mL/h. Her current vital signs are blood pressure of 79/43 mm Hg, heart rate of 128 beats per minute, respiratory rate of 26 breaths per minute, and a temperature of 39.2°C (102.5°F). She appears drowsy yet uncomfortable. Her extremities are warm with trace edema. What is the best next course of action?
- A. Begin norepinephrine infusion and titrate to mean arterial pressure greater than 65 mm Hg.
- B. Add vancomycin to her antibiotic regimen for improved gram-positive coverage.
- C. Administer a bolus of NS. (Correct Answer)
- D. Administer IV hydrocortisone at stress dose.
Explanation: ***Administer a bolus of NS.*** - The patient is showing signs of **septic shock** (hypotension, tachycardia, fever, altered mental status) likely due to pyelonephritis [1]. The initial management of septic shock involves aggressive **intravenous fluid resuscitation** to restore circulating volume and improve tissue perfusion [3]. - Her current IV fluid rate of 100 mL/h is insufficient given her clinical picture, and a **fluid bolus** (e.g., 500-1000 mL of normal saline over 15-30 minutes) is the immediate priority to address hypotension [4]. *Begin norepinephrine infusion and titrate to mean arterial pressure greater than 65 mm Hg.* - While **norepinephrine** is the first-line vasopressor for septic shock, it should generally be initiated after initial **fluid resuscitation** has failed to improve hypotension [3]. - Administering vasopressors without adequate fluid repletion can worsen tissue hypoperfusion. *Add vancomycin to her antibiotic regimen for improved gram-positive coverage.* - The patient is already on ciprofloxacin, a broad-spectrum antibiotic. While **broadening antibiotic coverage** is important in sepsis, it's not the immediate life-saving intervention when the patient is in shock due to hypovolemia [2]. - Adding vancomycin would be considered if there was concern for **MRSA** or other resistant gram-positive infections, but hemodynamic stabilization with fluids takes precedence. *Administer IV hydrocortisone at stress dose.* - **Hydrocortisone** may be considered in septic shock patients who are refractory to fluids and vasopressors, or those with known adrenal insufficiency. - However, it is not the primary intervention for initial hemodynamic stabilization in a patient who has not yet received adequate **fluid resuscitation**.
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