OET Reading Part A
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Sepsis: Texts
Text A
Sepsis: where it begins and who is vulnerable
Sepsis is life-threatening organ dysfunction caused by the body’s dysregulated response to infection. The harm comes not from the organism but from the reaction it provokes. Although treatment happens in hospital, most cases begin in the community.
Infection at any site can be responsible. The chest accounts for the largest share of cases; the abdomen ranks immediately below it, ahead of the urinary tract, with skin and soft tissue accounting for much of the remainder.
Susceptibility is increased in:
- infants under 1 year, adults over 75 and anyone who is frail
- patients whose immunity is impaired, including those on long-term corticosteroids or chemotherapy
- anyone who has had surgery or an invasive procedure within 6 weeks
- women who are pregnant, or who have given birth, miscarried or ended a pregnancy within 6 weeks
- people who inject drugs
- patients whose skin is broken by cuts, burns, blisters or infection
Urinary catheters, cannulas and central lines deserve separate mention: each offers organisms a route past the outer defences.
Sepsis after childbirth deserves particular suspicion; group A streptococcus is of greatest concern.
Fever in a patient on chemotherapy whose neutrophil count is 0.5 × 10⁹/L or lower is neutropenic sepsis, a medical emergency.
Text B
Recognising sepsis
No single test confirms sepsis. Recognition rests on the observations, on the trend they describe and on suspicion of infection.
Deterioration is tracked with the NEWS2, a tool which scores seven parameters:
| Parameter | Recorded as |
|---|---|
| Respiratory rate | breaths per minute |
| Oxygen saturation | Scale 1, or Scale 2 where a lower target range has been prescribed |
| Supplemental oxygen | air, or oxygen being given |
| Systolic blood pressure | mmHg |
| Pulse | beats per minute |
| Consciousness | ACVPU – alert, new confusion, voice, pain, unresponsive |
| Temperature | degrees Celsius |
Each parameter scores points, and the points are added together. A total of 5 or 6 indicates moderate risk and 7 or more high risk; any single parameter scoring 3 prompts medical review.
Observations can reassure falsely. A normal temperature does not exclude sepsis, and frail or immunosuppressed patients may be cold rather than hot. Patients taking beta-blockers may not show the expected rise in pulse. Blood pressure is often preserved until late, particularly in younger adults and during pregnancy.
Mottling, cyanosis and a rash that does not fade under pressure are grave signs that demand immediate action.
Text C
Treatment on recognition
Once sepsis is suspected and the risk is high, six actions are completed within one hour. Three take something from the patient; three give something to them.
- Take blood cultures before antibiotics, where this causes no delay.
- Measure lactate on a venous blood gas.
- Record urine output every hour.
- Give oxygen, targeting saturation of 94–98%, or 88–92% where carbon dioxide retention is a risk.
- Give a broad-spectrum antibiotic at the maximum recommended dose.
- Give a bolus of balanced crystalloid: 250 mL over 10 to 15 minutes.
Antibiotics are given intravenously. Where venous access proves difficult, use an intraosseous needle rather than waiting.
Reassess after each bolus and repeat to a total of 1,000 mL; seek senior advice before going beyond this.
Nothing in this sequence should be delayed while the source of infection is looked for.
Text D
Treatment continues after the initial resuscitation. Reassess at least hourly until the patient is clearly improving.
A lactate above 2 mmol/L is evidence of hypoperfusion, as is acute kidney injury; a systolic pressure below 90 mmHg is a further red flag. If the patient has not responded within an hour of any intervention, the senior decision maker must attend in person, critical care must be involved and the responsible consultant informed. Where the blood pressure remains low despite fluid, discuss vasopressors with critical care; these may be started peripherally.
Where pus has collected or an implanted device is infected, antibiotics alone rarely succeed. The focus must be dealt with – source control – as soon as the patient can tolerate it.
Culture results usually return within 48 hours. Review the antimicrobial against them, narrowing the spectrum where possible.
Not every patient will benefit from organ support. Where this is uncertain, discuss it early with the patient and those close to them, and record the outcome as a treatment escalation plan, so the position is clear overnight.
Acute Kidney Injury: Texts
Text A
Acute kidney injury: what it is and who is at risk
Acute kidney injury is a sudden reduction in kidney function over hours or days. It may produce no outward signs, and function can deteriorate rapidly in a patient who does not appear unwell.
In an adult with acute illness, serum creatinine is measured and compared with the baseline when any of the following is present:
- chronic kidney disease, particularly with an eGFR below 60 mL/min/1.73 m²
- hypovolaemia, or a urine output below 0.5 mL/kg/hour
- neurological or cognitive impairment, where reliance on a carer may limit access to fluids
- a drug that can harm the kidney (NSAID, aminoglycoside, ACE inhibitor, angiotensin II receptor antagonist or diuretic), or iodine-based contrast media, used within the past week
- sepsis, or a deteriorating early warning score
- age 65 or over.
Risk is also assessed before surgery. It is higher with emergency surgery, especially in a patient with sepsis or hypovolaemia, with surgery inside the abdomen, and where NSAIDs are given afterwards.
Text B
Detecting the injury
Acute kidney injury is detected from serum creatinine and urine output, using any one of the criteria in the table.
| Measure | Criterion |
|---|---|
| Serum creatinine | an increase of 26 micromol/L or more within 48 hours |
| Serum creatinine | an increase of 50% or more within the past 7 days |
| Urine output | less than 0.5 mL/kg/hour for more than 6 hours |
In hospital, creatinine is usually measured once a day. Urine output must be monitored; where the early warning score in use does not record it, a separate system must recognise and respond to oliguria.
In chronic kidney disease with no obvious acute illness, a rise in creatinine may represent acute kidney injury rather than progression. The injury should also be considered where the patient has stage 3B, 4 or 5 chronic kidney disease, new or markedly worse urinary symptoms, or signs of a disease involving several organ systems, such as a purpuric rash.
Text C
Finding the cause and first steps
The cause of the injury must be identified and recorded in the notes. As soon as it is suspected, the urine is tested with a dipstick for blood, protein, leucocytes, nitrites and glucose. The following steps then apply.
- Where no cause has been found, or obstruction is possible, arrange an urgent ultrasound of the urinary tract, to be performed within 24 hours. Where pyonephrosis (an infected and obstructed kidney) is suspected, the scan is immediate and in no case later than 6 hours after assessment.
- Refer upper urinary tract obstruction to a urologist.
- Review every medicine. ACE inhibitors and angiotensin II receptor antagonists are paused during diarrhoea, vomiting or sepsis, and a pharmacist advises on the dose and frequency of the remaining drugs.
- Do not use loop diuretics to treat the injury itself; reserve them for fluid overload or oedema while dialysis is awaited.
Inpatients at particularly high risk who need iodine-based contrast, such as those with an eGFR below 30 mL/min/1.73 m², may first be given intravenous fluid to reduce the risk of injury: isotonic sodium bicarbonate or 0.9% sodium chloride.
Text D
Treatment and referral
Where an obstructed kidney requires drainage or a stent needs to be put in, the procedure takes place within 12 hours of diagnosis.
A nephrologist is consulted within 24 hours of detection when:
- the injury is stage 3, has no clear cause or is not responding
- the cause may be a condition needing specialist treatment, such as vasculitis or the blood cancer myeloma
- the patient has stage 4 or 5 chronic kidney disease.
Where the cause is clear and the patient is responding promptly, referral is not needed, the exception being renal transplant recipients.
Dialysis is discussed at once with a nephrologist or critical care specialist where hyperkalaemia, acidosis, fluid overload or uraemia is not responding to medical treatment.
The decision to start dialysis rests on the patient’s condition as a whole, never on an isolated urea, creatinine or potassium value.
After recovery, patients still at risk are told about the danger of dehydrating illnesses and of NSAIDs bought over the counter.