14. Adult Sepsis

Question 1

two or more of the following criteria, core temp >38C or <36C, tachycardia or bradycardia for age, tachypnea or need for mechanical ventilation, elevated or decreased WBC count from >15K or <5K, or >10% band form, SIRS criteria may be present in noninfectious diseases

Answer 1

systemic inflammatory response syndrome

Question 2

life threatening organ dysfunction caused by a dysregulated host response to infection, occus as a result of both community acquired and health care associated infections, pneumonia, intra-abdominal, and urinary tract infections are the most common sources, staphylococcus aureus and streptococcus pneumoniae are the most common gram positive isolates, wheras eserichia coli, klebsiella, and pseudomonas are the most common gram negative, failure of the immune system to control an initially localized infection, exaggerated immune and inflammatory response leads to cellular dysfunction, vasodilation, and leaky capillaries, risk for extremes of age, elderly, infants, underlying chronic conditions with impaired immune response such as diabetes, cancer,r and malnutrition, patients who are on immune suppressive therapies, chronic use of corticosteroids, use of immunomodulators, and chronic indwelling catheters

Answer 2

sepsis

Question 3

increase in pro-inflammatory cytokines TGFa, Il1 and Il18 > decreases systemic vascular resistance > increases endothelial permeability, leading to vasodilatation and shock

Answer 3

pathophysiology of hypotension

Question 4

mental status changes, hypotension, weak peripheral pulses, tachycardia, tachypnea, delayed capillary refill, variable, presentation, high or low core body temperature, skin changes like clammy extremities, mottled skin, petechiae, in patients with suspected infection look for organ dysfunction, in patients with organ dysfunction, look for signs of infection, leukocytosis or leukopenia, elevated C reactive protein, azotemia with elevated BUN or creatinine, elevated lactate, metabolic acidosis, thrombocytopenia, hyperbilirubinemia, elevated LFTs

Answer 4

clinical presentation of sepsis with laboratory findings of organ dysfunction

Question 5

partial pressure of oxygen in arterial blood/fractional inspired oxygen PaO2/FiO2 ratio, glasgow coma scale, mean arterial pressure, vasopressor use, serum creatinine or urine output, bilirubin, platelet count

Answer 5

SOFA score parameters for sepsis

Question 6

respriatory rate >/=22 min, altered metabolic acidosis, altered mentation, sytemic blood pressure

Answer 6

qSOFA criteria for sepsis

Question 7

early identification, early foal directed therapy, early antibiotics, and cultures

Answer 7

early goal directed therapy for sepsis

Question 8

measure lactate level, re-measure if initial lactate is >2 mmol/L, obtain blood cultures prior to administration of antibiotics, adminster broad spectrum antibiotics, rapidly adminster 30 mL/kg crystaolloid for hypotension or lactate >/= 4 mmol, apply vasopressors if patient is hyptensive during or after fluid resuscitation to maintain mean arterial pressure >/= 65 mmHg

Answer 8

hour 1 bundle of care

Question 9

goal is to restore effective tissue perfusion, therapy selection aimed at the source of dysfunction, fluids used to increase preload, vasopressors used to increase vascular tone, check mean arterial pressure, urinary output, serum lactate is an indirect indicator of tissue perfusion

Answer 9

septic shock therapy

Question 10

SABP + 2DABP / 3, goal is 65 mmHg

Answer 10

mean arterial pressure goal for sepsis therapy

Question 11

obtain 2 IV sites, use crystalloids as initial fluid of choice such as lacate ringers or normal saline, initial volume is 30 mL/kg, hydroxyethyl starch use is not recommended

Answer 11

fluid therapy for sepsis

Question 12

sepsis in which the underlying circulatory and cellular or metabolic abnormalities are profound enough to increase mortality substantially

Answer 12

septic shock

Question 13

first line vasopressor for septic shock

Answer 13

norepinephrine

Question 14

target MAP > 65 mmHg, capillary refill, mental status, follow lactate level, urinary output >0.5ml/kg/hour

Answer 14

evaluating effectiveness of resuscitation

Question 15

do as soon as possible

Answer 15

administering antibiotics for sepsis

Question 16

blood cultures are only positive in 1/3 of cases,

Answer 16

pathogen identification

Question 17

start broad spectrum antibiotics within 1 hour of arrival, don’t wait for culture results to start therapy, empiric regiment broad enough to cover all likely pathogens, identify source of infection by predominant local pathogens, hospital antibiogram and resistance pattern and patient factors help selection of antimicrobial therapy, de-escalate to appropriate targeted therapy as soon as possible, once cultures and sensitivities are available

Answer 17

antimicrobial therapy for sepsis

Question 18

not indicated in refractory septic shock

Answer 18

corticosteroids