325 Severe Sepsis and Septic Shock

Question 1

When an infectious etiology is proven or strongly suspected and response results in hypoperfusion of uninfected organs

Answer 1

Sepsis/ Severe Sepsis

Question 2

Sepsis accompanied by hypotension that cannot be corrected by the infusion of fluids.

Answer 2

Septic shock

Question 3

Signs of organ hypofunction in sepsis - Cardio wise?

Answer 3

Cardio : SBP <90 or MAP <70

Question 4

Signs of organ hypofunction in sepsis - Renal wise?

Answer 4

Renal: Urine output <0.5 mL /kg per hour

Question 5

Signs of organ hypofunction in sepsis - Respi wise?

Answer 5

Respi: PaO2/Fio2 <250 or if the lung is the only dysfunctional organ, <200

Question 6

Signs of organ hypofunction in sepsis - Hematologic?

Answer 6

Hema: Platelet <80 or 50% decrease in platelet count (3 days)

Question 7

ABGs in sepsis? Plasma Lactate levels?

Answer 7

Unexplained metabolic acidosis pH < 7.3, base dficit >5 meq/L

Plasma lactate >1.5x ULN

Question 8

Septic shock that lasts >1hr and does NOT respond to fluid or pressor

Answer 8

Refractory septic shock

Question 9

Blood cutlures yield bacteria or fungi in how many percent of cases?

Answer 9

20- 40 % only

Question 10

Most common isolate in sepsis

Answer 10

62% were Gram negative bacteria

Pseudomonas and E.coli

Question 11

Commensal aerobic and facultatively anaerobic gram negs that trigger severe sepsis and septic shock (E.coli, Klebsiella and Enterobacter) has this structure.

Answer 11

Lipid A

Question 12

This organism has hexaacyl LPS that shields them from host recognition by its polysaccharide capsule.

Answer 12

Neisseria meningitidis

Question 13

These organisms has Lipid A with fewer than 6 acyl chains - induce very little inflammation, when they do it is after they have multiplied to high densities in tissues and blood.

Answer 13

Gram negative - Yersinia, Francisella, Vibrio vulnificus, Pseudomonas aeruginosa and Burkholderia

Question 14

Hallmark of the local inflammatory response, may help wall off invading microbes and prevent infection and inflammation from spreading to other tissues

Answer 14

Intravascular thrombosis

Question 15

Major procoagulant cytokine, an important stimulus to the hypothalamic-pituitary-adrenal axis

Answer 15

IL-6

Question 16

In severe sepsis, leukocyte hyporesponsiveness has been associated with increased risk of dying - the most predictive biomarker is

Answer 16

a decrease in expression of HLA-DR class II

Question 17

Major mechanism for Multiorgan Dysfunction

Answer 17

Vascular endothelial injury

Question 18

Hallmark of septic shock

Answer 18

Decrease in peripheral vascular resistance despite increased levels of vasopressor catecholamines

Question 19

Risk of developing severe sepsis depends on primary site of infection: severe sepsis is likely to arise eightfold if associated with what sources?

Answer 19

pulmonary or abdominal source

Question 20

Organisms that produce super antigens

Answer 20

S. aureus, S. pyogenes

Question 21

Absence of fever is common among which septic patients?

Answer 21

Neonates, elderly, persons with uremia or alcoholism

Question 22

Cutaneous lesion seen in neutropenic patients - bullous lesion surrounded by edema undergoes central hemorrhage and ncerosis

Answer 22

Ecthyma gangrenosum (p. aeuruginosa)

Question 23

In absence of pneumonia or heart failure, progressive diffuse pulmonary infiltrates and arterial hypoxemia occuring within 1 week of known insult indicates?

Answer 23

ARDS

Question 24

Cardiac effects of sepsis

Answer 24

depression of myocardial function, increased end diastolic and systolic ventricular volumes with decreased EF (develops within 24 hours in most patients with sepsis)

Question 25

Major clinical manifestation of critical illness related corticosteroid insufficiency (CIRCI)

Answer 25

Hypotension

Question 26

Platelet of <50,000 in patients with sepsis usually presents as

Answer 26

DIC

Question 27

Definitive etiologic diagnosis of sepsis

Answer 27

Culture

Question 28

How to obtain blood culture?

Answer 28

At least TWO 2 blood samples from TWO different venipucnture sites for culture,

In patient with indwelling catheter, one from lumen of catheter and another via venipuncture

Question 29

Negative blood cultures may indicate

Answer 29

Prior antibiotic

Slow-growing or Fastidious organisms

Question 30

Measures in severe sepsis and septic shock should be initiated within?

Answer 30

1 HOUR

Antibiotics be started as soon as samples of blood are obtained for culture

Question 31

Meta-analyses has conlcuded that combination antimicrobial is not superior to monotherapy for treating gram-negative bacteremia, EXCEPT

Answer 31

In treating Pseudomonas aeruginosia; aminoglycoside monotherapy is less effective than COMBINATION of AMINOGLYCOSIDE with ANTI PSEUDO B LACTAM

Question 32

Case: Septic patient is already recieving broad-spectrum antibiotics or parenteral nutrition, neutropenic for >5 days, has long term central venous cather and has been hospitalized in ICU for prolonged periods; what is the next step?

Answer 32

Consider starting empiric antifungal therapy

Question 33

Initial antimicrobial therapy for severe sepsis with no obvious source in a Immunocompetent adult

Answer 33

1) Piptazo
2) Imipinem cilastatin, ertapenem, meropenem
3) Cefipime
4) Ciprofloxacin 400q12 or Levofloxacin 500-750 q12 plus Clindamycin 600mg q8 (If allergic to B lactam)

Vancomycin q12 should be added to each of the above.

Please see table 325-3 (For neutropenic, splenectomized, IV drug user, AIDS)

Question 34

Initial management of hypotension in septic shock

Answer 34

1-2 L normal saline over 1-2 hours
CVP maintained at 8-12cm H2O
Urine output should be kept >0.5ml/kg per hour

Question 35

Goals in rescucitation

Answer 35

MAP >65mmHg (Systolic >90)

If If not met, vasopressor is indicated

Question 36

Case: Patiet with CIRCI, does not respond to fluid therapy, what will you give?

Answer 36

Hydrocortisone 50mg IVq6h

It hastens recovery from sepsis-induced hypotension but does not increase long-term survival

Question 37

Recommended tidal volume? Blood Hgb level target?

Answer 37

6ml/kg (as low as 4ml if plateau pressure exceeds 30mmH2O)

Target: 9 g/dL

Question 38

EPO is used to treat sepsis - related anemia. True or false.

Answer 38

FALSE.

Question 39

First Immunomodulatory drug to be approved by the US FDA for treatment of patients with severe sepsis or septic shock.

Answer 39

Recombinant activated protein C (aPC)

Question 40

Mortality rate of severe sepsis? of Septic shock? within 30 days

Answer 40

20-35%
40-60%

Others die within 6 months
Prime nyo na agad hehe