8 - Sepsis Flashcards
Common and less common causes of sepsis?
Most Common:
- gram +/- bacteria
Still possible:
- fungi
- virus
- mycobacteria
- rickettsia
- protozoans
Sepsis is a …
Heterogenous syndrome characterized by widespread inflammation and potential organ harm initiated by a microorganism
Mortality rate for sepsis?
20% in normal patients
50% with sick patients
Stages of sepsis?
Sepsis: infection with systemic inflammation
“Severe sepsis”: sepsis + new organ dysfunction (hypoperfusion)
- (severe sepsis is no longer a term)
Septic shock: cardiovascular failure
- elevated serum lactate
- hypotension
- need vasopressin despite fluid resuscitation
SIRS criteria
Systemic inflammation response syndrome
- Fever or hypothermia
- Pulse rate >90 or 2SD above
- Tachypenia >20 breaths per min
- WBC count
- Leukocytosis WBC >1200 or
- leukopenia WBC <400
- normal w >10% immature forms
qSOFA tool
Quick sequential organ failure assessment
OUTCOMES TOOL
qSOFA tool criteria
Altered mental
Respiratory >/= 22
Systolic BP = 100
Score >2 indicates high risk
qSOFA tool requires?
Requires validation, it replaces judgment about potential/actual infection and requires greater than one system involvement
- this is sepsis
SIRS criteria does not?
Confirm the presence of infection or sepsis. Can be many other things like trauma, pancreatitis or burns
But it is a good indicator of morbidity
How is lactate related to sepsis?
Serum lactate across a wide spectrum provides excellent prognosis data in those with sepsis but is not diagnostic alone
As lactate goes up so does mortality
Those pts that cant clear lactate die more
Pathophysiology for sepsis?
Host immune response fails to control and/or overreacts to invasive pathogens
2 critical events that sepsis overreaction causes?
- Marked abnormalities in inflammatory response in the host
- 1st hyper then hypo inflammatory response - Imbalance in procoagulant and anticoagulant functioning -> DIC
- DIC -> micro and macro vascular clot formation, impaired microvascular tissue perfusion and thrombosis of small vessels
Clinical presentation for sepsis?
Vital signs
- fever, HOTN, tachycardia
DIC
- warm periphery w increased CO
Lungs
- Decreased pulmonary function
- ARDS (new lung edema)
- Refractory hypoxemia
Kidney
- azotemia, oliguria, anuria
Hepatic:
- cholestatic jaundice (MC)
- H transaminase, alkphos, bilirubin
GI:
- ileus (MC)
- blood loss (painless erosions in mucosal layer)
Heme
- thrombocytopenia
Metabolic changes
- hyperglycemia, hypoglycemia
Cutaneous
- 5 manifestations
Cutaneous manifestations of sepsis?
- Direct bacterial;
- cellulitis, fasciitis - Hematogenous seeding of the skin;
- petechiae, pustules, cellulitis - Lesions from HOTN or DIC;
- acrocyanosis and necrosis - Lesions from IV infection;
- micro-emboli, immune complex - Lesions caused by toxins
- toxic shock syndrome
How do children respond differently to Sepsis?
They dont have hypotension until late b/c they can up regulate their heart rate as a compensatory response to tissue hypoperfusion
Common tests for Sepsis?
- CBC w paltelet
- Serum electrolytes (ca and glucose)
- Renal function panel
- Lactic acid level
- Liver function panel
- UA
- ABG
- type and screening of RBCs
- coag and PTT w bleed
- fibrinogen
- D-dimer
Radiology for sepsis?
CXR - (pneumonia) CT - Abdominal - Soft tissue - free air/abscess - Head - meningitis - LP
Cultures for sepsis?
Min 2 sets of blood cultures
Gram stain and culture of any potential infections
CRP, Procalcitonin - systemic inflammation
Cornerstone of tx for sepsis?
- Early recognition
- Early reversal of hemodynamic compromise
- Early infection control
Goals of resuscitation?
Improve
- preload
- Tissue perfusion
- O2 deliver
What is the set amount of fluid for sepsis?
No set amount
Typically total bolus of 2-5L of crystalloid in first 6hrs
Vasopression and sepsis
Dont delay vasopression when BP doesnt respond to volume overload seems likely
Elements that improve sepsis?
Early recognition
Abx
Adequate volume resuscitation
Adequate circulation
How to administer fluids
Replenish circulating volume - approx 20-30mg/kg crystalloid bolus
DOC for vasoconstriction?
Norepinephrine 0.5-30 micrograms/min
Can use epinephrine but the risk of med error is higher
How long to get abx onboard?
ASAP
W/in 1 hr of recognition
W/in 3 hrs of triage
Definition of septic shock?
Need for vaso pressor (after 2 L of fluid)
Elevated lactate
Infection source
Hartman: [quietly and strictly] Now, you listen to me, Private Pyle, and you listen good. I want that weapon. And I want it now. You will place that rifle on the deck at your feet… and step back away from it.
Hartman: [angrily bellowing] WHAT IS YOUR MAJOR MALFUNCTION, NUMBNUTS?! DIDN’T MOMMY AND DADDY SHOW YOU ENOUGH ATTENTION WHEN YOU WERE A CHILD?!
[Pyle shoots him in the heart, killing him instantly, then aims at Joker.]
