EXAM 2 Sepsis

Question 1

what are the interrelationships that form the conceptual framework of sepsis?

Answer 1

Question 2

what is described by the following:

sepsis-induced hypotension despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status

Answer 2

septic shock

Question 3

what is described by the following:

presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention

Answer 3

multiple organ dysfunction syndrome (MODS)

Question 4

sepsis and severe sepsis lie on a background of disturbed ___

Answer 4

homeostasis

Question 5

describe the progression of sepsis

Answer 5

Question 6

who can get sepsis?

Answer 6

anyone can present with sepsis and severe sepsis

Question 7

sepsis is most often present with ___

Answer 7

pre-existing diseases

Question 8

historically, sepsis with gram ___ organisms was more common, however, between 1979-2000, gram ___ infections were more common in the US

Answer 8

negative, positive

Question 9

describe the current worldwide distribution of sepsis organisms

Answer 9

• gram negative - 62%
• gram positive - 47%
• fungal - 19%

Question 10

what is defined as hypotension?

Answer 10

• <90 mmHg systolic, or
• reduction of SBP of 40 mmHg from baseline, or
• evidence of hypo-perfusion (lactic acidosis, low urine output or change in mental state)

Question 11

what is MAP?

Answer 11

• mean arterial pressure
• defined as the average pressure in a patient’s arteries during one cardiac cycle
• calculated using a formula of the SBP and the DBP
• MAP = SBP + 2 (DBP)/3

Question 12

describe the differential diagnosis of shock/hypotension

Answer 12

• endocrine
• neurologic, anaphylactic
• drugs, distributive
• septic
• hypovolemia
• overdose, obstruction
• cardiogenic
• kills

Question 13

___ is the clinical syndrome that results from a dysregulated inflammatory response to infection

Answer 13

sepsis

Question 14

describe clinical signs of septic shock

Answer 14

• patient with continued hypotension after a fluid bolus - usually 10-30 ml/kg
• hypotension is relative to baseline
  
  • <90 mmHg systolic or MAP of 70 mmHg
  • or reduction of SBP of 40 mmHg from baseline
• hypotension is often associated with organ damage or dysfunction

Question 15

what is primary multiple organ dysfunction caused by?

Answer 15

result of a well-defined insult (ie. renal failure from muscle breakdown products [rhabdomyolysis])

Question 16

what is secondary multiple organ dysfunction caused by?

Answer 16

• not due to infection itself, but due to the host’s response
  
  • possibly a dysregulation of the innate immune system

Question 17

following identification of a patient with sepsis, the clinician must assess the patient for the presence of ___

Answer 17

acute organ dysfunction (severe sepsis)

Question 18

the presence of acute organ dysfunction (severe sepsis) is often recognized clinically by the patient’s presenting signs and symptoms. however, in some instances, ___ will confirm the diagnosis of organ dysfunciton

Answer 18

laboratory data or results of invasive monitoring

Question 19

what are the indications in the central nervous system of organ dysfunction?

Answer 19

altered consciousness, confusion, psychosis, delirium

Question 20

what are the indications in the respiratory system of organ dysfunction?

Answer 20

tachypnea, hypoxemia, oxygen saturation <90%, decreased ratio of arterial oxygen vs inspired oxygen

Question 21

what are the indications in the liver of organ dysfunction?

Answer 21

jaundice, increased liver enzymes, hypoalbuminemia, increased prothrombin time

Question 22

what are the indications in the cardiovascular system of organ dysfunction?

Answer 22

tachycardia, hypotension, increased central venous pressure, increased pulmonary artery occlusive pressure

Question 23

what are the indications in the kidney of organ dysfunction?

Answer 23

oliguria, anuria, increased creatinine

Question 24

what are the hematological indications of organ dysfunction?

Answer 24

thrombocytopenia, abnormal coagulation tests, decreased levels of protein C, increased D-dimers

Question 25

what are the 3 mechanisms of tissue injury?

Answer 25

• ischemia
• cytopathic injury
• increased apoptosis

Question 26

describe ischemia as a mechanism of tissue injury

Answer 26

• decreased O2 given tissue needs
  
  • often an uptake and not just a delivery problem

Question 27

describe cytopathic injury as a mechanism of tissue injury

Answer 27

inflammatory mediators cause damage (direct and indirect)

Question 28

what is PIRO?

Answer 28

a pneumonic for the timeline of sepsis

• predisposition - host factors, comorbidities, genetics
• insult - specific infecting organism with special weapons (PAMPs)
• response - activation of the immune system (DAMPs)
• organ dysfunction - the collateral damage

Question 29

what are two examples of insults (PIRO) that are associated with sepsis?

Answer 29

• ebola
• gram negative with LPS or MRSA with cytolytic toxins

Question 30

describe the balance of pro- and anti-inflammatory molecules and their relationship with sepsis

Answer 30

Question 31

how do you monitor tissue perfusion?

Answer 31

• clinical assessment - skin, urine output, MSE, etc.
• pH and lactate
  
  • historic survival is <10% if lactate is >10
• rate of lactate clearance

Question 32

what are the mechanisms of monitoring pH and lactate?

Answer 32

1. hypoxic- anaerobic production of lactate (global with shock or local with bowel infarction)
2. non hypoxic- decreased clearance of lactate or accelerated aerobic glycolysis

Question 33

describe what we do today for patients with sepsis

Answer 33

• fluids
• pressors
• monitoring tissue perfusion
• physiology and fluid responsiveness
• consensus, bundles, standardization