fever and SIRS/sepsis I

Question 1

systemic inflammatory response (SIRS)

Answer 1

• inflammatory state of whole body –> response due to infectious or noninfectious insult**
• causes: trauma, burns, surgery, anaphylaxis, shock, ischemia etc.**
• 2x more likely to be infected and higher risk of mortality with SIRS

Question 2

criteria for SIRS**

Answer 2

1. Temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F)
2. Heart rate greater than 90 beats per minute.
3. Respiratory rate greater than 20 or PaC02 less than 32.
4. WBC greater than 12,000, or less than 4,000, or with greater than 10% band forms.

Question 3

sepsis**

Answer 3

• old definition: SIRS with suspected infection (not used anymore)
• new definition*: life threatening organ dysfunction caused by a dysregulated host response to infection (no SIRS component)
• do not have to be septic just bc you have infection

Question 4

organ dysfunction

Answer 4

-increase in 2 or more points on SOFA score

Question 5

severe sepsis

Answer 5

• sepsis with acute organ dysfunction (no longer used)

- may still see it for coding and reimbursement

Question 6

septic shock***

Answer 6

• sepsis with persisting hypotension, requiring vasopressors to maintain MAP >65mmHg and lactate levels >2mmol/L despite volume resuscitation**
• high risk of death
• mortality rate order: sepsis –> septic shock –> multiorgan dysfunction syndrome (MODS)

Question 7

multiorgan dysfunction syndrome (MODS)**

Answer 7

• multiple organ/multisystem failure from infection, injury, hypo perfusion, hyper metabolism
• sepsis most common cause**
• sepsis + MODS –> high mortality rate

Question 8

bacteremia

Answer 8

-bacterial infection in bloodstream

Question 9

septicemia

Answer 9

-bloodstream infection with many organisms

Question 10

SOFA (Sequential Organ Failure Assessment) score

Answer 10

• address severity of organ dysfunction in patients ill from sepsis (usually used in ICUs)
• scores calculated 24 after admission, every 48 hr. after that
• 6 categories (0-4 points/categorie)
• measure: PaO2/FiO2, Platelet count, Bilirubin level, BP and need for vasopressors, Glascow Coma Scale, and Creatinine level
• > or = 15 points –> 90% mortality, > or = 11 –> 50% mortality
• Logistic organ failure system (LODS)** also used in ICU

Question 11

qSOFA (quick Sequential Organ Failure Assessment) score

Answer 11

• used more broadly, faster, less blood tests
• assess patients with suspected infection –> done outside the ICU***
• 3 criteria***: low BP (systolic < or = 100mmHg), high respiratory ( > or = 22 bpm), altered mentation (Glascow coma scale <15)
• score > or = 2 –> might want to put them in ICU for close monitoring due to high risk of poor outcome**

Question 12

sepsis bundles*** 1-3 hr. bundle (time 0 is triage)

Answer 12

• during 1st hour: BLOOD and urine cultures always (wound and other cultures if necessary) before antibiotics; broad spectrum antibiotics immediately after; measure lactate levels (remeasure after volume resuscitation if initial one was >2mmol/L)***
• during next 3 hrs: volume resuscitation in hypotensive and septic –> give 30mL/Kg crystalloid (0.9NR or LR)* if hypotensive or lactate level > or = 4 on arrival; if still hypotensive, give vasopressors to maintain MAP (> or = 65mmHg)**

Question 13

sepsis bundles*** 6 hr. bundle

Answer 13

• everything prior + start vasopressors and repeat lactate (if initial was high) if still hypotensive despite volume resuscitation
• if hypotension still persists –> measure CVP with central line (want CVP > or = 8mmHg) and measure mixed venous O2 sat. from SVC (want > or = 70%)
• normalize lactate level

Question 14

sepsis bundles*** measure tissue perfusion

Answer 14

• need to document tissue perfusion anywhere in that 3-6hr. time frame
  1. passive leg raise - look at pulse pressure, CO/SV
  2. capillary refill
  3. measure CVP (central venous pressure) - central line in SVC
  4. mixed venous O2 sat. - from pulmonary line or central line in SVC
  5. IVC respiratory variation in diameter - use ECHO

Question 15

the exam during septic shock**

Answer 15

• very focused H&P while doing exam (quickly!!)

- listen to pods point and examine other areas

Question 16

labs to order STAT** - for septic shock

Answer 16

1. lactate, CBC, manual diff, ABG, procalcitonin, UA, troponin etc.
2. blood cultures 2x and urine cultures (+ any others)
3. chest X ray (+ CT to look at CNS bleed if needed)
4. EKG - sepsis may look like MI, DVT/PE (may use ECHO to test LV function)

Question 17

treatment STAT*** - for septic shock

Answer 17

1. broad spectrum antibiotics 1st after cultures***
2. IV (30mL/Kg of 0.9 NS or LR)*** for volume resuscitation if hypotensive or lactate >4
3. O2 supplement (want O2 sat. > or = 90%)
4. give vasopressors if IV fluids do not increase BP to MAP > or = 65 (NE or levophed)
5. start DVT prophylaxis or compression pumps
6. think gastric ulcer prophylaxis with GI bleed
7. continue to reassess volume status and respirations
8. if BP stays low (<65 MAP) despite volume resuscitation and vasopressors (refractory septic shock)** –> consider stress dose steroids, another vasopressor (vasopressin)***

Question 18

antibiotics in septic shock patients

Answer 18

• delaying antibiotic initiation can decrease survival**
• broad spectrums 1st (“shoot 1st, fix later”) to cover basics- think which ones will be most effective for each patient
• gram negatives more likely to kill someone

Question 19

vasopressors

Answer 19

1. NE** - potent alpha and beta agonist, drug of choice for septic shock
2. vasopressin (ADH)** - septic patients usually deplete it and need it for smooth muscle contraction (use in combination with NE)
3. phenylephrine - does not raise HR as much, used in tachycardia patients, but less effective pressor***
4. dopamine - can cause arrhythmias
5. dobutamine - increase muscle contraction
6. Epi - added to NE in septic shock

Question 20

warm (hyper dynamic) shock

Answer 20

• high CO and low peripheral vascular resistance (PVR)**
• occurs initially
• periphery is vasodilated –> ineffective intravascular volume (hypovolemia)
• need to get volume up

Question 21

cold (hypo dynamic) shock

Answer 21

• low CO and high peripheral vascular resistance (PVR)**
• late stage (6-72 hr. after warm shock)
• heart beats less and ejection fractions decrease
• hypoperfusion all over body –> mottling (shunting blood towards organs) –> can get necrosis
• hypoxemia and acidemia
• usually don’t survive