HYHO: SEPSIS Flashcards
Cardiogenic shock
results from poor pumping fxn or circulatory overload
Hypovolemic shock
results from poor fluid intake or excessive fluid loss (sweating, diarrhea, vomiting, hemorrhage)
Distributive shock
results from vasodilation leading to low SVR (sepsis, anaphylaxis, hepatic failure, neurogenic shock-autonomic dysfxn from TBI, spinal cord injury)
Obstructive shock
from extracardiac causes of heart failure (ex. cardiac tamponade, pulmonary embolism, tension pneumothorax, constrictive pericarditis)
which type of shock has increased CO, while all the others have decreased CO
Septic and anaphylactic distributive shock
Note: neurogenic shock has decreased tho
which type of shock has decreased systemic vascular resistance (SVR), while all the others have increased SVR
distributive shock (both subtypes)
which type of shock has increased pulmonary capillary wedge pressure (PCWP) ?
cardiogenic shock
which type of shock has variable pulmonary capillary wedge pressure (PCWP) or Central venous pressure(CVP) ?
obstructive shock
Sepsis definition
life-threatening organ dysfxn caused by dysregulated host response to an infection
organ dysfunction is defined by what scores
qSOFA score or SOFA score > or equal to 2
qSOFA score** and advantage of it
quick sequential organ failure assessment
**
RESP RATE >/22/ min
ALTERED MENTATION
SBP /<100 mmHg
**
advantage: Can be completed bedside with no need for labs
SOFA
Sequential Organ Failure Assessment
needs lab data to complete
6 systems involved in the SOFA score
respiration
coagulation
liver
CV
CNS
Renal
prognosis of sepsis
inpatient mortality > or equal to 10%
Septic shock
subset of septic patients in which circulatory and cellular metabolism abnormalities are profound
-SEPSIS w/ persisting hypotension requiring vasopressors to maintain MAP>/65 mmHg AND having serum lactate >2mmol?L despite adequate volume resuscitation
prognosis of septic shock
substantially increase risk of hospital mortality >40%
Glasgow Coma Scale
- has 3 diff categories (eye opening, verbal response, best motor response)
- score 3-15 (15 = best)
Sepsis algorithm (apparently we have to memorize this and im kinda upset about it but how many questions max will it be like cmon)
you suspect pt infection–> check qsofa–> if 2 or greater, assess for evidence of organ dysfxn thru SOFA–> if 2 or greater–> SEPSIS
**if no to either of above Qs—> monitor clinical condition and reevaluate for possible sepsis if clinically indicated
once got dx of SEPSIS, check for SEPTIC SHOCK if ALL of these are a YES==> 1) vasopressors required to maintain MAP >/65 mmHg AND 2) serum lactate level >2 mmol/L (all despite adequate fluid resusc)
if no then its sepsis
a person presenting with septic shock would have what signs and syxs
hypotension
tachycardia
altered mental status
oliguria
cool extremities (espec cardiogenic shock)
skin mottling
signs and syx of sepsis
non-specific but include:
Temp >38C or <36C
HR>90
Tachypnea (RR>20)
leukocytosis(>12000) or leukopenia (<4000)
signs of end organ perfusion:
- early= warm extremities–> can become cool if septic shock develops)
- skin mottling (septic shock)
- CNS altered mental status
- kindey (oliguria)
- bowel (absent bowel soudns or ileus often signs of end-organ hypoperfusion)
diagnostic evaluation
CMP (acute liver/kidney injury, electrolytes)
CBC w/ diff
PT(INR), PTT, fibrinogen, D-dimer, periph blood smear (assess for DIC)
arterial blood gases (hypoxemia, possible ARDS)
Serum lactate (poor organ perfusion)
plasma procalcitonin (bacterial infections, sepsis; helpful tool for determining duration of antibiotics)
identify source of infection (maybe urinalysis w/ micro, urine culture, blood culture, sputum, etc.)
complications of sepsis
- DIC
- AKI
- Acute hepatic injury
- ARDS
DIC labs
- thrombocytopenia
- elevated PT/PTT
- elevated D-dimer and fibrin degradation products
- decreased fibrinogen levels
- abnormal peripheral blood smear (schistocytes + helmet cells present)
what is needed for dx of ARDS
PaO2: FiO2 ratio <300 mmHg
not necessary for dx, but might be impt to know:
CXR- bilateral opacities
Treatment/mgmt of sepsi
- place 2 large bore peripheral IVs
- place central line (typically right internal jugular vein-RIJ catheter)
- place arterial line
- place urinary catheter (foley); goal urine output >/0.5 ml/kg/hr
- endotracheal intubation if indicated
- Hour 1 bundle
what is the hour 1 bundle for sepsis mgmt
- measure lactate level
- obtain blood cultures prior to AB administration
- administer empiric broad-spectrum ABs
- fluid resuscitation w/ IV fluids (at least 30 ml/kg) for hypotensive pts or lactate >/4 ; crystalloid fluids are preferred
- Add vasopressors in adequately volume resuscitated pts to maintain MAP >/65 mmHg
what vasopressors can you have in adequately volume resuscitated pts to maintain MAP >65 mmHg
Norepinephrine= preferred initial vasopressor
Vasopressin/Epinephrine = can be added as next vasopressor choice if still needed to meet MAP goal
Dobutamine = can be subseq added to pts with ongoing evidence of persistent hypoperfusion despite adequate fluid resusc and vasopressor agents
If pt has lactate >2 what should you do
you need to repeat the lactate every few hrs until its normal
lactate = marker of tissue hypoperfusion
a1 vasopressor receptor
located in vascular SM
activation–> vasoconstriction
ex. Phenylephrine, Norepinephrine, Epinephrine
B1 vasopressor receptor
located mostly in heart
activation–> increases HR (chronotropy) and cardiac contraction (ionotropy)
ex. Epinephrine, Dobutamine
B-2 vasopressor receptors
located in vascular and bronchial SMs
activation–> VD and bronchodilation
Dopamine vasopressor receptors (D1)
located in renal and splanchnic (mesenteric) vascular beds
activation–> VD
Vasopressin receptors (V1+V2)
V1: vascular smooth muscles; activation–> VC
V2: located in renal collecting duct; activation–> antidiuresis
Chapmans point for bronchi
Anterior - ICS bw second and third ribs at the sternocostal jxn, bilateral
Posterior- midway bw spinous process and tip of the TP of T2, bilateral
Chapmans point for upper lung/lower lung
UPPER LUNG:
anterior- ICS bw/ 3rd +4th ribs @SCJ, bilateral
posterior- in space bw TP of T3+T4, midway bw SP and tip of TP, bilateral
LOWER LUNG:
anterior- ICS b/w 4th and 5th ribs @SCJ, bilateral
posterior- in space bw TP of T4+T5, midway bw SP and tip of TP, bilateral
Chapmans pt for liver/GB
anterior- ICS bw 5th,6th, and 7th ribs (from mid mamm line to sternum); R side only
posterior- bw TP of T5,T6, and T7, midway bw tips of SP and TP); R side only
Chapmans pt for kidney
anterior- one inch above umbilicus, laterally on either side of midline
posterior- bw TP of T12 + L1, midway bw SP and TP, bilateral
autonomic - parasympathetic innervation of heart, lungs, liver, kidney
parasympathetics: Vagus n. (OA, AA)
autonomic sympathetic innervation for heart
T1-T6
autonomic sympathetic innervation of lungs
T1-T7
autonomic sympathetic innervation for liver
T5-T9
autonomic sympathetic innervation for kidney
T10-T11
5 models of care for septic pt
most impt action = STABILIZE PT
biomechanical: OMT as indicated for SDs
respiratory/circulatory: fluid status, vent settings, lymphatic OMT txs
neurologic: PT/OT for any neuro compromise, OMT to normalize sympathetics + parasympathetics
metabolic/energetic/immune: assess ability for oral intake vs. TPN, Renal/hepatic dosing of meds, monitor ins and outs, daily weights
behavior: address factors leading to sepsis
