Immune

Question 1

target UO in sepsis

Answer 1

> 0.5mL/kg/hr
this is based on KDIGO definition of AKI being Urine output less than 0.5 mL/kg/h for 6 hours

Question 2

Sepsis treatment pathway

💵💵💵💵 MONEY SLIDE 💵💵💵💵

Answer 2

Cultures and source control (ie. drain abscess)
Early Antibiotics
Restore Perfusion (fluid loading)
Adjuncts (ie. vasopressors, steroids)

Question 3

sepsis MAP goal in early resuscitation

Answer 3

MAP ≥ 65 (based on original EGDT data)

Question 4

A higher MAP goal (ie. 80) may be beneficial in what septic populations?

Answer 4

History of CKD
2. History of chronic HTN

Question 5

As norepinephrine doses rise, what adjunct should be considered?

Answer 5

Vasopressin
2. dose 0.03 - 0.04 units/min

Question 6

Components of the 1 hour sepsis bundle

Answer 6

1) Measure lactate
2) Obtain cultures
3) Begin broad-spectrum ABx
4) Isotonic 30mL/kg bolus if MAP < 65 or Lactate > 4
5) Vasopressor if MAP <65 (following fluid admin)

this is based on american “CMS Core Measures” protocol for centre for medicare and Medicaid services guidelines

Question 7

refractory septic shock treatment pathway

Answer 7

1) Optimize DO2 (Preload, afterload, contractility)
2) Source control (remove infected lines)
3) Correct profound metabolic acidosis (pH <7.0)
4) Correct hypocalcemia (serum ionized Ca++ < 1.0)
5) Adjunctive therapies (corticosteroids)

Question 8

Early Goal Directed Therapy (EGDT) cocktail

Answer 8

Target Parameters:

CVP 8-12 mmHg
MAP 65 – 90 mmHg
Urine output >0.5 ml/kg/hr
Mixed venous oxygen saturation >65% / ScvO2 >70%
Haematocrit >30%
Target Interventions

Reduce work of breathing by early use of mechanical ventilation
Large-volume fluid resuscitation
Use of vasoactive agents: noradrenaline, dobutamine
Transfusion

Question 9

when are Adjunctive corticosteroids recommended in sepsis?

💵💵💵💵 MONEY SLIDE 💵💵💵💵

Answer 9

shock that are refractory to catecholamines and volume resuscitation
defined as IV fluids to the limit of volume responsiveness and requires two vasopressors to reach a MAP goal >65 mmHg

Question 10

sepsis initial treatment pathway

💵💵💵💵 MONEY SLIDE 💵💵💵💵

Answer 10

Early investigations to determine infectious source
Early source control with appropriate antibiotics
Ongoing crystalloid resuscitation (Plasmalyte or LR preferred) as long as fluid responsive
First line vasopressor NORepinephrine 2 to 200 mcg/min for MAP goal of 65 mmHg
consider EPInephrine 2 to 50mcg/min if bradycardic
consider vasopressin 0.03-0.04 units/min when NORepinephrine >15mcg/min
foley/central line/invasive arterial monitoring
trend lactate and fluid responsiveness
If lactate fails to improve on subsequent readings consider septic-induced cardiomyopathy or other source of hyperlactatemia
adjunctive agents such as corticosteroids if refractory shock

Question 11

initial broad-spectrum ABX coverage for sepsis at any site

Answer 11

1. vancomycin + piperacillin-tazobactam

Question 12

initial broad-spectrum ABX coverage for CNS infection (meningitis)

Answer 12

vancomycin + cefTRIAXone + acyclovir

Question 13

initial broad-spectrum ABX coverage for GI/GU infection

Answer 13

piperacillin-tazobactam

Question 14

initial broad-spectrum ABX coverage for skin infection

Answer 14

vancomycin

Question 15

initial broad-spectrum ABX coverage for Community Acquired Pneumonia (CAP) infection

Answer 15

cefTRIAXone
2. azithroMYCIN

Question 16

steroid dosing in refractory septic shock

Answer 16

Hydrocortisone 50 mg IV q6h for shock refractory to catecholamines and volume resuscitation