Immune Sepsis Flashcards
How to you performa preload/assessment?
1) ScvO2
2) JVD
3) Passive leg raise. => 10 mm Hg increase in MAP in art line
4) CVD < 8 => give fluid
5) Pulse pressure variation
How do you assessment afterload?
Skin -> warm, means things are perfusioning
How do you assess contractility?
Echo -> Wall motion abnormalities
ECG
ScvO2 -> Decrease Q causes increased extraction
How do you assess overall cardiac output?
Skin, cap refill
What is the approach for refractory distributive shock state?
1) Optimize DO2 - Preload, contractility (septic induced cardiomyopathy)
2) Source control (remove infected lines)
3) Metabolic acidosis ( < 7.10)
4) Hypocalcemia - if iCa < 1, give 1 gram
5) Adjustive therapies (another ethology of shock) —Steroids - hydrocortisone, 100 mg/dose - peak effect 12-24 hours and risk is immunocompromise
What patient population is important to give steroids for in distributive shock?
Existing adrenal insufficiency patient who are already taking steroids
What is the risk of VAP per day?
Increase 3%/day for the first week
What is in the VAP bundle?
HOSEHead of bed elevatedOral decontaminationSuction oropharynxExtubate
What are the layers of skin and potential infections in those layers? Typical symptoms
Epidermis - does not lead to sepsis
Dermis - Cellulitis, red/hot/blanche
Fascia - Nec fasc - Painful with lots of necrosis, Need surgery for treatment
Muscle - myositis - pain with stretching, need sx
Bone - osteomyelitis, deep pain
What are the SIRS criteria?
HR > 90
RR > 20 or PaCO < 32 mm HG
WBC < 4 or > 12 or > 10% immature (band) neutrophils
Temp < 36 or > 38.3
Can be cause by infectious or non-infectious sources.
What is the 2001 definition of Sepsis, Severe Sepsis and Septic shock?
(2001)Sepsis - Suspected or confirmed infection with 2 SIRS criteriaSevere sepsis is sepsis with organ dysfunction, hypoperfusion or hypotension (SBP < 90, or less than 40 from baseline)Septic shock was if they continue to have hypotension or hypoperfusion after adequate volume resuscitation.
What are some examples of non-infection etiologies that can cause SIRS?
Trauma, burns, pancreatitis, blood transfusion
What is the definition of sepsis?
Life threatening organ dysfunction cause by a dysregulated host response to infectionEither 2 or more points on sofa or qsofa score
What are the qSOFA criteria?
Two or more criteria presentRR > 22Acute change in LOCBP < 100More useful as a predictor of mortality rather than a diagnostic tool.
What is MODS?
Organ dysfunction where interventions are required just to maintain homeostasis - it is the end game of sepsis if caused by infection but it can also be caused by non-infectious sirs
What is the definition of septic shock as per sepsis 3?
1) Vasopressors required after sufficient fluid resuscitation to maintain map > 65
2) Lactate greater than 2(And have definition of sepsis)
What are the organ systemic effects of sepsis?
CNS - EncephalopathyCVS - Vasodilation and hypotension and fluid extravasation, maldistribution of blood flood at capillary levelRESP - Pulmonary edema from pulmonary vascular injury (Shunts)GI - Decreased barrier functions allowing bacteria to cross into circulationGU - AKI, acute tubular necrosis from renal hypoperfusion
What is the normal response to infection and how does it progress to sepsis?
Normal response - Innate immune cells contain PRR (pattern recognition receptors) that recognize PAMP (Pathogen associated molecular patterns) parts of infectious substance. Pro-inflammatory (TNFa and IL-1) and anti-inflammatory mediators regulate this inflammatory process causing recognition, chemotaxis, phagocytosis and killing of bacteria and debris and healing of tissue.Transition to sepsis occurs when the pro-inflammatory mediators overpower the anti-inflammatory mediators and inflammatory process becomes systemic and dysregulated (no-homeostasis).
What is early goal directed therapy?
Utilized IV fluids to target a CVP of 8 to 12, vasopressors to get a map of 65 to 90, and inotropes and transfusion to achieve ScvO2 greater 70
What is lactate clearance?How is lactate excreted?
The rate at which lactate is cleared by the bodyMostly excreted by the liver, but also by kidney. Decreased lactate clearance can be secondary to impaired hepatic excretion.
What is AIDS?
A syndrome caused by infection of the HIV virus where a CD4 T cell count is < 200 cell/uL or the presence of a defining illness
What is the basic pathophysiology of AIDS?
Host is infected by HIV virus which attacks cells that express CD+ (T helper cells). As the CD4 count decreases, the ADAPTIVE immune response is impacted and when the cell count falls below 200 cells/uL, opportunistic infections and cancers occur.
What is general management of AIDS?
Early utilization of anti-retro viral therapy to prevent disease progression and transmission.
