Immune Sepsis

Question 1

How to you performa preload/assessment?

Answer 1

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

Question 2

How do you assessment afterload?

Answer 2

Skin -> warm, means things are perfusioning

Question 3

How do you assess contractility?

Answer 3

Echo -> Wall motion abnormalities
ECG
ScvO2 -> Decrease Q causes increased extraction

Question 4

How do you assess overall cardiac output?

Answer 4

Skin, cap refill

Question 5

What is the approach for refractory distributive shock state?

Answer 5

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

Question 6

What patient population is important to give steroids for in distributive shock?

Answer 6

Existing adrenal insufficiency patient who are already taking steroids

Question 7

What is the risk of VAP per day?

Answer 7

Increase 3%/day for the first week

Question 8

What is in the VAP bundle?

Answer 8

HOSEHead of bed elevatedOral decontaminationSuction oropharynxExtubate

Question 9

What are the layers of skin and potential infections in those layers? Typical symptoms

Answer 9

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

Question 10

What are the SIRS criteria?

Answer 10

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.

Question 11

What is the 2001 definition of Sepsis, Severe Sepsis and Septic shock?

Answer 11

(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.

Question 12

What are some examples of non-infection etiologies that can cause SIRS?

Answer 12

Trauma, burns, pancreatitis, blood transfusion

Question 13

What is the definition of sepsis?

Answer 13

Life threatening organ dysfunction cause by a dysregulated host response to infectionEither 2 or more points on sofa or qsofa score

Question 14

What are the qSOFA criteria?

Answer 14

Two or more criteria presentRR > 22Acute change in LOCBP < 100More useful as a predictor of mortality rather than a diagnostic tool.

Question 15

What is MODS?

Answer 15

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

Question 16

What is the definition of septic shock as per sepsis 3?

Answer 16

1) Vasopressors required after sufficient fluid resuscitation to maintain map > 65
2) Lactate greater than 2(And have definition of sepsis)

Question 17

What are the organ systemic effects of sepsis?

Answer 17

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

Question 18

What is the normal response to infection and how does it progress to sepsis?

Answer 18

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).

Question 19

What is early goal directed therapy?

Answer 19

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

Question 20

What is lactate clearance?How is lactate excreted?

Answer 20

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.

Question 21

What is AIDS?

Answer 21

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

Question 22

What is the basic pathophysiology of AIDS?

Answer 22

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.

Question 23

What is general management of AIDS?

Answer 23

Early utilization of anti-retro viral therapy to prevent disease progression and transmission.