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PMP-201 > Infections - clinical management of sepsis > Flashcards

Infections - clinical management of sepsis Flashcards

1
Q

§What is sepsis?

A

body response to an infection injures its own tissues and organs

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2
Q

What is the difference between sepsis and septic shock?

A

septic shock = is a subset of sepsis, circulatory, cellular and metabolic abnormalities and increases risk of mortality

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3
Q

How many people is affected by sepsis annually?

A

141,722 cases (2014-15)
increases 11.5%

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4
Q

Why is there an increase in sepsis in population?

A
  • aging population (older, more likely to develop sepsis)
  • people living with co-morbidities
  • immuno-suppriessive drugs
  • ^ in antimicrobial resistance
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5
Q

What causes sepsis?

A

exact - unknown

1) patient factors
2) pathogen factors
3) enviromental factors

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6
Q

1) patient factors - cause

A

genetics, age and co-morbidities

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7
Q

2) pathogen factors - causes

A

type of pathogen, virulence, burden

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8
Q

3) enviromental factors - causes

A

anti-microbial resistance (differ from country to country)

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9
Q

Coagulation and immune responses are switched on by infection, what does this cause?

A

Dysfunction to one or more organs with variable severity&raquo_space; multiple organ failure

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10
Q

What are the signs & symptoms of sepsis?

A
  • sweaty skin
  • disorientation
  • shivering
  • high HR
  • extreme pain or discomfort
  • short of breath
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11
Q

symptoms of sepsis - continued

A

signs of dehydration; reduced output in past 18hrs, dry mucosal membranes

altered behaviour / mental state (confusion, irritability- children)

sudden changes in functional ability - walking, balance, unable to dress

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12
Q

SYMPTOMS - acronym
SEPSIS

A

S = slurred speech or confusion
E = extreme shivering or muscle pain
P = passing no urine (in a day)
S = severe breathlessness
I = “i feel like im going to die”
S = Skin mottled or discoloured

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13
Q

Whos is at risk of sepsis

A

Adults over 65 years
Children younger than 1
Sepsis survivors
People with severe illness resulting in hospitalization
Prople with chronic conditions
People with weakened immune system

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14
Q

What are the risk factors or sepsis?

A

age
recent surgery ( within last 6 weeks / biopsy)
Breaches in skin integrity (cuts/ burns/ blisters/ skin infec.)
Misuse of IV drugs
Pregnancy (given birth in last 6 weeks, if c-section, miscarried or termination in last 6 weeks)

Pateinst with an impared immune function - treated fir cnacer with chemotherapy, impared immune system e.g. diabetes, p taking long term steroids, patients on immunosuppressant drugs e.g. biologics used to tread iBD/RA)

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15
Q

How to diagnose Sepsis (can be challenging - nonspecific symptoms)

A
  • misconception - high temp, can be low

NEED thorough history;
SYMPTOMS ; deteriation
- conceers from relatives > appearance/ behaviour

RISK OF SEPSIS
>1 risk factor

OTHER
risk of antibimrobial resistance
immunisation status - all childhood vaccinations?

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16
Q

What to include when doing a thorough patient assessment?

A

examine patients
full examination - possible source of infec.
- capillary refill time (slow = poor peripheral perfusion)
- cold peripheries
- skin; mottled/ ashen skin, cyanosis
- rashes?
- signs of dehydration

Cognitive assessment - brain tests (check confusion)

Observtions
- temp - fever
- HR - tend to be elevated
- Resp rate - distress? high or low RR
- BP: 40% septic patients hypotension

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17
Q

What diagnostic tests must be done when diagnosing sepsis?

A

Chest X - ray
CT scan
Urine sample
Sputum sample
Faeces sample
Wound swab
Blood cultures
Blood - U&Es (kidney function), lactate (tend to be ^^) CRP (tend to be ^^) , FBC, glucose
Arterial blood gases ABG) - says o2 saturation

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18
Q

Complication of sepsis?

A
  1. Death
    5 patients per hr in Uk, 20% will die, sepsis claim more lives than lung, bowel, prostate and breast cancer combined)
  2. Organ failure
    an infection triggers response - body attack itself
  3. Coagulopathy
    DIC - start to from microemoli, get stuck in periphery, but all of platelet have been used to form clots in body&raquo_space; loss of fingers, toes, and loss of limbs
  4. Permanent life changing affects
    PTSD, chronic pain and fatigue, ^ risk of infec. amd SEPSIS again in future
    Memory loss
19
Q

Suspect sepsis if….

A
  1. Urine infec - but deteriate rapidly
  2. one or more risk factors
  3. Relative concers of p behaviour and appearence
  4. Red flags - deteriation
20
Q

Red flags for sepsis:

A
  1. new onset confusion
  2. systonic is <90mmHg (drop of >40mmHg from normal)
  3. HR >130bpm
  4. resp rate >25 bpm
  5. needs oxygen therapy to maintain o@ sats > 92% (88% COPD)
  6. skin sumptoms
    non-blanching rash, mottled, asehn, cyanosis (lips/tongue)
  7. Lactate >2mmol/L
  8. recent chemo
  9. Not passing urine in the last 18hrs
21
Q

SEPSIS SIX, what is it?

A

Should be done in the first hour!
1. give high flow oxygen
2. take blood cultures - BEFORE starting Abx)
3. Give IV antibiotics (pharmacists, correct drug and dose)
4. GIVE IV fluids
5. Measure lactate
6. Measure urine output

22
Q

antibiotic choice - ‘smart smart then focus’

A
  • broad spectrum anti-biotics > cover potential causative agents

Antimicrobial revoew - 48-72 hrs of starting inition IV antibiotic

rarely only one antimicrobial used > often a combo of antibiotics

23
Q

in ALL WALES drug chart

A

antibiotic review is in built

if e-drug chart
if antibiotic is prescirbed = suspended within 72hrs to be reviewed by doctor

24
Q

antibiotic review:

A
  • following 48-72 hrs > reviewed by SENIOR CLINICAN
  • decision need to be made regarding antimicrobial management
  • Abx to stop? - infection rules out
  • IV to ORAL switch > if p well enough

Infection marker showing a trend towards normal; temp, BP stable, CRP - marker for inflammation usually lag in 24-48 hrs, pulse <90
, resp rate <20, WCC between 4-12

25
Q

antibiotic CHOICE:

A
  • antibiotic vary from health board to “
    anti microb. resistance, circulating causative agent, local antibiotic guidlines

consider; source of infec (chest, urine, abdominal)

Patient charicteristics - allergies/ renal and hepatic func./ interacting medication

Risk of anti mircob resistance > p been given any antibiotics recently

immunisation status

local/ national antimicrobial guile-lines > anti microbial stewarship - funamental role of pharmacist.

26
Q

What antibiotic regimen?

A

unkown source

chest source

abdominal source

urine source

27
Q

Sepsis on unknown source;

A

Renal func >20mls/min
No penicillin allergy

Drug & route - amoxicillin (IV) 1g TDS / Gentamycin (IV) 5mg/kg OD - dose banded

Consider adding; Clarythromycin (IV) 500mg BD / Metronidazole (IV) 500mg OD - dose banded

Penicillin allergy?
Levofloxacin (IV/PO) 500mg BD
Gentamycin (IV) 5mg/kg OD - dose banded

Consider addinng;
Metronidazole (IV) 500mg TDS

No penicillin allergy but renal func/ <20mls/mis
Tazocin (IV) 4.5mg (as CrCL <20ml/min)
Clarythromycin (IV) 500mg BD

28
Q

Gentamycin

A

durg class - aminoglycoside

acterial cover - Gram -ive bacilli

Dose - 5mg/kg OD

Route - IV - not absorbed through gut

S.e - otoxicity - deafness
nephrotoxicity - renal failure

contraindications - blindness, renal impairmetn (<20ml/min), myasthenia gravis, allergy ti amunoglycoside

Monitoring - NARROW therapeutic index drug > small changes in dose or clearnec of drug >&raquo_space; change in therapeutic effect and drug levels
clearer by kidney

MUST monitor
drug levels

29
Q

Monitoring renal function (GENTAMYCIN)

A

Cock-croft and gault equation

Monitor BEFORE using equation

monitor x2 weekly whilst on this drug if CrCL stable
deterioration in CrCL - daily monitoring maybe indicated

30
Q

Cock-croft and gault equation:

A

estimated creatinine clearance (eCrCL) = (140-age) x weight (kg) / serum creatinine X 1.04 female or 1.23 male

what if patient obese ? ideal body weight can be used (IBW)

adjusted body weight (ABW) if patient is >120% of IBW

31
Q

Therapeutic drug monitoring:

A
  • narrow therapeutic drug

When? through level 18-24 hrs post dose, after first dose

range <1mg/L

How often? stable? (<1mg/L) twice weekly whilst on gentamycin

WHEN Level >1mg/L (chelc renal func., if worsening <20-30ml/min > alternative Abx needs to be prescribed

If level is high (> 1mg/L), hold drug for 12 hrs > retake the level 36 hrs post dose)
if still >1mg/L > hold for another 12 hrs and retake level (48hrs post op)

ADJUST DOSE

32
Q

Councelling gentamycin

A

Risk of otoxicity and nephrotoxicity > VL risk of short courses

very effective antibiotic
bloods will be check to monitoring kindey function and level of antibiotics in blood

report any hearning problems e.g. ringing / noises in ear, dizziness or balance problems

33
Q

Metronidazole

A

drug class - nitroimidazole
Bacterial cover - anaerobic bacteria and protoxoa
route - oral or IV
dose - 400mgTDS/ 500mg TDS

s.e - rare - peripheral neuropathy, pins and needles
central neuropathy - dizziness, convulsions
Blood dyscrasias (low PLT/ eosinophils)

Contra-indications - allergic reaction

monitor -
cleared by kideny
metobolised by liver

Counselling -
Topical ad: avoid sun light when using topically > wear sun cream
Oral/ Iv use
Avoid alcohol consumption whilst on metronidazole for at least 48 hrs after course
disulfiram- like reaction > flushing/ throbbing headachje / N&V

34
Q

Vacomycin

A

drug class ; glycopeptide
bacterial cover; aeorbic gra +ive
anaerobic gram +ive - multi drug resistance staphycocci

dose: loading dose > determined by patient actual body weight
maintenance dose > determined by patients renal function (obese patients > IBW or AsBW)

route; IV\

s.e;
ototoxicity
nephrotoxocity> monitor kidney function closley
Infusion related reactions
allergic reactions

contra-indications; previous Hx of hearing loss

Monitoring;
narrow ther. index drug > small changes to drug >. large changes in ther. effects and drug levels

clearer by kidney

renal func + drug levels

administration; given slowly over hrs > red man syndrome (if developed, stop)

35
Q

Vancomycin dosing

A

Initial loading dose ius based on thepatients actual body weight

36
Q

vacomycin dosing - maintanence dose based on….

A

renal function

37
Q

Vancomycin levels - monitor
what are normal?

A

10-15mg/L
- monitor x2 weekly

38
Q

Sepsis - CHEST source

A

if <48 hrs since admission - community acquired pneumonia

> 48 hrs - hospital “

39
Q

Sepsis - ABDOMINAL source

A

> 20 mls/min RENAL FUNC

No pen allergy:
amoxicillin (IV) 1g TDS
Gentamycin (IV) 5mg/kg OD
Metronidazole (IV) 500mg TDS

Pen allergic:
Gentamycin (IV) 5mg/kg OD
Metrodinazole (IV) 500mg TDS
Teicoplanin (IV) 6mg/kg

<20 mls/min RENAL FUNC.
No pen allergy;
tazocin (IV) 4.5g BD

Non-severe pen allergy
Meropenem (IV)
1g BD

Severe pen allergy
Teicoplanin (IV) 6mg/kg
Vancomycin (IV) - dep on CrCL
Caiplofloxacin (IV) - dep on CrcL

40
Q

Teicoplanin

A

drug class - glycopeptide
Bacterial cover - aerobic gram +ive
anaerobic gram +ive

dose - loading dose > det on ABW
maint. dose > det by pateints weight & renal func.
route (IV)

s.e
blood dyscrasias
nephrtotoxicity > renal func monitor
allergic reaction
infusion related reaction
hearing loss

MONITOR
therapeutic druh levels (only if patient on period over 7 days)
Trough level, before 5th dose
target is 15-60mg/L
Blood count

41
Q

teicoplanin dosing considering CrCL (mL/min)

A

30-80 > dose from table 1 every 48 hrs
<30 > give dose from tabel 1 every 72 hrs

42
Q

sepsis - URINE source (urosepsis)

A

> 20 mls/lin renal func
Gentamycin (IV) 5mg/kg

(w or w/o penicillin allergy)

<20mls/min renal func.
no pen allerg.
Tazocin (IV) 4.5g BD

non-severe pen allerg.
Merepenem (IV) 1g BD

severe pen allerg. Ciprofolaxin (IV) - dep on CrCL

43
Q

look at case study - wk 8

A

PMP-201 (34 decks)

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