Kays Sepsis and Septic Shock Notes Flashcards
Systemic inflammatory response syndrome symptoms (requires 2 symptoms minimum)
- Temperature lower than 36C or higher than 38
- Heart rate over 90
- Respiratory rate greater than 20, or PaCO2 less than CO2
- WBC greater than 12000, less than 4000, or greater than 10% immature band forms
What is SOFA score
- a measure of organ dysfunction
Sofa score of 2 or higher indicates what
- an overall mortality risk of 10% in a general hospital population
- new guidelines recommend against quick SOFA
Septic shock
- particular subset of sepsis
- patients requiring pressers to have mean arterial pressure greater than 65 and serum lactate over 2mmol/L in the absence of hypovolemia
Gram negative sepsis causing organisms
- E. coli (consider GI trauma, mechanicl barrier)
- Klebsiella (consider GI trauma, mechanical barrier)
- P. aeruginosa (mechanical ventilation, hospitalization and burn injury)
Gram positive sepsis causing organisms
- Staph
- Enterococci
Fungi sepsis causing organisms
- C. albicans
- C. glabrata
LPS endotoxin and gram-negative organisms pathogenesis
- ## LPS causes recruitment of immune cells and releases cytokines
Peptidoglycan activity and gram positive organisms
- S. aureus and S. pyogenes are associated with septic shock
Effects that bacterial cell walls have on hosts immune cells
- hemodynamic changes and platelet aggregation
- microvascular thrombis formations in organs
- increased capillary permeability
- fluid leakage into the interstitial space
macrophages role in sepsis
- remove and destroy bacterial products and produce potent mediators of inflammation (TNFalpha, IL1 )
- try and remember that I cases fever and activates other cells.
IL-6 role in sepsis
- induces elevation in body temp
Neutrophils role in sepsis
- contribute to vascular and tissue injury by releasing oxygen metabolites
Endothelial cells role in sepsis
- key target for inflammatory
Plasma procalcitonin
- less than 0.25 antibiotics strongly discouraged
- greater than 1 strongly encouraged
Things to considerer for treatment of sepsis
- need source control to eliminate infection rapidly
- need early and aggressive antimicrobial therapy
- need one or more drugs with in vitro activity against most likely pathogens
to do within first 3 hours of presentation
- measure lactate concentration
- obtain blood cultures prior administration to antibiotics
- administer broad spectrum antibiotics
- administer crystallodids (LR) for sepsis induced hypotension or lactate over 4mmol
to be completed within first 6 hours of presentation
- apply vasopressors to maintain Mean arterial pressure 65 mmHG. add norepinephrine, then vasopressin, then epinephrine.
Community acquired empiric treatment for sepsis pneumonia
- Ceftriaxone plus azithromycin/ respiratory FQ
Community acquired empiric treatment for urinary tract sources
- 3rd of 4th gen cephalosporin with or without aminoglycoside
- Pip/Tazo with or without aminoglycoside
- Fluoroquinolone (concern for resistance)
Community acquired empiric therapy for suspected intra-abdominal source
- Pip/Tazo
- Carbapenem
- 3rd or 4th generation cephalosporin + metronidazole
- Ciprofloxacin or Levofloxacin + metronidazole
Community acquired suspected skin and soft-tissue infection empiric treatment
- vancomycin
- Linezolid
- Daptomycin
Hospital-acquired infection from suspected pneumonia empiric therapy
- Antipseudomonal Beta-Lactam + aminoglycoside or antipseudomonal FQ + Vanc or linezolid
Hospital-acquired suspected urinary tract source (P. aeruginosa) empiric therapy
- cefepime + aminoglycoside (tobra) or FQ
- Pip/Tazo + aminoglycoside (tobramycin) or FQ
Hospital acquired into-abdominal suspected source empiric therapy
- Pip/Tazo
- Carbapenem (not ertapenem)
Hospital-acquired infections in neutropenic patients empiric treatment
- pip/tazo plus or minus aminoglycoside
- antipseudomonal carbapenem plus or minus aminoglycoside
- ceftazidime or cefepime plus or minus aminoglycoside
Thermal injury to at least 20% of bod area empiric therapy
- antipseudomonal Beta-lactam + aminoglycoside + vanc
Suspicion of sepsis from indwelling vascular catheter infections
- vancomycin
- daptomycin
- linezolid
duration of therapy for sepsis
7-10 days, longer if little
guidelines for starting and stopping antibiotics based on PCT concentrations
- stopping antibiotics when less than 0.25 PCT
- increase concentration compared to peak and 0.5mg ML consider switching antibiotics
