Kays Sepsis and Septic Shock Notes

Question 1

Systemic inflammatory response syndrome symptoms (requires 2 symptoms minimum)

Answer 1

• 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

Question 2

What is SOFA score

Answer 2

• a measure of organ dysfunction

Question 3

Sofa score of 2 or higher indicates what

Answer 3

• an overall mortality risk of 10% in a general hospital population
• new guidelines recommend against quick SOFA

Question 4

Septic shock

Answer 4

• 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

Question 5

Gram negative sepsis causing organisms

Answer 5

• E. coli (consider GI trauma, mechanicl barrier)
• Klebsiella (consider GI trauma, mechanical barrier)
• P. aeruginosa (mechanical ventilation, hospitalization and burn injury)

Question 6

Gram positive sepsis causing organisms

Answer 6

• Staph

- Enterococci

Question 7

Fungi sepsis causing organisms

Answer 7

• C. albicans

- C. glabrata

Question 8

LPS endotoxin and gram-negative organisms pathogenesis

Answer 8

• ## LPS causes recruitment of immune cells and releases cytokines

Question 9

Peptidoglycan activity and gram positive organisms

Answer 9

• S. aureus and S. pyogenes are associated with septic shock

Question 10

Effects that bacterial cell walls have on hosts immune cells

Answer 10

• hemodynamic changes and platelet aggregation
• microvascular thrombis formations in organs
• increased capillary permeability
• fluid leakage into the interstitial space

Question 11

macrophages role in sepsis

Answer 11

• remove and destroy bacterial products and produce potent mediators of inflammation (TNFalpha, IL1 )
• try and remember that I cases fever and activates other cells.

Question 12

IL-6 role in sepsis

Answer 12

• induces elevation in body temp

Question 13

Neutrophils role in sepsis

Answer 13

• contribute to vascular and tissue injury by releasing oxygen metabolites

Question 14

Endothelial cells role in sepsis

Answer 14

• key target for inflammatory

Question 15

Plasma procalcitonin

Answer 15

• less than 0.25 antibiotics strongly discouraged

- greater than 1 strongly encouraged

Question 16

Things to considerer for treatment of sepsis

Answer 16

• 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

Question 17

to do within first 3 hours of presentation

Answer 17

• 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

Question 18

to be completed within first 6 hours of presentation

Answer 18

• apply vasopressors to maintain Mean arterial pressure 65 mmHG. add norepinephrine, then vasopressin, then epinephrine.

Question 19

Community acquired empiric treatment for sepsis pneumonia

Answer 19

• Ceftriaxone plus azithromycin/ respiratory FQ

Question 20

Community acquired empiric treatment for urinary tract sources

Answer 20

• 3rd of 4th gen cephalosporin with or without aminoglycoside
• Pip/Tazo with or without aminoglycoside
• Fluoroquinolone (concern for resistance)

Question 21

Community acquired empiric therapy for suspected intra-abdominal source

Answer 21

• Pip/Tazo
• Carbapenem
• 3rd or 4th generation cephalosporin + metronidazole
• Ciprofloxacin or Levofloxacin + metronidazole

Question 22

Community acquired suspected skin and soft-tissue infection empiric treatment

Answer 22

• vancomycin
• Linezolid
• Daptomycin

Question 23

Hospital-acquired infection from suspected pneumonia empiric therapy

Answer 23

• Antipseudomonal Beta-Lactam + aminoglycoside or antipseudomonal FQ + Vanc or linezolid

Question 24

Hospital-acquired suspected urinary tract source (P. aeruginosa) empiric therapy

Answer 24

• cefepime + aminoglycoside (tobra) or FQ

- Pip/Tazo + aminoglycoside (tobramycin) or FQ

Question 25

Hospital acquired into-abdominal suspected source empiric therapy

Answer 25

• Pip/Tazo

- Carbapenem (not ertapenem)

Question 26

Hospital-acquired infections in neutropenic patients empiric treatment

Answer 26

• pip/tazo plus or minus aminoglycoside
• antipseudomonal carbapenem plus or minus aminoglycoside
• ceftazidime or cefepime plus or minus aminoglycoside

Question 27

Thermal injury to at least 20% of bod area empiric therapy

Answer 27

• antipseudomonal Beta-lactam + aminoglycoside + vanc

Question 28

Suspicion of sepsis from indwelling vascular catheter infections

Answer 28

• vancomycin
• daptomycin
• linezolid

Question 29

duration of therapy for sepsis

Answer 29

7-10 days, longer if little

Question 30

guidelines for starting and stopping antibiotics based on PCT concentrations

Answer 30

• stopping antibiotics when less than 0.25 PCT

- increase concentration compared to peak and 0.5mg ML consider switching antibiotics