Lecture 5 - Sepsis Flashcards
Systemic Inflammatory Response Syndrome (SIRS) definition
2 of the following
Temp > 38 or < 36
HR > 90BPM
RR > 20 or PaCo < 32
WBC > 12,000, < 4,000 or > 10% bands
Sepsis definition
SIRS with a presumed or confirmed infection process
Severe Sepsis defintion
Sepsis associated with organ dysfunction and hypo perfusion
Septic shock definition
Sepsis with hypotension and perfusion abnormalities despite adequate fluid restriction
Low need organs
Periphery
stomach
kidney
liver
High need organs
Heart
Brain
Distributive Shock (sepsis)
Low - tissue perfusion
Low - Preload
Low - Afterload
Cardiac output - normal or harder
Sepsis bundle to be completed within 1hr
- Measure serum lactate lvl
- obtain blood cultures prior to admin of ABX
- Admin broad-spec aBX
Sepsis bundle to be completed within 3hrs
- Admin 30ml/kg of crystalloid for Hypotension if (< 90 mm HG)
- Apply vasopressors (for hypotension that doesn’t respond to initial fluid resuscitation) to keep SBP > 90mm HG
Signs of hypovolemia
Urine output = < 0.5ml/kg/hr, oliguria
Central venous pressure (CVP) < 7
Pulmonary edema = no
BUN: Cr ratio = > 20:1
Treatment of Hypovolemia
need aggressive fluid now
1 or more signs then treat
Signs of Hypervolemia
Urine output > 0.5ml/kg/hr
CVP > 13**
Pulmonary edema = yes**
BUN: Cr ration > 20:1….nah
Treatment for Hypervolemia
continue maintenance fluid and consider IV furosemide
Types of Resuscitation Fluids
Crystalloids
Colloids
Crystalloid fluids
Normal Saline
Dextrose
Lactated ringeres
Colloid fluids
Natural = albumin
Semi-synth = Hydroxyethyl Starch (HES)
Hypovovolemia recommendations
Crystalloids, strong recommendation
min 30ml/kg of crystalloid 1st 3 hours…only if they need fluid**
1st dose usually over 30-60min, subsequent doses over 30-60min but lower amounts 500-1000ml
common barriers to rapid ABX admin
- excessive workload
- no notification from MD of new abx order in EPIC
- inadequate IV access bc of multiple non-abx mds
- no IV access
- lack of availability of abx on unit
- pt off unit for urgent procedure/test
1st line vasopressor of choice for septic shock?
Norepinephrine
inc MAP + dose dependent incr in systemic vascular resistance
** Dont use Dopamine except in rare instances **
When to use Vasopressin for septic shock?
- dont go over 0.04u/min due to necrosis, 2nd line
- used in those who dont respond to catecholamine vasopressors
Using Vasopressin info
> 15mcg/min NE or > 200mcg/min phenylephrine = didn’t respond
No bolus should be given
dont use as single agent for refractory hypotenstion
1/10 bleeding varices dose
0.04 u/min
When is phenylephrine good
patients w/ severe tachycardia ( > 150) or moderate tachycardia ( > 100 + active MI or A.fib)
vasopressors SSC recomednations
- target SBP of 90 mmHG = strong rec
- NE is 1st choice vasopressor = strong rec
- Can add 0.04 u/min vasopressin to NE when SBP < 90 and NE infusion rate > 15mcg/min = ungraded rec
When is IV hydrocortisone used?
if adequate fluid restrictions and NE infusion at > 15mcg/min failed to maintain systolic BP > 90
& vaso 0.04 for purpose of this course
Dose: 50mg IV q6hrs
