Lecture 8: Sepsis

Question 1

What are the 4 SIRS criteria?

Answer 1

• Temp > 38C or < 36C
• HR > 90
• RR > 20 or PaCO2 < 32
• WBC > 12k or < 4k or > 10% bands

You must meet at least 2 out of 4!

Question 2

How high is the mortality risk for SIRS?

Answer 2

10%

Question 3

What is the difference between sepsis and SIRS?

Answer 3

Presence of an infection (presumed or culture-proven)

20% mortality, so 2x from SIRS.

Question 4

Who should we have a lower threshold for in suspicion of sepsis?

Answer 4

Elderly

Even if they don’t meet criteria

Question 5

What is severe sepsis?

Answer 5

Sepsis + organ dysfunction/tissue hypoperfusion

Must be due to sepsis, and persist despite 2-3L fluids

20-40% Mortality

Question 6

What is septic shock?

Answer 6

Refractory hypotension with mean SBP < 65 unresponsive to 3L of fluids minimum.

40-60% mortality

Question 7

What is MODS?

Answer 7

• Sepsis
• Trauma
• Burns
• Severe inflammatory conditions

2+ organ system lasting 24-48h

Question 8

What is the main underlying cause of MODS?

Answer 8

Uncontrolled hyperinflammatory response

Question 9

What two things does MODS depend on for mortality rate?

Answer 9

• Number of dysfunctional organs
• Duration of dysfunction

Question 10

What is the result of MODS?

Answer 10

Tissue ischemia

Question 11

What 3 things can meet SIRS criteria? (but aren’t sepsis)

Answer 11

• Nonmassive PE
• Alcohol withdrawal
• COPD Exacerbations

Question 12

Where are the two MC sites for infection?

Answer 12

1. Urinary tract
2. Respiratory tract

Question 13

What is the mainstay of tx for an infection?

Answer 13

Stabilize

Until you knw what it is

Question 14

3 main principles in treating suspected sepsis

Answer 14

1. Early aggressive resus
2. Early ABX
3. Early source identification

Question 15

When would we consider antifungals in empiric ABX tx for suspected sepsis?

Answer 15

• Recent abd surgery
• TPN
• Chronic steroids

Question 16

How soon do we want to initiate ABX in suspected sepsis?

Answer 16

Within 1 hour

Question 17

Top 4 MC organisms for sepsis

Answer 17

• E. coli
• Staph Aureus
• Klebsiella Pneumo
• Strep Pneumo

Consider MRSA or pseudomonas

Question 18

Initial choice of ABX with unlikely pseudomonas

Answer 18

• Vanco (if concerned for MRSA)
• 3rd gen/4th gen cephalo OR
• Piptazo or tircarcillin-clavulanate OR
• Carbapenem

Question 19

Initial ABX if pseudomonas IS likely

Answer 19

• Vanco Plus 2 of the following:
• Ceftazidime/cefepime OR
• Imipenem/meropenem OR
• Zosyn/ticarcillin-clavulanate OR
• Cipro OR
• gentamicin/amikacin OR
• aztreonam

Question 20

How soon do we want fluids in early goal directed treatment (EGDT)?

Answer 20

First 6 hours

NS or LR

Question 21

If a central line is needed, what is ideal CVP?

Answer 21

8-12 cm H2O

Question 22

What lab is potentially good for monitoring overall sepsis status?

Answer 22

Lactate levels

Question 23

Normal blood transfusion threshold is 7mg with resolved hypoperfusion, except in what 4 settings?

Answer 23

• Active cardiac ischemia
• Blood loss
• Severe hypoxemia
• Ischemic Heart Disease

Question 24

Goal MAP for sepsis

Answer 24

> = 65

Question 25

First-line vasopressor for sepsis (usually)

Answer 25

Norepinephrine (0.01-3 mcg/kg/hr)

Positive inotrope, chronotrope, and arterial vasoconstriction

Question 26

2nd line vasopressors for sepsis

Answer 26

• Epinephrine (similar profile as NE)
• Phenylephrine (Only a vasoconstrictor)

Question 27

How soon do we want to begin enteral feedings in sepsis?

Answer 27

< 48 hours

Catabolism is high in protein

Question 28

General glucose goal in sepsis

Answer 28

140-180

Question 29

When are corticosteroids indicated in sepsis?

Answer 29

Suboptimal adrenal response to severe sepsis: use Corticosteroids < 7d, no mineral