Lecture 8: Sepsis Flashcards
What are the 4 SIRS criteria?
- 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!
How high is the mortality risk for SIRS?
10%
What is the difference between sepsis and SIRS?
Presence of an infection (presumed or culture-proven)
20% mortality, so 2x from SIRS.
Who should we have a lower threshold for in suspicion of sepsis?
Elderly
Even if they don’t meet criteria
What is severe sepsis?
Sepsis + organ dysfunction/tissue hypoperfusion
Must be due to sepsis, and persist despite 2-3L fluids
20-40% Mortality
What is septic shock?
Refractory hypotension with mean SBP < 65 unresponsive to 3L of fluids minimum.
40-60% mortality
What is MODS?
- Sepsis
- Trauma
- Burns
- Severe inflammatory conditions
2+ organ system lasting 24-48h
What is the main underlying cause of MODS?
Uncontrolled hyperinflammatory response
What two things does MODS depend on for mortality rate?
- Number of dysfunctional organs
- Duration of dysfunction
What is the result of MODS?
Tissue ischemia
What 3 things can meet SIRS criteria? (but aren’t sepsis)
- Nonmassive PE
- Alcohol withdrawal
- COPD Exacerbations
Where are the two MC sites for infection?
- Urinary tract
- Respiratory tract
What is the mainstay of tx for an infection?
Stabilize
Until you knw what it is
3 main principles in treating suspected sepsis
- Early aggressive resus
- Early ABX
- Early source identification
When would we consider antifungals in empiric ABX tx for suspected sepsis?
- Recent abd surgery
- TPN
- Chronic steroids
How soon do we want to initiate ABX in suspected sepsis?
Within 1 hour
Top 4 MC organisms for sepsis
- E. coli
- Staph Aureus
- Klebsiella Pneumo
- Strep Pneumo
Consider MRSA or pseudomonas
Initial choice of ABX with unlikely pseudomonas
- Vanco (if concerned for MRSA)
- 3rd gen/4th gen cephalo OR
- Piptazo or tircarcillin-clavulanate OR
- Carbapenem
Initial ABX if pseudomonas IS likely
- Vanco Plus 2 of the following:
- Ceftazidime/cefepime OR
- Imipenem/meropenem OR
- Zosyn/ticarcillin-clavulanate OR
- Cipro OR
- gentamicin/amikacin OR
- aztreonam
How soon do we want fluids in early goal directed treatment (EGDT)?
First 6 hours
NS or LR
If a central line is needed, what is ideal CVP?
8-12 cm H2O
What lab is potentially good for monitoring overall sepsis status?
Lactate levels
Normal blood transfusion threshold is 7mg with resolved hypoperfusion, except in what 4 settings?
- Active cardiac ischemia
- Blood loss
- Severe hypoxemia
- Ischemic Heart Disease
Goal MAP for sepsis
> = 65
First-line vasopressor for sepsis (usually)
Norepinephrine (0.01-3 mcg/kg/hr)
Positive inotrope, chronotrope, and arterial vasoconstriction
2nd line vasopressors for sepsis
- Epinephrine (similar profile as NE)
- Phenylephrine (Only a vasoconstrictor)
How soon do we want to begin enteral feedings in sepsis?
< 48 hours
Catabolism is high in protein
General glucose goal in sepsis
140-180
When are corticosteroids indicated in sepsis?
Suboptimal adrenal response to severe sepsis: use Corticosteroids < 7d, no mineral
