PATHOPHYS: Sepsis

Question 1

True or false: the majority of patients with sepsis have a positive blood culture.

Answer 1

FALSE

Question 2

What is the definition of sepsis?

Answer 2

Systemic inflammatory response syndrome (SIRS) due to an infection (proven or suspected)

Question 3

The rate of sepsis due to what organisms has risen 207%?

Answer 3

fungal organisms

Question 4

What are the predominant pathogens that cause sepsis?

Answer 4

gram positive bacteria

Question 5

List the 4 conditions that can define SIRS (if 2 are met).

Answer 5

1) Temp >38 or 90
3) Tachypnea >20
4) WBC >12,000 or 10% bands

Question 6

What is the major cytokine that can produce SIRS?

Answer 6

GM-CSF

Question 7

Which groups of patients with sepsis do NOT become febrile?

Answer 7

elderly
patients with uremia
NSAID/Acetaminophen use
diabetics

Question 8

If you see a respiratory rate of 20, what should you do?

Answer 8

you should retake it–it is probably wrong

Question 9

What is severe sepsis?

Answer 9

sepsis plus either organ dysfunctionor evidence of hypoperfusion or hypotension

Question 10

What is septic shock?

Answer 10

sepsis-induced hypotension (persisting despite adequate fluid resuscitation)

Question 11

If a patient has septic shock, what drug is required to reverse the hypotension?

Answer 11

vasopressors

Question 12

Describe the pathogenesis of septic shock.

Answer 12

• Nidus of infection
• Blood stream invasion
• Host defense system activated and mediators are released (cyclic reaction)
• Shock or multiorgan failure ensues

Question 13

How do cytokines cause shock?

Answer 13

they lead to mitochondrial dysfunction that causes tissue injury

Question 14

What are two reasons sepsis may produce mental status change?

Answer 14

1) brain hypoperfusion

2) brain dysfunction (due to mitochondrial damage)

Question 15

List some symptoms of sepsis.

Answer 15

fever
tachycardia
tachypnea
hypotension
N/V (children)
Not tolerating feeds (ICU patients)

Question 16

Why do you get hypotension in sepsis?

Answer 16

vasodilation and increased vascular permeability

Question 17

What is the “silver day” for sepsis?

Answer 17

Perspective that early resuscitation improves outcome

Question 18

What lab work should be done before starting antibiotics?

Answer 18

1) Gram stain and culture of body fluids
2) Blood cultures (peripherally AND through vascular access device)
3) Imaging (CXR, CT, and HIDA scan to rule out cholecystitis)

Question 19

What drugs can be given to neutralize gram negative microbial toxins or TSS?

Answer 19

• Antitoxin
• Clindamycin and Lineolazid (immediately stop toxin production)
• IV-Ig will bind to toxin

Question 20

List the criteria in goal-directed resuscitation.

Answer 20

• CVP 8-12 mmHg
• MAP > 65 mmHg
• Urine output > 0.5 mL/kg/hr
• Central venous O2 saturation >70%

Question 21

Why do you want an increased CVP in sepsis patients?

Answer 21

make use of Frank-Starling law to increase perfusion (by increasing stroke volume)

Question 22

What can cause central venous O2 saturation to decrease?

Answer 22

• Decreased cardiac output
• Increased metabolism (extraction of oxygen by tissues)
• Decreased O2 carrying capacity (anemia)

Question 23

When should you start antibiotics on a septic patient?

Answer 23

by at least 4 hours (every hour delay increases mortality 6-7%

Question 24

What is the first thing you do to a septic patient?

Answer 24

replace fluids (normal saline then Ringer’s lactate)–CRYSTALLOIDS

Question 25

Along with fluids and antibiotics, what other drug class has been found to improve outcomes for septic patients?

Answer 25

Low dose hydrocortisone

Question 26

Who should get the pneumococcal vaccine?

Answer 26

• All adults > 65 y/o
• Residents of nursing homes
• 2-64 y/o with various chronic problems (CKD, DM, steroid use)