Sepsis Flashcards
Sepsis
ABx Therapy :
If meningitis adult …
Decadron 10 mg IV
Rocephin 2gm IV
Vanc 15-20 mg/kg IV
Ampicillin 1 gm IV (If immune compromised)
Plus minus Acyclovir 10mg/kg IV
Sepsis
-Carbapenems (imipenem/cilastatin, meropenem, ertapenem, doripenem):
Broadest spectrum of antibiotics, gram positives,
gram neg including pseudomonas and ESBL, anaerobes. Does Not cover MRSA, most VRE, atypicals, stenotrophomonas.
Ertapenem does not cover pseudomonas. Lowers seizure threshold
Sepsis
Vasopressors:
-Vasopressin:
Antidiuretic hormone. 0.03/units/min.
Use as second-line agent in refractory.
Can be added to NE.
Has no effect if not deficient in vasopressin so can start early
Sepsis
Labs for Sepsis
CBC, BMP, hepatic function, PT, PTT, INR, Lactic acid, VBG, D-stick, UA, Ucx, Bcx, type and screen, troponin, procalcitonin, CXR, EKG, LP, possible CT head
Sepsis
Signs and Symptoms of Sepsis
Neurology: AMS, septic encephalopathy
CV: myocardial depression, distributive shock (flushed warm skin → mottled and cyanotic)
Pulm: R–>L shunting, arterial hypoxia, ARDS
GI: ileus, increase in LFTs, bili, splanchnic
Endo: adrenal
Heme: DIC, protein C
Renal: oliguria
Sepsis
Sepsis =
2 SIRS criteria + suspected or documented infection
Sepsis
Pediatric ABX:
0-28 days: ampicillin 50mg/kg, cefotaxime 50mg/kg (higher in meningitis) , +/- acyclovir 20 mg/kg
28 d +: ceftriaxone 25-50mg/kg
Sepsis
ABx Therapy :
If dental / ENT…
Pen G 4 mil U IV, Clindamycin 900 mg IV, & Metronidazole 1 gm IV
Sepsis
ABx Therapy :
If skin/soft tissue…
Vanc, Zosyn, & Gent
Sepsis
Inotropic:
-Dobutamine:
Beta 1 → increase inotropy and chronotropy. Used when myocardial dysfunction (elevated cardiac filling
pressures and low CO) or ongoing signs of hypoperfusion, despite adequate intravascular volume and MAP. 5-20 mcg/kg/min
Sepsis
SIRS Criteria:
Temp > 38 or < 36 C
HR > 90
RR > 20 or PCO2 < 32
WBC > 12 or < 4 or > 10% bands
Sepsis
-Vancomycin:
15-20 mg/kg q8-12 hours- inhibits cell wall synthesis in Gram positives. gram positive agent with activity against staph (MRSA), strep and non VRE enterococcus
Sepsis
Organ dysfunction =
AMS, heart, liver or renal failure, coagulopathy / thrombocytopenia, lactic acidosis, d/t ↓ perfusion
Acute Lung Injury
Sepsis
Antibiotics: start within the first hour. Broad spectrum.
-Vancomycin
-Ceftriaxone
-Zosyn
-Carbapenems
Sepsis
Sepsis 3
SOFA- Hypotension (SBP <100), Altered mental status (<15), Tachypnea (RR> 22)
Sepsis- SOFA score of 2
Septic shock- sepsis and persistent hypotension requiring pressors and lactate > 2
Sepsis
Treatment:
Early airway management
Circulatory resuscitation goals:
MAP > 65
Urine output > 0.5-1 ml/kg/hr
CVP > 8mm Hg
CV oxygen saturation > 70%
Decreasing lactate concentration
Fluid resuscitation may require 6-10L
Vasopressor if MAP < 65 after 40 ml/kg bolus
Sepsis
Severe sepsis =
Sepsis + ↓BP (SBP < 90 or MAP < 65) before IVF, or organ dysfunction, or Lactate ≥ 4
Sepsis
Septic shock =
Severe sepsis + persistent ↓BP despite IVF (req pressors)
Sepsis
-Ceftriaxone:
1-2 g daily, 2g q12 for meningitis. good gram positive, excellent gram negative (e. coli, proteus, klebsiella,
neisseria, H. influenzae)
- No pseudomonas coverage or anaerobes ( Ceftazidime and cefepime cover pseudomonas, Cefoxitin
and cefotetan cover anaerobic, ceftaroline covers enterococcus)
Sepsis
ABx Therapy :
If UTI / abd / pelvic…
Zosyn 4.5 gm IV & Gent, Cipro 400mg IV
Sepsis
Vasopressors:
-Dopamine:
Used as second line in those with absolute or relative bradycardia and a low risk of tachyarrhythmias. 2-20
mcg/min
Sepsis
ABx Therapy :
Unknown source or PNA…
Vancomycin 20mg/kg IV, Zosyn 4.5gm (or Gentamycin 7mg/kg IV) & Levaquin 750 mg IV (or Moxi ox
400mg IV)
Sepsis
Other Treatments for Sepsis:
Source control
Consider: steroids in adrenal insufficiency, blood products
ARDS settings: Tidal volume: 6mL/kg, upper limit of plateau pressure <30, PEEP, head of bed elevated, glucose control, DVT and ulcer
prophylaxis, nutrition
Sepsis
Sepsis Leading Causes
Pneumonia, abdominal infection, urogenital infections
Sepsis
Vasopressors:
-Epinephrine:
Potent beta 1 and moderate beta 1 and alpha 1- needs high dose for vasoconstriction. can cause dysrhythmias,
splanchnic vasoconstriction. Second line. 5-20 mcg/kg
Sepsis
Vasopressors:
-Phenylephrine:
Alpha 1 agonists. used when NE is associated with serious arrhythmias, CO is known to be high and BP is
persistently low or as salvage therapy when combined inotrope/vasopressor and low dose vasopressin has failed. 2-20
mcg/min
Sepsis
Vasopressors:
-Norepinephrine (levophed):
Alpha 1 and beta 1 adrenergic receptors→ vasoconstriction and modest increase in CO.
Preferred treatment. 2-12 mcg/kg. Start at 0.5-1 mcg/min and titrate to effect. consider early, decrease amount of fluid needed
Sepsis
Sepsis
ABx Therapy : If fungal…
Fluconazole 400mg IV or Caspofungin 70mg IV
Sepsis
-Zosyn:
3.375 g q6 or over 4 hours, q8 and 4.5 g q6 for PNA/pseudomonas coverage. gram positive, gram negative, anaerobic, pseudomonas, spice a organisms
