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Clinical Decision Making RRPA > Sepsis > Flashcards

Sepsis Flashcards

1
Q

2016 Sepsis definition

A

Life-threatening organ dysfunction caused by dysregulated host response to infection

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2
Q

Septic shock definition

A

circulatory and cellular/metabolic abnormalities are profound and increase mortality

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3
Q

How is organ dysfunction identified in the setting of sepsis?

A

By acute change in SOFA score

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4
Q

What is a baseline SOFA score assumed to be?

A

0

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5
Q

What does a SOFA score of 2 or more indicate?

A

Overall mortality risk of 10% in hospitalized patient.

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6
Q

What parameters are included on SOFA score?

A 
Pa02/FiO2 ratio
platelets
Bili
MAP
GCS
Creatinine
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7
Q

Components of qSOFA

A

R’s 22 or more
GCS less than 13
Systolic pressure <100

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8
Q

Overall, or broadly, what does sepsis do?

A

Disrupts homeostasis

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9
Q

What is the driving force in acute organ dysfunction?

A

Coagulopathy (coag activated/fibrinolysis supressed)

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10
Q

Which mediators are activated by gram negative bacteria during sepsis?

A

TNF
IL1 and IL6
PAF

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11
Q

You just drew cultures on a pt 4-6 hours ago and the lab has narrowed it down to 2 bacteria due to CO2 emission. Which are they?

A

Staph

E. coli

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12
Q

Which two mediators are responsible for the down regulation of initial proinflammatory response?

A

IL4

IL10

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13
Q

Early in the sepsis process, regulation of what is lost?

A

early proinflammatory response (failure of IL4 and IL10 to downregulate)

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14
Q

What is promoting coagulation in sepsis?

A

inflammatory mediators released to fight infection

- infectious agent itself can cause endothelial damage when clotting factors in blood contact damaged tissue

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15
Q

What is a key inhibiting mediator in fibrinolysis?

A

Plasminogen activator inhibitor-1 (PAI-1)

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16
Q

Where is PAI-1 produced?

A

endothelial cells

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17
Q

What increases the activity of PAI-1?

A

Endotoxins released from gram neg bacteria

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18
Q

What are the broad results of sepsis?

A

Decreased O2 delivery due to microvascular injury

  • Decreased CO
  • Increased anaerobic metabolism
  • DIC
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19
Q

What is DIC definition?

A

Widespread imbalance of coagulation and fibrinolysis

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20
Q

What lab values are up/down in DIC?

A

UP:

  • PT
  • PTT
  • Fibrin monomers
  • D-dimer

Down:

  • Protein C
  • Fibrinogen
  • Platelet count
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21
Q

Lab values or clinical findings up/down in sepsis?

A

UP:

  • creatinine
  • ALT, AST, T bili
  • Lactate > 4 mmol/L
  • Procalcitonin > 2 ng/mL

Down:

  • urine output
  • mental status
  • BP
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22
Q

What is the lactate level goal in tx of sepsis?

A

Get pts below 5 mmol/L and fast

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23
Q

What causes decreased urine output in sepsis?

A

Kidney damage and 3rd spacing

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24
Q

What is procalcitonin and its normal values?

Sepsis values?

A

Protein biomarker for bacterial only infection. Released by bacteria 2ndary to endotoxin release.

  • NML is < 0.15 ng/mL
  • > 2.0 ng/mL highly suggestive of sepsis
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25
Q

What is procalcitonin levels clinically used for?

A

Backing down abx after initiation and improvement

26
Q

Do humans poses the enzyme to break down procalcitonin?

A

Most cells do not

27
Q

Which pts are at risk for sepsis?

A
  • All critically ill
  • Severe CAP
  • Intra abdominal surgery
  • Meningitis
  • Chronic dz (DM, HF, CRF, COPD)
  • Immunosuppressed (HIV, transplants, chemo)
  • Cellulitis
  • UTI
28
Q

What is the leading cause of sepsis?

A

Strep pneumo CAP

29
Q

Of the at risk pts, what three factors put them at even greater risk?

A
  • 65 or older
  • Underlying comorbidity
  • Higher body weight
30
Q

SEPSIS pneumonic

A
  • Shivering, fever or very cold
  • Extreme pain/discomfort
  • Pale or discolored skin
  • Sleepy (hard to wake, confused)
  • “I feel like I might die”
  • Short of breath
31
Q

SIRS criteria?

A
  • Temp > 100.4 or < 96.8
  • > 90 BPM
  • R’s > 20 or PaCO2 < 32
  • > 12,000 WBC or <4000 or >10% immature neuts (left shift)
32
Q

List SIRS mimics

A
  • Pancreatitis
  • GI bleed
  • SLE flare
  • DKA
  • Anaphylaxis
  • Adrenal insufficiency
  • PE/DVT
33
Q

What is SEVERE sepsis?

A

Sepsis + acute organ dysfunction

34
Q

Severe sepsis s/sxs?

A
  • areas of mottled skin
  • cap refill >/= 3 seconds
  • less than 0.5 mL/kg > 1 hr or RRT
  • Lactate >2 mmol/L
  • abrupt changes in mental status
  • Platelets <100,000 or DIC
  • Acute lung injury, ARDS
  • Cardiac dysfunction
35
Q

What is MCC neonatal sepsis and where does it come from?

A 
Strep agalactias aka GBS
-E. coli
-Klebsiella
-H. flu
-Listeria
From GUT during birth or nasal mucosa of caregivers
36
Q

What is another name for GAS?

A

Strep pyogenes

37
Q

Strep pneumo is part of what grouping?

A

A for alpha-hemolytic

*leaves greenish ring on agar

38
Q

Outpatient sepsis pts will generally be on abx for how many days?

A

7-10 days IV

39
Q

How soon will a central line be placed in a septic pt?

A

24-48 hrs after abx initiation

40
Q

Sepsis outpatients will generally be on abx for how many days?

A

7-10 days IV

41
Q

How soon will a central line be placed in a septic pt?

A

24-48 hrs after abx initiation

42
Q

What are the three tx phases of sepsis?

A
  • Resuscitation phase (1st 6h, sooner the better, strive first 3hrs)
  • Initial management 24 hrs
  • Maintenance phase > 24 hrs
43
Q

What is tricky about transplant pts and sepsis?

A

They can present with low (99) or no fever

44
Q

What is done during resuscitation phase?

A
  • airway
  • Pan culture (spit/urine/blood, +/- LP)
  • Initiate abx therapy (p 66 Sanford)
  • IV fluids if MAP <65 or lactate >/=4 @ 30 mL/kg/hr
  • Tight glycemic control w/ continuous insulin drip
  • Vasopressors: dobutamine, NE, ddddopamine, phenylephrine, epi, vasopressin
  • sedation
  • steroids if adrenal insufficiency
45
Q

What do you do if your initial lactate is elevated >/=2 mmol/L?

A

redraw to verify

46
Q

What is MAP goal?

A

> /=65

47
Q

What are the goals in 1st 6 hrs of resuscitation phase?

A
  • CVP 8-12 mm Hg
  • MAP >/=65 mm Hg
  • Urine output 0.5 mL/kg/hr
  • Central venous O2 sat of 70% or mixed venous of 65%
  • striving for these reduces 28-day mortality rate
48
Q

What is in the hour 1 bundle?

A
  1. Measure lactate (remeasure if elevated 2 or more)
  2. Blood cx b/f abx
  3. Start broad spec abx
  4. Fluids 30 ml/kg/hr if MAP <65 or lac >/=4
  5. Maintain MAP >/=65 w/ vasopressors if hypo during or after fluids
49
Q

What do vasopressor do? List five.

A

Cause vasoconstriction.

  • NE (preferred 1st line)
  • Epi
  • Dopamine
  • Dobutamine
  • Phenylephrine (common addon)
50
Q

What is done during Initial management phase?

A
  • Continue resuscitation phase
  • Monitor cx for targeting abx
  • Constant monitoring of vasopressors for MAP >/=65
51
Q

What is paid close attention to in ARDS and what is done?

A
  • Pressures and volumes
  • Elevate head of bed
  • Use weaning protocols
52
Q

What is seen on xr with ARDS?

A
  • Bilateral diffuse fluffy infiltrates
  • NORMAL cardiac size
  • Tracheostomy tube
53
Q

What is done to support central nervous system in setting of sepsis?

A
  • Sedation protocols

- Avoid NMBD drugs if possible (in pts w/o ARDS)

54
Q

When is it okay to use NMDB drugs in sepsis?

A

Short course for pts w/ early, severe ARDS okay BUT should still be minimized.

55
Q

What is done during the maintenance phase?

A

If you live >24 hrs, goal to prevent nosocomial infx

  • Restore premorbid condition
  • Tailor abx as more cx info becomes available
56
Q

What are general supportive care measures for sepsis pt?

A
  • BGL <180 mg/dl
  • Dialysis for renal failure or fluid overload
  • DVT ppx
  • Stress ulcer ppx
  • Enteral feeding if possible
57
Q

What is a stress ulcer? What is ppx tx? Concern w/ tx?

A
  • caused by stress of being critically ill
  • Tx usually PPI, +/- H2 blocker with famotidine
  • Concern of C. diff w/ PPI AND hypomagnesemia
58
Q

Infx in what areas of body commonly lead to sepsis?

A
  • Lungs
  • UTI progressing to urosepsis
  • GI (diverticulitis/colitis/surgeries)
  • Skin and soft tissue deep wounds
59
Q

MCC bacteria for sepsis?

A

Strep pneumo > staph aureus > gram neg aka E. coli

60
Q

How many cases of severe sepsis per 100 hospital discharges?

A

2.26 cases

61
Q

How many pts die of severe sepsis each day?

A

500

62
Q

What is the only anti-fungal that penetrates the bladder?

A

Fluconazole

Clinical Decision Making RRPA (3 decks)

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