Sepsis Flashcards
2016 Sepsis definition
Life-threatening organ dysfunction caused by dysregulated host response to infection
Septic shock definition
circulatory and cellular/metabolic abnormalities are profound and increase mortality
How is organ dysfunction identified in the setting of sepsis?
By acute change in SOFA score
What is a baseline SOFA score assumed to be?
0
What does a SOFA score of 2 or more indicate?
Overall mortality risk of 10% in hospitalized patient.
What parameters are included on SOFA score?
Pa02/FiO2 ratio platelets Bili MAP GCS Creatinine
Components of qSOFA
R’s 22 or more
GCS less than 13
Systolic pressure <100
Overall, or broadly, what does sepsis do?
Disrupts homeostasis
What is the driving force in acute organ dysfunction?
Coagulopathy (coag activated/fibrinolysis supressed)
Which mediators are activated by gram negative bacteria during sepsis?
TNF
IL1 and IL6
PAF
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?
Staph
E. coli
Which two mediators are responsible for the down regulation of initial proinflammatory response?
IL4
IL10
Early in the sepsis process, regulation of what is lost?
early proinflammatory response (failure of IL4 and IL10 to downregulate)
What is promoting coagulation in sepsis?
inflammatory mediators released to fight infection
- infectious agent itself can cause endothelial damage when clotting factors in blood contact damaged tissue
What is a key inhibiting mediator in fibrinolysis?
Plasminogen activator inhibitor-1 (PAI-1)
Where is PAI-1 produced?
endothelial cells
What increases the activity of PAI-1?
Endotoxins released from gram neg bacteria
What are the broad results of sepsis?
Decreased O2 delivery due to microvascular injury
- Decreased CO
- Increased anaerobic metabolism
- DIC
What is DIC definition?
Widespread imbalance of coagulation and fibrinolysis
What lab values are up/down in DIC?
UP:
- PT
- PTT
- Fibrin monomers
- D-dimer
Down:
- Protein C
- Fibrinogen
- Platelet count
Lab values or clinical findings up/down in sepsis?
UP:
- creatinine
- ALT, AST, T bili
- Lactate > 4 mmol/L
- Procalcitonin > 2 ng/mL
Down:
- urine output
- mental status
- BP
What is the lactate level goal in tx of sepsis?
Get pts below 5 mmol/L and fast
What causes decreased urine output in sepsis?
Kidney damage and 3rd spacing
What is procalcitonin and its normal values?
Sepsis values?
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
What is procalcitonin levels clinically used for?
Backing down abx after initiation and improvement
Do humans poses the enzyme to break down procalcitonin?
Most cells do not
Which pts are at risk for sepsis?
- All critically ill
- Severe CAP
- Intra abdominal surgery
- Meningitis
- Chronic dz (DM, HF, CRF, COPD)
- Immunosuppressed (HIV, transplants, chemo)
- Cellulitis
- UTI
What is the leading cause of sepsis?
Strep pneumo CAP
Of the at risk pts, what three factors put them at even greater risk?
- 65 or older
- Underlying comorbidity
- Higher body weight
SEPSIS pneumonic
- 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
SIRS criteria?
- 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)
List SIRS mimics
- Pancreatitis
- GI bleed
- SLE flare
- DKA
- Anaphylaxis
- Adrenal insufficiency
- PE/DVT
What is SEVERE sepsis?
Sepsis + acute organ dysfunction
Severe sepsis s/sxs?
- 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
What is MCC neonatal sepsis and where does it come from?
Strep agalactias aka GBS -E. coli -Klebsiella -H. flu -Listeria From GUT during birth or nasal mucosa of caregivers
What is another name for GAS?
Strep pyogenes
Strep pneumo is part of what grouping?
A for alpha-hemolytic
*leaves greenish ring on agar
Outpatient sepsis pts will generally be on abx for how many days?
7-10 days IV
How soon will a central line be placed in a septic pt?
24-48 hrs after abx initiation
Sepsis outpatients will generally be on abx for how many days?
7-10 days IV
How soon will a central line be placed in a septic pt?
24-48 hrs after abx initiation
What are the three tx phases of sepsis?
- Resuscitation phase (1st 6h, sooner the better, strive first 3hrs)
- Initial management 24 hrs
- Maintenance phase > 24 hrs
What is tricky about transplant pts and sepsis?
They can present with low (99) or no fever
What is done during resuscitation phase?
- 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
What do you do if your initial lactate is elevated >/=2 mmol/L?
redraw to verify
What is MAP goal?
> /=65
What are the goals in 1st 6 hrs of resuscitation phase?
- 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
What is in the hour 1 bundle?
- Measure lactate (remeasure if elevated 2 or more)
- Blood cx b/f abx
- Start broad spec abx
- Fluids 30 ml/kg/hr if MAP <65 or lac >/=4
- Maintain MAP >/=65 w/ vasopressors if hypo during or after fluids
What do vasopressor do? List five.
Cause vasoconstriction.
- NE (preferred 1st line)
- Epi
- Dopamine
- Dobutamine
- Phenylephrine (common addon)
What is done during Initial management phase?
- Continue resuscitation phase
- Monitor cx for targeting abx
- Constant monitoring of vasopressors for MAP >/=65
What is paid close attention to in ARDS and what is done?
- Pressures and volumes
- Elevate head of bed
- Use weaning protocols
What is seen on xr with ARDS?
- Bilateral diffuse fluffy infiltrates
- NORMAL cardiac size
- Tracheostomy tube
What is done to support central nervous system in setting of sepsis?
- Sedation protocols
- Avoid NMBD drugs if possible (in pts w/o ARDS)
When is it okay to use NMDB drugs in sepsis?
Short course for pts w/ early, severe ARDS okay BUT should still be minimized.
What is done during the maintenance phase?
If you live >24 hrs, goal to prevent nosocomial infx
- Restore premorbid condition
- Tailor abx as more cx info becomes available
What are general supportive care measures for sepsis pt?
- BGL <180 mg/dl
- Dialysis for renal failure or fluid overload
- DVT ppx
- Stress ulcer ppx
- Enteral feeding if possible
What is a stress ulcer? What is ppx tx? Concern w/ tx?
- caused by stress of being critically ill
- Tx usually PPI, +/- H2 blocker with famotidine
- Concern of C. diff w/ PPI AND hypomagnesemia
Infx in what areas of body commonly lead to sepsis?
- Lungs
- UTI progressing to urosepsis
- GI (diverticulitis/colitis/surgeries)
- Skin and soft tissue deep wounds
MCC bacteria for sepsis?
Strep pneumo > staph aureus > gram neg aka E. coli
How many cases of severe sepsis per 100 hospital discharges?
2.26 cases
How many pts die of severe sepsis each day?
500
What is the only anti-fungal that penetrates the bladder?
Fluconazole
