SEPSIS Flashcards
What is Sepsis?
Life-threatening organ dysfunction caused by dysregulated host response to infection
What is Bacteremia?
Bacteria in the bloodstream
T/F: Bacteremia can be transient or overwhelming?
True.
Is a UTI a transient or overwhelming bacteremia?
Transient
Signs of Overhwhelming Bacteremia
(+) BCx, Sx
Fever, chills
SEPSIS SxS
Shivering/Fever Extreme Pain Pale skin Sleepy/confused "I feel like I might die" SOB
Sepsis v Septic Shock.
Septic shock can progress quickly Inability of body to compensate. - Lactic acid >2 -HYPOTENSION (MAP <65)
Severe Sepsis definition
Infection + SIRS+Organ dysfunction
“SIRS” in the setting of infection, assoc w/acute organ dysfunction
How do we quantify organ dysfunction?
Acute change in SOFA score
Septic Shock Definition. Key finding?
Subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound
HYPOTENSION
What is the Sofa Score?
What does a high score mean?
Sequential Organ Failure Assessment
High SOFA score means worse sepsis
Baseline SOFA score?
Baseline Sofa score is 0
How high does mortality risk increase with a SOFA score >2?
10% mortality risk in admitted pts
What lab value is not found in a sofa score?
lactic acid
is qSOFA sensitive enough to meet Sepsis Dx?
No
What are the disruptions to homeostasis in Severe Sepsis?
Inflammation activated
Coagulation Activated
Fibrinolysis Suppressed
What is the driving force in acute organ dysfunction and death?
Coagulopahty
What (Bacterial) cause of inflammation is activated in sepsis?
Lipopolysaccharide wall from gram (-) bacteria
What factors/mediators are released in response to sepsis?
Proinflammatory mediators, TNF, Interleukins, platelet activating factors
4 classic signs of Inflammation
Rubor-redness
Calor-Heat
Tumor- swelling
Dolor- Pain
Which mediators are responsible for cytokine storm?
Excess TNF, IL1 IL6
cause tissue & diffuse capillary injury
What are the 3 ways coagulation is activated in Sepsis?
- Inflammatory mediators released to fight infect also activate coagulation
- Infectious agent itself can cause endothelial damage=promotes coagulation
- Factors activated upon blood contacting damaged tissue= more clotting
T/F: D-dimer is a screening tool for Sepsis
False
What is PAI-1?
- Plasminogen activator inhibitor
- Key inhibitor of fibrinolysis in Sepsis
What 2 factors increase PAI-1 activity in sepsis?
- Endothelial cells
- Endotoxins released by gram (-) rods
What are 2 reasons for increased anaerobic metabolism in sepsis?
- Decreased O2 delivery because of capillary damage
- Decreased cardiac output
What metabolite is increased in anaerobic metabolism
Lactic aid
What disease state can result from Sepsis?
DIC
What is SIRS in regard to sepsis?
systemic inflammatory response syndrome, an overwhelming response to infection
SIRS criteria: (2+ to meet criteria)
1. temp >100.4 or <96.8
2. HR > 90bpm
3. tachypnea-resp rate > 20 or PaCO < 32mmhg
4. >12,000 WBC, or <4,000, or > 10% immature neutrophils ie a left shift
What do you need to confirm Dx of Sepsis?
SIRS + a suspected source of infection=confirm diagnosis of sepsis.
SIRS clinical utility
SIRS is used as early recognition to make a diagnosis and early intervention to impact survivability
What is DIC? What are the labs of DIC (high/low)?
- Disseminated Intravascular Coagulation
- Widespread imbalance between inflammation, coagulation and fibrinolysis
↑PT, PTT, Fibrin monomers, D-dimer
↓Protein C, Fibrinogen, Platelet count
What are the labs/findings of Severe Sepsis (high/low)?
↑ Creatinine, ALT,AST, Total bilirubin, Lactate (>2 mmol/L),- Procalcitonin (>2.0 ng/ml)
↓ Urine output, Mental status, BP
What is procalcitonin?
What level is indicative of Sepsis?
Protein biomarker→ bacterial infect
Utilized to deescalate ABX
> 2.0 ng/ml → highly suggestive Sepsis
Severe Sepsis pts are lively to have (5)?
↑ mortality rates Long lengths of stay ↑ ventilator usage ↑ costs ↑ probability of outlier status ↓ payment-to-cost ratios (Low SES)
Pts at risk for sepsis?
- All critically ill
- Severe CAP
- Intra abdominal surgery
- MENINGITIS
- Chronic Disease (DM, HF, CRF and COPD)
- ↓ immune function –HIV, transplants (Solid organ & blood), chemo
- Cellulitis
- UTI
Decrease in what 2 findings can negate cessation of fluid rescuscitation?
↓ Cap refill time & ↓ Lactate
What is the MCC of Severe Sepsis?
PNA
Phases of Sepsis Management?
1. Resuscitation Phase (6hrs-sooner=better –strive for 3hrs) 2. Initial Management Phase (24 hours) 3. Maintenance Phase (>24 hours)
Resuscitation Phase algorithm
- Access & maintain airway
- BCx & Blood work
- Initiate ABX therapy
- IV fluids 30ml/kg
(If MAP <65 or lactate >2) - Tight glycemic control Insulin
continuous IV drip - Vasopressors-**NOREPINEPHRINE,
- Sedation?
- Steroids?
use for pts in septic shock
ABX therapy?
Broad Spectrum:
Vanco=gram (+), & resistant
gram (+)
Pip/tazo (Zosyn) =(-), anaerobes, Pseudomonas
can also use carbapenems (not ertapenem)
Vasopressor therapy?
**Norepinephrine-use first
dobutamine, phenylephrine, epinephrine, vasopressin,
dopamine- use LAST
pts often need combo of pressors
Goals of 1st 6hrs
- *MAP <65
- urine output 0.5mL/hr
- Central venous O2 sat >70%
Hour 1 bundle
- Measure lactate level
- Obtain BCx before admin of ABX
- Admin broad spectrum ABX
- Begin rapid admin of 30ml/kg crystalloid for hypotension or lactate>2
- Maintain MAP ≥ 65 mmHg via Vasopressors
Goals of Initial management phase?
- Continue Rescusitation
- Monitor ↓Cap refill time &↓Lactic acid to reduce fluids
- Monitor Cx for ABX therapy
- Constant monitor Vasopressors
- Maintain MAP >65
Types of Support in Management phase?
Respiratory support:
- Watch for ARDS
- ↑ HOB
- Use weaning protocols
CNS Support (sedation protocols)
- Avoid NM blockers if possible (in pts w/o ARDS)
- Short course NM blocker for pt w/ early, severe ARDS
Maintenance Phase goals?
- Preventing nosocomial infections
- Restore premorbid condition
- Tailor antibiotic therapy as culture info available
General supportive care in Maintenance phase sepsis
- BGL <180 mg/dl
- Dialysis for renal failure or fluid overload
- DVT prophylaxis
- Stress ulcer prophylaxis
=Stress on GI system- sitting in pool of stomach acid
(Tx: PPI’s) - Enteral feeding if possible
tube feeds
What bacteria are most common in Sepsis?
What sources for infection MC?
Gram (-) rods, Strep PNA (gram (+))
Lungs
Urinary tract
GI
Skin/Soft tissue
T/F: COVID sepsis will have (+) BCx?
False
How do we manage ICU pts w/severe COVID-19?
Recommend use of:
- Corticosteroids (**dexamethasone)
- VTE prophylaxis
Recommend Use in non ventilated pts:
- Remdisivir
-Recommend prone ventilation:
when ventilation is necessary
Recommend AGAINST use of:
- Hydroxychloroquine
Severe sepsis is ____, ______, and ______.
Common
Deadly
Costly
______ is key in sepsis tx
Early recognition
1st signs of sepsis are _____
1st hours of sepsis are ______
_____ resuscitation is 1st step
Subtle
Crucial
Fluid
MAP calculation?
(SBP+2DBP)/3
Procalcitonin uses:
Can detect severity of Bacterial infect - higher number-more severe Dz Role in ABX stuartship: - When to start ABX - to reduce or r/o ABX use Also: - Arthritis (infectious or not) - Acute Endocarditis - Meningitis (bacterial or not)
MC bacteria for sepsis in neonates?
Ecoli, GBS = colonizations
Listeria = mom exposure
How can mom be exposed to listeria?
What can Listeria cause?
Soft cheeses (unpasteurized) Deli Meat
Meningitis–>sepsis
MC bacteria for sepsis in IVDU?
Staph/Strep & MRSA
