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Sepsis Flashcards

1
Q

Definition

Sepsis

A

life-threatening organ dysfunction caused by a dysregulated host response to infection

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2
Q

Definitions

Sepsis-3 (2016)

Sepsis

A

life-threatening organ dysfunction caused by a dysregulated host response to infection

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3
Q

Clinical variables

qSOFA Score

non-ICU patients

A

SBP ≤ 100
Altered mental status (GCS ≤ 15)
RR ≥ 22

qSOFA >= 2 indicates sepsis

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4
Q

Definition

Sepsis-3 (2016)

Septic shock

A

Definition: A subset of sepsis in which underlying circulatory/cellular/metabolic abnormalities are profound enough to substantially increase mortality

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5
Q

Clinical criteria

Sepsis-3 (2016)

Septic shock

A
  1. persistant hypotension requiring vasopressors to maintain MAP >= 65 –> cirulatory dysfunction
    AND
  2. serum lactate level >2 mmol/L –> cellular dysfunction
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6
Q

Clinical criteria

Sepsis-3 (2016)

Sepsis

A

2 or more SOFA (ICU patients)
2 or more qSOFA (non-ICU patients)

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7
Q

Clinical values

SOFA Score

ICU patients

A

PaO2/FiO2
Platelet, bilirubin
MAP (pressor requirements)
Glasgow Coma Scale (GCS)
SCr/UO

2 or more SOFA –> sepsis

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8
Q

Initial resuscitation

Hour-1 Bundle

Elements to be initiated within the first hour

A
  1. measure lactate level; re-measure if initial lactate is >2 mmol/L
  2. Obtain blood cultures prior to administration of antibiotics (aneanerobic AND aerobic)
  3. Administer braod spectrum abx
  4. Administer 30mL/kg cystalloid for hypotension ot lactate >= 4 mmol/L
  5. apply vasopressors if patient is hypotensive during OR after fluid resuscitation to maintain mean arterial pressure >= 65mmHg
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9
Q

Management of Septic Shock

A
  1. control infection
  2. hemodynamic stability
  3. other supportive measures
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10
Q

Management of Septic Shock

Hemodynamic stability

Fluid resuscitation

A

Begin immediately (within 1 hr)

  1. first line: crystalloids 30 mg/kg BOLUS
    * NS > LR
  2. colloids
    * may consider albumin in addition to crystalloid
    * avoid HES
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11
Q

Management of Septic Shock

Hemodynamic stability

Vasopressors - for fluid-refractory hypoperfusion

A

Goal: MAP of 65

  1. first-line: norepi
    * titrate to MAP
  2. second-line: vasopressin
    * can be added to NE up to 0.03u/min IV infusion
    * used to rach target MAP or dec NE usage
  3. second-line: epinephrine
    * can be added to NE
    * titrate to goal MAP
    * used to reach target MAP
  4. Dopamine
    * alternative to NE ONLY in patients with compromised systolic function and low risk of tachyarrythmias
  5. dobutamine
    * use if persistent hypoperfusion despite fluid/vasopressor agents
  6. phenylephrine
    * limit use
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12
Q

Management of septic shock: hemodynamic stability

Norepinephrine

Vasopressor, MOA

A

agonist
a1 > b1

Inc SVR, HR, contractility

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13
Q

Management of septic shock: hemodynamic stability

Epinephrine

Vasopressor, MOA

A

agonist
b1 > b2 > a1 > a2

Inc HR, contractility
Vasodilation, bronchodilation

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14
Q

Management of septic shock: hemodynamic stability

Vasopressin

Vasopressor, MOA

A

agonist
V123R

Inc SVR, PVR
Plt aggregation, anti-duiresis

Effective in acidosis

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15
Q

Management of septic shock: hemodynamic stability

Phenylephrine

Vasopressor, MOA

A

pure a agonist

Inc SVR

No effect on HR or contractility

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16
Q

Management of septic shock: hemodynamic stability

Dopamine

inotrope, MOA

A

Dose-dependent agonist (mcg/kg/hr)
1-5 –> DA
5-10 –> b
10-20 –> a

b –> inc HR, contractility
a –> SVR

17
Q

Management of septic shock: hemodynamic stability

Dobutamine

inotrope, MOA

A

agonist
b1 > b2

Inc HR, contractility
Mild dec SVR and P(pulmonary)VR

18
Q

Management of septic shock: hemodynamic stability

Milrinone

inotrope, MOA

A

inhibitor
PDE-3

Inc HR, contractility
Mild dec SVR and P(pulmonary)VR

Effective in b-blockade, little effect on HR

19
Q

Management of septic shock

Other supportive measures

A
  1. corticosteroids
  2. bicarbs
  3. blood products
  4. glucose control
  5. VTE ppx
  6. stress ulcer ppx
20
Q

Management of septic shock: other treatments

Corticosteroids

indication, meds

A

If fractory to fluids AND vasopressors…
Hydrocortisone 200mg/d IV
* ACTH test not reommended

taper once patient does not require vasopressors

21
Q

Management of septic shock: other treatments

Bicarb

indication, pathophysio

A

pathophysio: hypoperfusion induces lactic acidosis
indication: pH =< 7.15

22
Q

Management of septic shock: other treatments

Blood products

indication, medications

A

Indication: after hypoperfusion has resolved
1. RBC - if Hgb < 7, goal 7-9
2. frozen fresh plasma (FFP) - if bleeding/invasive procesures
3. plt - give if plt < 20,000 AND significant risk of bleeding OR plt < 10,000 BUT not bleeding

erythropoetin (e.g. epogen), antithrombin not recommended

23
Q

Management of septic shock: other treatments

Glucose control

indication, meds, goal, monitoring

A

Insulin
indication: BG >180 x2 during hospital
goal: upper level BG <180
check BG q1-2hrs until glucose/inf rates are stable, then q4hrs

24
Q

Management of septic shock: other treatments

VTE ppx

indication, meds, contraindications

A

rationale: hemodynamically unstable pts have risk of fatal PE/DVT

DOC: LMWH (unless CrCl <30 –> UFH)
Recommended unless contraindicated

Contraindications: thrombocytopenia, severe coagulopathy, active bleeding, recent intracerebral hemorrhage
If contraindicated –> mechanical ppx (e.g. compression devices, socks)

25
Q

Management of septic shock: other treatments

Stress ulcer ppx

indication, meds

A

Indication: pts who have inc risk of bleeding during hospital
RF: coagulopathy, mechanical vent >= 48hrs, hypotension

  1. PPI (pantoprazole)
  2. H2RA (famotidine)
26
Q

Clinical criteria

SIRS

A

SIRs >= 2
WBC > 12k or < 4k or > 10% immature bands
HR > 90
RR > 20
T > 38 or < 36

Pharm (7 decks)

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