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Intensive Care > Sepsis > Flashcards

Sepsis Flashcards

1
Q

What is the definition of sepsis

A

SEPSIS 3 definition

‘A potentially life threatening organ dysfunction caused by dysregulated host response to infection’

The following terms are no longer used
1. SIRS
2. Severe Sepsis
3. Septicaemia

Hospital mortality in septic shock > 40%

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2
Q

How is Sepsis recognized or suspected in the ward? Sepsis 3 vs SSC Guidelines 2021

A

SEPSIS 3 2016:

qSOFA (quick SOFA) > 2 of:

  1. RR > 22
  2. SBP < 100
  3. GCS < 15

SSC Guidelines 2021

Recommends against using qSOFA as a single screening tool (leads to missed diagnoses and worse outcomes)

Includes Lactate. Raised lactate should prompt a thorough clinical assessment of the patient.

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3
Q

How is sepsis recognized or suspected in the ICU (why is this different)

A

SOFA score increase of 2 or more

(More complex patients)

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4
Q

Summarise the SOFA Score

A

CNS
- GCS 15 (0).
- GCS 13 - 14 (1)
- GCS 10 - 12 (2)
- GCS 6 - 9 (3)
- GCS < 6

CVS
- MAP > 70 (0)
- MAP < 70 no inotropes (1)
- Dopamine < 5 or Dobutamine any dose (2)
- Adrenalin < 0.1 ug/kg/min (3)
- Adrenalin > 0.1 ug/kg/min (4)

RSP
- PF >400 (0)
- PF 300 - 400 (1)
- PF 200 - 300 (2)
- PF 100 - 200 (3)
- PF < 100 (4)

RENAL
- Creat < 110 (0)
- Creat 110 - 170 (1)
- Creat 170 - 300 (2)
- Creat 300 - 440. UO < 500. (3)
- Creat > 440. UO < 200. or on dialysis (4)

LIVER
- TBR < 20 (0)
- TBR 20 - 32 (1)
- TBR 33 - 101 (2)
- TBR 102 - 204 (3)
- TBR > 204 (4)

COAGULATION
- Plts > 150 (0)
- Plts 100 - 150 (1)
- Plts 50 - 100 (2)
- Plts 20 - 50 (3)
- Plts < 20 (4)

Higher score - higher mortality (> 14 = 100%)

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5
Q

Define septic shock (Sepsis 3)

A

Circulatory, Metabolic and cellular derangement - Subset of sepsis

Vasoconstrictors for MAP < 65 after adequate fluid replacement

AND

Lactate > 2

MOrtality is > 40%

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6
Q

What are the Big 5 most likely sources of sepsis in a patient

A
  1. Lungs: “VAP’
  2. Abdomen
  3. Wound/Surgical site
  4. Lines
  5. Urinary tract
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7
Q

Summarise the pathophysiology of sepsis

A

Bacteria/Virus/Fungi/Protazoa

Cytokine Storm (TNFa, IL1. IL6)

(All initiated by the innate immune response)
1. Endothelial activation
2. Nitric Oxide generation
3. Microvascular damage with poor perfusion
4. Mitochondrial damage

Innate immune system activation

  1. Pathogen releases PAMPS (Pathogen associated molecular patterns)
  2. Recognised by receptors on immune cell surface: PRRs. Pathogen Recognition Receptors
  3. Genetic variability of the magnitude and pattern of response
  4. Inflammatory response can be perpetuated by DAMPS (Danger Associated Molecular Patterns) - Dead host cell fragments –> amplify response.
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8
Q

What is the main function of the endothelial glycocalyx

A

Prevents loss of fluid from the blood vessels

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9
Q

List typical ICU infections with low virulence

A

Acinetobacter
Stenotrophomonis
Candida

Reactivation of dromant viruses
- HSV
- CMV

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10
Q

Describe Sepsis effects on the CVS

A
  1. Hypovolaemia (glycocalyx failure)
  2. Vasodilatation/Vasoplegia
  3. Myocardial depression (High CO as low afterload with compensatory tachycardia)
    - Receptor down regulation
    - Cytokine mediated reduced Calcium movement
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11
Q

Summarise Emmanuel Rivers Early Goal Directed therapy in the treatment of severe sepsis and septic shock 2001.

A

Early (Emergency department) intervention
- Improve DO2 within 6 hours with IVF/Dobutamine keeping Hct > 30%.
- Noradrenalin for SBP < 90
- Target SvO2 > 70%
- Mortality 30% vs 46%

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12
Q

Name three studies consequent to the Rivers Study that contradicted the findings Rivers and suggest a reason why?

A

ProCESS 2014
ARISE 2014
ProMISe 2015

These three trials did not favour EGDT. It is possible that in these subsequent studies, that the control patients were also receiving established early resuscitation subsequent to the Rivers trial. i.e. most of these patients were also receiving 30ml/kg within the first 3 hours as ‘usual care’

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13
Q

How does Sepsis affect the respiratory system

A
  1. ARDS (Increase permeability of lung capillaries)
    - Fluid and neutrophils in alveoli
    - V:Q mismatch.
    - Respiratory Failure and increase WOB
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14
Q

How are the kidneys affected by sepsis

A

Later on during ICU –> renal failure develops

Oliguria
ATN

–> Increased mortality!

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15
Q

How is the liver affected by sepsis

A

Septic shock –> extreme liver ischaemia –> long standing damage to liver–> Raised liver enzymes –> gradual rise in TBR with unresolved sepsis

Cirrhosis with septic shock –> indication to discontinue ICU

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16
Q

How does sepsis affect the brain

A

Cytokines cross BBB –> delirium.

Incidence is 23 - 71%

Cytokines cross BBB
Brain oedema
Hyperammonaemia
Neurotransmission altered

Long term cognitive dysfunction
Increased mortality

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17
Q

What is critical illness neuro-myopathy in sepsis

A

Usually starts after about a week

Axonal conduction defect
Neuromuscular junction affected
Myopathy

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18
Q

How does Sepsis 3 2016 and SSC Guidelines 2021 differ with regards to recommendations for initial fluid therapy in sepsis.

A

Sepsis 3 2016
- 30ml/kg within first 3 hours - strong recommendation

SSC Guidelines 2021
- 30 ml/kg first 3 hours - weak recommendation.

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19
Q

Summarise your initial evaluation of a patient suspected with sepsis/septic shock

A

INITIAL EVALUATION
- Acknowledgement that although this approach is systematic, in reality, most of the following occur simultaneously

  • HHH ABCDE
  • ANTIBIOTICS within 1st hour of recognition
  • FLUIDS 30ml/kg first 3 hours of recognition
  • Simultaneously investigate
    1. Blood gas analysis with serum lactate
    2. Blood cultures x 2 distinct sites.
    3. Routine laboratory studies as per institution
    4. Cultures from easily accessible sites (sputum/urine).
    5. Imaging of suspected sources (CXR/US/CT/ECHO etc.)
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20
Q

Summarise the initial resuscitation of a patient with sepsis

A

IV FLUIDS
- Commence within 1st hour
- Complete within 3 hours
- 250 - 500 ml crystalloid (balanced solutions) boluses every 5 - 10 minutes titrated to dynamic parameters (PPV, SVV, CI, PLR), clinical parameters (CRT, MAP) and biochemical parameters (Lactate) and early signs of overload (discontinue at first suspicion of pulmonary oedema).
- Latest recommendation is that colloids are contraindicated in sepsis and septic shock

ANTIBIOTICS
- Empiric broad spectrum within 1 hour of sepsis recognition. If suspected must also cover fungi/viruses.
- If suspected gram negative sepsis: Two agents from different AB classes are recommended to ensure effective treatment of resistant organisms

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21
Q

What factors guide the choice of broad spectrum antibiotics in sepsis

A
  1. Patient history
  2. Comorbidities
  3. Immune function
  4. Clinical context
  5. Suspected site of infection
  6. Presence of invasive devices
  7. Gram Stain data
  8. Local prevalence and resistance patterns
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22
Q

When is an antifungal agent added empirically

A

In neutropaenic patients

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23
Q

What do the SSC Guidelines 2021 recommended with regard to monitoring response to initial fluid therapy?

A

Dynamic measures (PPV, SVV, PLR) in addition to static measures (MAP, CRT, physical examination).

CRT is NB in septic shock!

In addition, SSC 2021 suggest that a decreasing serum lactate indicates response to fluid resuscitation but to be cognizant that the aetiology of hyperlactataemia is broad failure of lactate to reduce should prompt thorough clinical assessment of the patient.

24
Q

What target BP does SSC 2021 recommend for patients with septic shock in vasopressors

A

MAP of 65. No benefit to higher MAP targets.

25
Q

What do the SSC guidelines 2021 recommend with regard to the admission of patients with septic shock to the ICU

A

Suggest that patient moved into the ICU within 6 hours

26
Q

How did the time period for the initial administration of antibiotics in sepsis change from Sepsis 3 in 2016 to SSC Guidelines 2021

A

Sepsis 3 2016
Administer AB as possible after recognition and within 1 hour

SSC 2021
Administer immediately/within 1 hour of recognition.

27
Q

What does SSC 2021 recommend with regards to investigating patients with suspected sepsis without shock prior to administration of AB

A

Time-limited course of rapid investigation and if concern for sepsis persists, administer AB within 3 hours from then time when sepsis was first recognised.

28
Q

What does SSC 2021 recommend with regard to the use of procalcitonin plus clinical evaluation to decide when to start antibiotics, as compared to clinical evaluation alone?

A

Suggest clinical evaluation alone

29
Q

What antibioitic is used to treat suspected MRSA

A

Vancomycin

30
Q

If sepsis is suspected likely to be caused by MultiDrug Resistant Organisms, how should empiric antimicrobial therapy by administered

A

Two different class antimicrobials both with gram negative cover. De-escalate once organism identified

31
Q

What recommendation does SSC 2021 make with regard to antifungals and antivirals

A

Antifungals
- if patient at high risk of fungal infection

Antivirals
- no recommendation

32
Q

SSC 2021: After initial bolus of AB, Prolonged infusion beta lactams vs conventional bolus infusion??

A

SSC 2021 recommended AB bolus then prolonged infusion

33
Q

SSC 2021: when should procalcitonin be used

A

Source control achieved. Optimal duratoin of antimicrobial is unclear. Then use clinical evaluation + procalcitonin.

34
Q

SSC 2021: Fluid recommendations?

A

Recommend balanced crystalloids over Normal Saline

Recommmend against starches/gelatin for resuscitation

Recommend albumin in patients who received large volumes of crystalloid

35
Q

SSC 2021: first choice vasopressor

A

Noradrenalin

(Add vasopressin instead of escalating dose of noradrenlin)

If mean < 65 on these two agents - add adrenalin

If cardiac dysfunction present, consider adding dobutamine to noradrenalin or use adrenalin alone

36
Q

Describe the vasopressor / Inotropic therapy strategy in septic shock used at GSH

A

Target MAP 65
Adrenalin titrated.
(If noradrenalin used, can add vasopressin to minimize noradrenalin dose)

Phenylephrine
1. Adrenalin or noradrenalin is associated with severe dysrhtyhmia
2. CO is known to be high and BP persistently low
3. Salvage therapy when combined inotrope/vasopressor drugs have failed to acheice MAP 65

Dobutamine (20ug/kg/minute)
Added in the presence of
1. Myocardial dysfunction (elevated filling pressures and low CO.
2. Ongoing signs hypoperfusion despite adequate intravascular volume and MAP.

37
Q

SSC 2021: HFNO2 vs other noninvaseve ventilation

A

HFNO2 preferred

38
Q

SSC 2021: Proning?

A

In moderate to severe ARDS –> proning suggested for > 12 hours a day

39
Q

SSC 2021: ? corticosteroid use

A

For patients in septic shock and ongoing vasopressor requirement, SSC 2021 suggest using corticosteroids.

40
Q

SSC Guidelines 2021: Adjunctive therapies in sepsis

A

Steroids: YES - in septic shock with vasopressors
Immunoglobulins: NO
Pantoloc: YES
Pharmacological VTE prophylaxis: YES
RRT: If indicated
Actrapid: If Hgt > 10 –> infusion
Vitamin C IV: NO
NaHCO3: Yes. If pH < 7.2 and AKIN 2 or 3
Early enteral feed: YES

41
Q

When and how should steroids be used in septic shock

A

Evidence showed that corticosteroid use resulted in faster resolution of shock, at the expense of a possible increase in neuromuscular weakness, while the effect on mortality was somewhat unclear.

The 2021 Guidelines included a weak recommendation to use corticosteroids in adults with septic shock and an ongoing requirement for vasopressor therapy despite adequate fluid resuscitation, and proposed using 200 mg/day of hydrocortisone, either divided into 6-hour doses or as a continuous infusion.

42
Q

What is the definition of ventilator acquired pneumonia

A

Pneumonia occurring in a patient > 48 hours post-intubation

43
Q

How and why is ventilator acquired pneumonia classified

A

Early
- < 4 days post intubation
- Cause: community acquired antibiotic S organisms e.g. Strep. pneumoniae,; Staph aureus; Haemophilus influenzae

Late
- 4 - 5 days post intubation
- Pseudomonas aeruginosa
- Acinetobactor
- Coliform species
- May be antibiotic resistant

44
Q

What are the Johansen criteria for the diagnosis of VAP

A
  1. CXR - progressive infiltrates + two of:
  • Fever > 38
  • Leucytosis or leucopaenia
  • Purulent secretions
45
Q

What is the modified Clinical Pulmonary Infection Score CPIS

A

If score of > 6 –> suggestive of a VAP in the presence of clinical suspicion

  1. Tracheal secretions
  2. CXR changes
  3. Temp
  4. Leukocyte
  5. PF ration ± ARDS
  6. Microbiology
46
Q

Why are tracheal aspirates unreliable

A

False positive TA are common. This is due to colonization of large airways

Commencement of antibiotics based on TA alone is not appropriate and propogates AB resistance. Decision to treat a VAP must be on clinical criteria

47
Q

What is the VAP prevention bundle

A
  1. Head up > 30 degrees
  2. Oral care 4 hourly
  3. Chlorhexidine rinse 12 hourly
  4. Sedation protocol ordered
  5. Sedation vacation documented
  6. Daily SBT
  7. Cuff pressure documented 12 hourly
48
Q

What is the definition of central line associated blood stream infection (CLABSI)

A

Bloodstream infection in a pateint with a CVC in situ, where the catheter is proven to be the source of septicaemia.

49
Q

What are the pathogens commonly associated with CLABSI

A

Coagulase negative Staph (most common)
Staph Aureus
Candida
Gram negative bacteria (pseudomonas/coliforms)

50
Q

What are the diagnostic criteria for a CLABSI

A
  1. Presence of a recognized pathogen cultured from one or more blood cultures

AND

Organism cultured from blood not related to infection at another site.

OR

  1. Presence of at least one of the following
    - T > 38. Chills. Hypotension
    - S + S not related to infection at another site

AND

Presence of at leaset one of the following
- common skin contaminant cultured from 2 or more blood cultures drawn on separate occasions
- common skin contaminant cultured from 2 or more BCs drawn on separate occasions

51
Q

Describe the antimicrobial strategy for catheter tip culture positive for the following organisms:
1. Coag neg. staphylococcus
2. Staph. Aureus
3. Gram neg rods
4. Pseudomonas and candida

A
  1. Coag neg. staphylococcus
    - infection may settle with line removal.
    - If sepsis persists –> Vancomycin 5 - 7 days
  2. Staph. Aureus
    - 4 - 6 weeks antimicrobial therapy (high risk endocarditis)
  3. Gram neg rods
    - 7 - 10 days antimicrobial therapy
  4. Pseudomonas and candida
    - 2 weeks antimicrobial
52
Q

How are CLABSI prevented

A

Hand hygiene
Maximal barrier precaution on insertion (cap, mask, gowns, gloves, drapes, Chlorhexidine sterile field)
Optimal CVC site selection
Daily line review

53
Q

When should diarrhoea from Clostridium Difficile be suspected and how is the diagnosis made

A

Antibiotics in the last 60 days
Diarrhoea, Fever, Leucocytosis
Send stool sample for C. Difficile

54
Q

When is UTI likely to be the cause of sepsis.
When should antibiotics be started in UTI

A
  1. Obstructive uropathy
  2. Recent Urological manipulation/instrumentation
  3. Neutropaenic patients

Catheter associated bacturia or candiduria usually represents colonization and is rarely the cause of fever and secondary bloodstream infection.

Start antibioitics if cultured at two different sites Urine AND BLood

55
Q

Summarise the non-infections causes of fever

A

SIRS (Pancreatitis)
Drugs (any drug)
Post-op (FIrst 72 hours)
VTE

Intensive Care (22 decks)

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