Sepsis Flashcards
Sepsis symptoms in adults?
SEPSIS
S= slurred speech or confusion
E= extreme shivering or muscle pain
P= passing no urine in 18 hours
S= severe breathlessness
I= it feels like you’re going to die
S= skin mottled or discoloured
What is the sepsis 6 management plan?
Give 3, Take 3 / BODFUL
- Administer high flow oxygen
- To keep sats ≥94%, 88-92% if risk of CO2 retention e.g. COPD - Take blood culture before antibiotics
- Give IV antibiotics
- Give IV fluids
- Rapid administration of 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L - Check serum lactate and haemoglobin
- Ensure HB OVER 7g/DL
- Remeasure lactate within 2-4 hours if initial lactate elevated (> 2 mmol/L)
- If lactate >4mmol/l, call Critical Care and
recheck after each 10ml/kg challenge - Measure urine output
- Ensure fluid balance chart commenced and completed hourly
Also apply vasopressors if remains hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥ 65 mm Hg.
Aim to complete in first hour.
What is the early management of Sepsis?
Take a culture/sample before initiating antibiotics
Broad spectrum antibiotic at max. recommended dose ASAP (ideally within one hour)
Clinical examinination to identify source of infection - change antibiotics as appropriate
Assess need for IV fluids, inotropes, vasopressors and oxygen - consider lactate conc., systolic BP and risk of severe illness/death
What’s typically used to treat sepsis?
Tazobactam STAT
and gentamicin
How often should high risk patients be monitored?
Continuously if possible
At least every 30 minutes
What are the RED flag symptoms for sepsis?
Sepsis 6 pathway should be started if how many of them are present?
- Responds only to voice or pain/unresponsive
- Acute confusional state
- Systolic B.P ≤ 90 mmHg (or drop >40 from normal)
- Heart rate > 130 per minute
- Respiratory rate ≥ 25 per minute
- Needs oxygen to keep SpO 2 ≥92%
- Non-blanching rash, mottled/ ashen/ cyanotic
- Not passed urine in last 18 hrs / output <0.5 ml/kg/hr
- Lactate ≥2 mmol/l
- Recent chemotherapy
Start sepsis 6 pathway if ONE symptom if present
What are the AMBER flag symptoms for sepsis?
What should be done if they are present?
- Relatives concerned about mental status
- Acute deterioration in functional ability
- Immunosuppressed
- Trauma/ surgery/ procedure in last 6 weeks
- Respiratory rate 21-24
- Systolic B.P 91-100 mmHg
- Heart rate 91-130 OR new dysrhythmia
- Not passed urine in last 12-18 hours
- Temperature < 36ºC
- Clinical signs of wound, device or skin infection
Send bloods (FBCs, U+Es, clotting, CRP, LFTs) if TWO present (consider if only one)
Needs senior review within 1 hour
What should be done if a patient has amber flag symptoms but is found to be in AKI?
Start sepsis 6 pathway
For an amber flag patient, when should a decision on antimicrobial treatment be made?
3 hours
When should critical care outreach be contacted?
If after delivering the Sepsis Six, patient still has:
* systolic B.P <90 mmHg
* reduced level of consciousness despite resuscitation
* respiratory rate over 25 breaths per minute
* lactate not reducing
Or if patient is clearly critically ill at any time
What is the FASTHUG-MAIDENS mnemonic?
What does it stand for?
A standardized, structured approach to identifying drug-related problems
in the ICU
F - Feeding
- Ensuring appropriate formulation depending if patient is feeding orally, swallowing etc.
- Assessing the possibility of an
interaction between a drug and a nutritional formulation
- Monitoring nutrition parameters
A - Analgesia
- Ensuring pain suitably controlled but not overtreated
S - Sedation
- Decision to initiate, discontinue, and adjust doses and administration route of sedative medications
- Propofol may be suitable if the patient requires only short-term sedation
- Benzodiazepines (midazolam, lorazepam) may be more appropriate if longer-term sedation is needed
T - Thromboprophylaxis
- Appropriate type of VTE prophylaxis depending on presentation
H - Hyperactive or hypoactive delirium*
- Identifying potential drug-related causes of delirium
- Assess need for antipsychotics and continued monitoring
U - Stress ulcer prophylaxis
- Patients receiving mechanical ventilation in the ICU are at risk of stress ulcers
- Prophylaxis with a PPI or H2 antagonist
G - Glucose control
- Identify drug-related causes such as
glucocorticoids, propofol, and atypical antipsychotics
- Initiation of appropriate treatment
M - Medication reconciliation
- Accurate medication history
- For many patients, medications taken before admission are not restarted
because acute medical conditions preclude their use
- Identifying discontinued medications for
which there is a high risk of experiencing withdrawal symptoms (e.g., benzodiazepines and SSRIs). Typically, these medications should be restarted as
soon as possible to reduce complications.
A - Antibiotics or anti-infectives
- Antimicrobial stewardship and therapeutic dose monitoring
I - Indications for medications
- Any medication that is no longer indicated should be discontinued
D - Drug dosing
- Suggest dose adjustments based on clinical parameters
E - Electrolytes, hematology, and other
laboratory results
- Monitor patients for drug-related causes of abnormalities and discuss treatment alternative
N - No drug interactions, allergies, duplications, side effects
S - Stop date
- Discuss the appropriate duration of medications
How are pharmacokinetics changed in people with sepsis?
In sepsis, increased cardiac output and interstitial fluid shifts (due to increased capillary leakage) induce a larger volume of distribution (Vd), which may decrease antibiotic plasma levels
Peripheral effusions, the use of
drains or extra-corporeal circuits may further change the distribution of antibiotics.
Decreased protein binding, as
observed with hypoalbuminemia, can result in higher free-drug concentration and increased total clearance
Renal blood flow may also be increased
Organ dysfunction, however, may reduce clearance
Delayed antimicrobial administration increases the risk of death in hypotensive patients by what percentage for every additional hour without antibiotic?
7%
The changes in pharmacokinetics of septic patients mainly affect what type of drugs?
Hydrophilic compounds
- aminoglycosides, β-lactams and glycopeptides
As they have a small Vd (limited to extracellular fluids) and are more
likely to be excreted unchanged by the kidneys.
Thus, adequate dosing for these drugs should be reconsidered to avoid under and overdosing.
Describe the PK/PD relationship of:
- B-lactams (penicillins, monobactams,
cephalosporins, and carbapenem)
Effective against gram negative bacteria
A better control of the infection is
achieved when B-lactam concentrations are maintained above the MIC for extended period of time
- Require multiple daily dosing
The concentration of the drug should be > 4 times the MIC for at least 70%, 50% and 40% of the dosing intervals for cephalosporins, penicillins and carbapenems respectively
Describe the PK/PD relationship of:
- Aminoglycosides (gentamicin, streptomycin, neomycin, tobramycin, amikacin)
Effective against Pseudomonas
C max /MIC between 8 - 10 was the major
determinant for optimal antibacterial activity and clinical response
Significant post antibiotic effect (PAE, continued inhibition of bacterial growth even for drug concentrations below the MIC)
- Single daily dosing
Higher than usual doses needed in septic patients
Monitoring via measuring trough levels
Describe the PK/PD relationship of:
- Glycopeptides (vancomycin and teico-
planin)
Effective against gram positive bacteria, including Staphylo-
coccus aureus and epidermidis or Enterococcus spp
Cmin monitoring is the most accurate and
practical method to adjust vancomycin regimens
Cmin more than 15–20 μg/mL is needed to
ensure efficacy of the drug.
Administration of the conventional dose of vancomycin (15 mg/kg of body weight
every 12 h) would probably fail to achieve therapeutic drug concentrations in the majority of critically ill patients.
Therefore, 30 mg/kg daily dosage has been
proposed to optimize PD vancomycin
However, the efficacy of vancomycin is limited by the poor penetration into solid organs, particularly the lung or central nervous system
