Sepsis Flashcards
What is the definition of sepsis?
Systemic Inflammatory Response Syndrome (SIRS) due to infection (proven or suspected)
do you need a positive blood culture for the dx of sepsis?
no
what happened (need a number) to the rate of sepsis due to fungal organisms from 1979 to 2000?
the rate of sepsis due to fungal organisms increased by 207%
what happened to the total in-hospital mortality rate from 1979-2000?
it fell
what happened to the average length of the hospital stay from 1979-2000?
it decreased
besides aging, what is another big reason why incidence of fungal infections is increasing?
overuse of antibiotics - inhibit normal flora, allow Candida to grow
why has length of hospital stay decreased recently? (might help to remember why)
insurance companies are urging to get shorter length of stay
what diagnostic criteria does our definiton of Sepsis (SIRS + infection) lack?
it lacks sensitivity and specificity
what are the SIRS criteria?
two or more of the following
1) Temp >38 C or less than 36 C
2) HR greater than 90 bpm
3) Tachypnea, RR >20
4) WBC >12,000 or less than 4,000 or > 10% bands
what is the association of fever and sepsis?
most pts in whom sepsis develops do not become febrile
they do not have a robust enough immune system t
what are 7 examples of afebrile infections?
1) extremes of age
2) immunocompromised
3) corticosteroid use **
4) NSAID/acetaminophen use **
5) CKD
6) diabetes
7) neurologic insults - strokes, brain malformations
which vital sign is the major practical flaw in recording vital signs
respiratory rate (it is subjective ish - all pts are 20 b/c nurses don’t actually measure this)
define severe sepsis
sepsis + organ dysfunction or evidence of hypoperfusion or hypotension
define septic shock
sepsis-induce hypotension
persisting despite adequate fluid resuscitation
how do we know, how can we determine that there is hypotension, leading to end organ ischemia, in the setting of septic shock
measure the level of lactic acid in the blood
if there is end organ ischemia, they will be in anaerobic metabolism, so generating lactic acid
what does septic shock require as treatment
vasopressors
what is Muthiah’s simplistic definition of the pathogenesis of septic shock leading to death?
an excessive host immune response to insult/infection that causes tissue injury - shock and multiorgan failure - and death
what are 9 clinical manifestations of sepsis?
1) fever
2) tachycardia
3) tachypnea
4) increase in minute ventilation *
5) hypotension
6) mental status change*
7) nausea, vomiting
8) loss of appetite
9) ICU pts not tolerating feeds
what is the pathogenesis of why shock is accompanied by hypotension?
vasodilation is a characteristic feature of shock - this causes some hypotension b/c of pressure volume relationship
also, vessels become more leaky, and there is hypovolemia
which pts is the mental status change in shock most noticeable in
neonates and the elderly
what is the term/buzzword for the perspective of early resuscitation that is applied to severe sepsis and septic shock regarding time frame
silver day
what are the 4 goals of goal directed resuscitation? (red box, must know)
1) central venous pressure 8-12 mm Hg
2) mean arterial pressure >65 mm Hg
3) Urine output >0.5 mL/kg/hr
4) central venous O2 saturation >70%
what are two other important points to add on w/ the goal directed resuscitation of a pt in sepsis
1) source control
2) don’t stop when you have Bacteremia - need to know where the bacteria is coming from
we must give antibiotics early when suspected sepsis - how much does each hour delay in antibiotics increase mortality?
6-7 % immediate ABX - 20% mortality 1 hour delay - 27% mortality 3 hour delay - 44% 5 hour delay - 58%
severe sepsis with hypotension necessitates the need for what medication, and what is the side effect of this?
vasopressors
causes dry gangrene of extremities and digits
what are the 4 main categories for lab work that we want to gather in suspected sepsis?
1) gram stain and culture of appropriate body fluids
2) blood cultures x2 - peripherally and through a vascular access device while present
3) appropriate imaging - CXR, CT scan, HIDA scan, etc
4) a good H and P will direct investigation
do a majority of pts w/ sepsis get a positive blood culture?
no - most of the time will not be able to get positive culture
(bacteremia is an episodic phenomenon)
early goal directed resuscitation…
saves lives
what is the most optimal and cost effective fluid for resuscitation?
normal saline
for septic shock, a pt that is already volume resuscitated, and is on vasopressors, what additional medication can you give them? (I doubt this will show up, but it is in critical care guidelines)
hydrocortisone
has been shown to decrease mortality
what is a good preventive care against infection?
hand washing
what is the pH of “normal saline”? what are 3 effects of this
nml saline pH = 5.4
1) NS - hyperchloremia and metabolic acidosis
2) alterations in renal blood flow
3) potentially important effects on immune function
what is more desirable than normal saline for volume resuscitation
balanced fluids - like Ringer’s lactate
choice of vasopressors between Levophed and Dopamine
Levophed is better
For the Exam: sepsis = ?
SIRS + infection
For the Exam: severe sepsis =?
Sepsis + organ dysfunction
for the Exam: septic shock = ?
sepsis + hypotension not responding to fluid resuscitation
For the Exam: what is the resuscitation fluid of choice?
crystalloids = saline + Lactate Ringer’s
For the Exam: what does Early Goal Directed Therapy do?
improves mortality
For the Exam: What are two general things for the EGDT (not the specific 4 components)
early antibiotics
source control
For the Exam: who gets afebrile infections?
very young / old
CKD
DM
Steroid use
For the Exam: the pathogenesis of sepsis is a considered a condition associated with what in the host?
profound initial immune activation
For the Exam: what do we see elvated in the blood with sepsis?
Pro-inflammatory cytokine levels are elevated along with neutrophilic leukocytosis
For the Exam: what is the criteria for SIRS (systemic inflammatory response syndrome)
two or more of
1) temp >38C or less than 36C
2) HR >90 bpm
3) tachypnea, RR >20
4) WBC count >12,000 or less than 4,000 or > 10% bands
For the Exam: what are the 4 goals of EGDT?
1) Central venous pressure: 8-12 mm Hg
2) MAP >65 mm Hg
3) urine output >0.5 mL/kg/hr
4) central venous O2 saturation >70%
For the Exam: what is a good surrogate for inadequate oxygen delivery?
lactic acid elevation - therefore a low central venous O2 sat
For the Exam: what are 8 preventative measures in sepsis?
1) hand washing
2) DVT prophylaxis
3) Stress ulcer prophylaxis (H2 blocker vs PPI)
4) head of bed elevation to prevent VAP/HAP
5) Chlorhexidine mouthwash?
6) remove Foley catheter and central lines ASAP
7) early ambulation and physical therapy
8) target glucose less than 150 mg/dL
Have your pts been FASTHUG ed?
Feeds Analgesics Sedation protocol Thromboembolism prophylaxis Head of bed elevated >30 deg Ulcer prophylaxis Glucose Control
Clicker - autopsy, immunohistochemical studies in sepsis have shown which of the following cell lines to be dying?
lymphocytes and GI epithelial cells
