Sepsis

Question 1

SIRS Criteria

Answer 1

T < 36C or T > 38C
HR > 90
RR > 20 or PaCO2 < 32
WBC < 4k or WBC > 12k or >10% bands

SIRS = 2 or more

Question 2

Sepsis Definition

Answer 2

SIRS + documented infection

Question 3

Severe Sepsis vs Septic Shock

Answer 3

Severe Sepsis: Sepsis associated w organ dysfunction, organ hypoperfusion, or hypotension

Septic Shock: Sepsis-induced hypotension despite adequate IVF along w organ hypoperfusion

Question 4

Most common bacteria in sepsis

Answer 4

1. GPC - S. aureus, CoNS, Enterococci, Strep
2. GNR - E. coli, Klebs, Pseudomonas
3. Fungi - 5% of cases, commonly Candida

Question 5

Empiric Abx timing and outcomes

Answer 5

Some studies show each hour of delay in starting Abx is assoc w 7.6% decreased survival

Question 6

Empiric Abx for Sepsis

Answer 6

Cefep/Ceftaz/CTX vs Carbapenems vs Zosyn are equally effective single agents (cover both GPC & GNR)
Vanc for GPC in MRSA endemic areas
Nosocomial risk factors - Zosyn (covers Psa) or antipseudomonal ceph + quinolone (eg. Ceftaz + Cipro)

Question 7

Empiric antifungals in Sepsis

Answer 7

Fungal infections occur too infrequently to warrant empiric coverage (unless there is a clear predisposition like neutropenia, immunosuppressed, etc)

Question 8

Objective findings c/w hypovolemia and organ hypoperfusion

Answer 8

MAP < 65
CVP < 8
Mixed venous O2 sat < 70%
Lactate > 2
UOP < 0.5 mL/kg/hr
Tachycardia

Question 9

Early Goal-Directed Therapy

Answer 9

Using a combination of IVF, pressors, other meds to achieve goals of:

MAP > 65
CVP > 8
SvO2 > 70%
Lactate > 2
UOP > 0.5 mL/kg/hr
Tachycardia

Question 10

Choice of fluid for resuscitation

Answer 10

Options: Crystalloids (NS, LR); Natural Colloids (alb) ; Synthetic Colloids (dextrans, gelatins, hydroxyethyl starch); Blood Products

No real concensus on whether one is the best.

Blood products are disfavored b/c TRICC results and risk of infxn

Question 11

Major outcomes of the Rivers study (Early Goal-Directed Therapy)

Answer 11

After 6hrs, EGD pts had better organ dysfxn scores, lower lactate, higher pH, higher BPs, lower HRs
After 6hrs, EGD pts required less mechanical ventilation or pressors
28- and 60-day mortalities reduced by 1/3 in EGD pts

Question 12

Why do Early-Goal Directed pts have better outcomes?

Answer 12

Two possibilities:

1. Administering IVF & pressors early sustains pts during acute period of greatest vulnerability
2. Improved O2 delivery w inotropes and transfusions improves outcomes

Most clinicians feel that (1) plays a much larger role given the negative results of past trials w dobutamine in sepsis

Question 13

Central vs Mixed Venous O2 saturation

Answer 13

Central - measured using central line
Mixed - from PA catheter; often used as proxy for CO
Central usually 5% lower than Mixed

Question 14

Surviving Sepsis Campaign:

To be done within 3 hours

Answer 14

1. Lactate
2. BCx before Abx
3. BS Abx
4. If hypotensive or Lactate>4 -> Crystalloid (>30ml/kg)

Question 15

Surviving Sepsis Campaign:

To be done within 6 hours

Answer 15

1. Vasopressors if still hypotensive despite IVF for MAP>65
2. If MAP still low despite IVF or lactate>4, get CVP and ScVO2
3. Remeasure lactate if high

Question 16

Goal CVP and ScVO2 in sepsis

Answer 16

CVP>8

ScVO2>70%