Sepsis

Question 1

What is the old Definition of Sepsis?
• are positive blood cultures needed?

Answer 1

Systemic Inflammatory Response Syndrome (SIRS) + Infection (proven or suspected) = SEPSIS

• NO - positive blood cultures are not need to prove sepsis, in fact only 15-20% of the people we call septic have bacteremia.

Question 2

Are men or women more likely to get septic?
• what about white/non-white?

Answer 2

Men are MORE LIKELY to get septic
Non-whites are MORE LIKELY to get septic

Question 3

The annual incidence of sepsis has increased in recent years, what organisms have seen the greatest increase in the rate of sepsis?
• Has the death rate from sepsis increased or decreased? what about in hospital mortality?

Answer 3

• Fungal organisms have increased by 207%
• Total number of deaths related to sepsis has also increased, BUT In Hosptial Mortality has DECREASED and Average length of the hospital stay has DECREASED

Question 4

New definition of sepsis:
Life-threatening organ dysfunction caused by a dysregulated host response to infection

Question 5

***What are the 4 things to look for to see if someone has SIRS (systemic inflammatory response syndrome)?***

Answer 5

1. Temperature greater than 38 degrees or less than 36 degrees

2. Heart Rate greater than 90 bpm

3. Tachypnea, Respiratory Rate greater than 20

4. WBC greater than 12,000 or less than 4000

Question 6

T or F: Transfusion of BLOOD PRODUCTS is one of the most important non-infective causes of SIRS.

Answer 6

True

Question 7

What are some important reasons that someone could be septic and not be febrile?

Answer 7

• Any Reason for an Underactive Immune System (Elderly, NEONATES, Immunocompromized, corticosteroid use, DIABETES)
• Chronic Kidney Disease
• NSAID/Acetaminiphen use
• NEUROLOGIC INSULTS - strokes, brain malformaitons

Question 8

Why should we not treat fever until it meets a threshold?

Answer 8

Fever enhances phagocytosis and Antibody binding, etc.

Question 9

Indetermining if someone is septic, what is the most subjective of the vital signs?

Answer 9

Respiratory Rate is always the most subjective

Question 10

What is needed to meet the criteria of SEVERE sepsis?

Answer 10

severe sepsis = sepsis + organ dysfunction or evidence of Hypoperfusion/Hypotension

Question 11

What defines septic shock?
• how do we treat it?

Answer 11

Septic shock = sepsis + Hypotension that persists despite adequte fluid resuscitation

Treatment: VASOPRESSORS

Question 12

Do you expect someone to experience bradycardia or tachycardia during septic shock, why?

Answer 12

Vasodilation + Edema = Hypotension

Carotid Sinus and other sensors should respond by increasing HR = >TACHYCARDIA

Tachycardia is good, its the normal physiological response, BRADYCARDIA is a bad prognostic indicator

Question 13

T or F: mental status change in sepsis is normal and not associated with outcome.

Answer 13

FALSE, mental status change in sepsis patients is associated with POOR OUTCOME

Question 14

What are some of the clinical manifestations of sepsis?

Answer 14

Fever, Tachycardia, Tachypnea, Increase in Minute Ventilation (measurable on ventilator), hypotension, Mental Status Change, N/V, loss of appetite (not good)

Question 15

What are some physiologic reasons to see tachypnea in sepsis?

Answer 15

Metabolic Requirement of the body are high and its producing a lot of CO2 that is tripping the H+ receptor in the brain

In pts. with pneumonia it could be tripping the J-receptor

Question 16

***What are the 4 keys to Goal Directed Rescscitation?***

Answer 16

1. Central Venous Pressure: 8-12 mmHg
2. Mean Arterial Pressure: greater than 65 mmHg
3. Urine Output: greater than 0.5 ml/kg/hr
4. Central venous O2 saturation: greater than 70%

Question 17

Why is urine output of greater than 0.5 mL/kg/hr one of the main goals in resuscitation from sepsis?

Answer 17

Each Kidney recieves 10% of CO so these are good indicators of perfusion of other organs by the heart

Question 18

Once you get a sepitic patient stabilized what should be your 2 principle concerns?

Answer 18

1. What is bug is causing the Bacteremia
2. What is the source of the Bacteremia

Question 19

What is a normal Venous O2 saturation?
• how do we correct a low one in sepsis?
• what is a good surrogate of SvO2?

Answer 19

SvO2 normally is 65-75%

Surrogate = lactic acid, hypoxic tissues will start producing this

Question 20

How much does the risk of death from sepsis increase as each hour passes?

Answer 20

6-7% increase in death rate with each hour that passes

Question 21

Important Note:
• Sepsis is diagnosed by the signs and symptoms of the host response to the septic event

• This may only be evident HOURS to DAYs after the inciting event

Answer 21

Important Note:
• Sepsis is diagnosed by the signs and symptoms of the host response to the septic event

• This may only be evident HOURS to DAYs after the inciting event

Question 22

What two antibiotics are good at protecting against the production of bacterial toxins?

Answer 22

Clindamycin

Linezolid

Question 23

How should you manage shock at the following stages?
• Nidus of Infection
• Blood Stream Invasion
• Inflammatory Reaction
• Shock and Multiorgan Failure

Answer 23

Question 24

Which is better during a life-saving effort in sepsis: Saline or Albumin?
• what do you need to remember about saline?

Answer 24

Saline is better because they both confer the same survival advantage, but saline is much cheaper BUT you need to remember that it is pH 5.4 (you can make the patient acidotic)

Question 25

Why would you see a leukocytopenia and GI distress after sepsis?

Answer 25

Lack of adequate nutrition to lymph and GI tissues leads to depletion of cells because these are high turnover tissues

Question 26

Note: Normal Saline is good but BALANCED solutions are better because pH is balanced because saline can lead to a HYPERCHLOREMIC METABOLIC acidosis

Answer 26

Note: Normal Saline is good but BALANCED solutions are better because pH is balanced

Question 27

What vasopressors should be used in septic shock?
• HOW should they be used?

Answer 27

Vasopressors:
• Levophed then add Vasopressin (ADH)

• Wean off Levophed 1st
• Stepwise Reduction in Vasopressin

Question 28

What are some methods you could use to prevent sepsis?

Answer 28

• Hand Washing
• DVT prophylaxis, Early Ambulation
• Stress Ulcer Prophylaxis
• Chorhexidine Mouthwash
• Remove Foley and Central Lines ASAP
• Get glucose back down below 150 mg/dL

Question 29

FASTHUG pneumonic

Answer 29

Feeds
Analgesics
Sedation protocol
Thrombo-embolism prophylaxis
Head of bed elevated greater than 30 degrees
Ulcer Prophylaxis
Glucose Control