Sepsis Flashcards
What does SIRS stand for?
Systemic
Inflammatory
Response
Syndrome
What is the criteria for SIRS?
At least 2 or more of the following:
- Fever >38˚ C
- Hypothermia < 36˚ C
- Tachycardia > 90
- Tachypnea > 20
or
- Hypocapnia < 32 Co2
or
- Need for mechanical ventilator assistance
Definition of Sepsis?
- Life threatening organ dysfunction
- Caused by a dysregulated host response to infection
What triggers sepsis?
- Pre-existing infection
- Triggers an inflammatory response
- Results in a chain reaction throughout the body’s organ systems
Organs affected in sepsis during a inflammatory response?
- Lungs
- Kidney
- Skin
- GI tract
Sepsis is defined by?
- At least 2 of the items under SIRS criteria
PLUS
- Leukocytosis
> 12K - Leukopenia
< 4K
or
- Left shift (>0%) immature band cells
AND
- Suspected or Proven infection
Definition of Septic Shock?
- Subset of sepsis with profound Circulatory + Cellular/Metabolic dysfunction
Ex.
Severe sepsis + Hypotension despite adequate fluid resuscitation
What type of infection can lead to Sepsis?
Any type of infection;
- Bacterial
- Viral
- Fungal
- Parasitic
What are some risk factors for Sepsis and Sepsis Shock?
- Extreme ages
- Genetics
- Recent surgery
- Hospitalization
- Malnutrition
- Chronic Illness
- Immunosuppression
- Indwelling catheters
What are the age ranges for risk factors for sepsis and septic shock?
- Infants (Premature, Low birth weight, Maternal Group B Strep infection)
- Elderly > 65 y/o
What are some genetic risk factors for sepsis and septic shock?
- Interleukin IB-511
Increased risk of mortality from sepsis - Deficiency of Mannose Binding Lectin
Increased risk of Sepsis
What are examples of Indwelling catheters and can they cause sepsis?
- Foley Catheters
- Central lines
- Yes at higher risk of sepsis
What are some causes of sepsis?
- Respiratory 35%
Most Common - Genitourinary 25%
- GI 11%
- Skin and Soft Tissue 11%
-
What are the most common primary sites (80%) of infection causing sepsis?
- Respiratory
- Genitourinary
- GI
- Skin and Soft Tissue
What is the most common respiratory cause leading to sepsis?
- Pneumonia
- Strep and Staph
Most common site leading to sepsis in pt’s > 65
- GU tract (Genitourinary)
- DM pt’s or on broad spectrum abx
- Candida infection
Most common cause of GI sepsis?
- Poly microbial
Skin and Soft tissue causes of Sepsis?
- Cellulitis (Staph most common or Strep)
- Wounds
- Necrotizing Fasciitis
- MRSA prevalent
Less common sites of Sepsis?
- Bone and Joint (Osteomylitis, Septic Arthritis)
- CNS (Meningitis, Encephalitis, Epidural abscess)
What are the important PE exam finding sites for sepsis?
- Vitals
- Skin
- EENT
- CV
- GI
- Respiratory
- GU
- Neuro
Important SKIN PE findings for sepsis?
- Cellulitis
- IV Sites
- Catheters
- Abscesses
- Petechiae
Important EENT PE findings for sepsis?
- Mastoid tenderness
- Sinus pain pressure
- Sore throat
Important CV PE findings for sepsis?
- New Murmur
Important respiratory findings for sepsis?
- Cough
- Hemoptysis
- Rales
- Rhonchi
- Diminished breath sound
GI important PE findings for sepsis?
- Pain
- Guarding
- Rebound
- Diarrhea
GU important PE findings for sepsis?
- Indwelling catheter
- Suprapubic tenderness
- CVA Tenderness
Most common clinical manifestations for sepsis?
- Fever
- Most common presentation
What pt’s can be afebrile and still be septic?
- Elderly patients
- Debilitated
- Chronic alcohol use
- Due to their fever threshold being atypical
Other common clinical findings in septic pt’s?
- Hypotension (Very common)
- Tachcardia
- Tachypnea
- Withdrawal & Agitation (Elderly important sign - increased Lactase)
Dx of sepsis based on signs and symptoms is very concrete
T of F
- False
- S&S very variable
- Providers need to have a low threshold of suspicion
What are some key pt history components?
- Underlying disease
- Co-morbidities
- Recent antibiotic use
- Travel
- Sick contacts
Dx of sepsis is primarily based on ?
- History & PE
What do lab results and cultures provide in dx sepsis?
- Lab results = Evidence of Inflammation & Infection
- Culture = Confirms DX
Initial lab test for sepsis pt’s must include?
- Lactate (Very important, key finding)
- CBC
- Metabolic panel
- Coagualtion test
- Blood gas
- UA
- Blood cultures
- Cultures from possible sources
- Mean arterial pressure
What does the SOFA criteria evaluate in sepsis pt’s?
- Uses 6 key physiological parameters to predict mortality
- Sequential
- Organ
- Failure
- Assessment
0-4
0 = Normal 4 = Really Really Abnormal
Max score 24
What are the 6 key physiological parameters of the SOFA criteria?
- Respiratory
(O2 transfer in lungs) - Coagulation (Platelets)
- Liver
(Bilirubin count) - Heart
(MAP & Vasopressors Dopamine, Epi, NorEpi) - CNS
(GCS Score) - Kidney
(Creatinine and Urine output)
What are the SOFA respiratory ranges?
- Normal 300 - 500
< 300 Abnormal gas exchange
< 200 Severe hypoxia (Respiratory support)
Glasgow Coma Scale
- Motor (6-1)
- Verbal (5-1)
- Eye (4-1)
- 3 Min
- 15 Max
Management of sepsis consist of?
- ICU admission
- Respiratory stabilization (Intubation)
- Hemodynamic stabilization (Vasopressors)
- Source control
What must be initiated within 1 hour with a septic pt?
- Fluids with crystalloids
- Consider Vasopressors NorEpi (First Choice)
- Antibiotics AFTER collecting cultures (Decreases mortality by 33%)
What must be done within 12 hours with a septic pt?
- Source control
- D&I
- Drain abscess
- Debride tissue
- Remove infected device
How do you initiate antibiotic therapy in a septic pt?
- Initiate after culture
- Administer broad spectrum antibiotics
What are the CAP broad spectrum antibiotics used for septic pts?
Broad-spectrum β-lactam agent
- Cefotaxime
- Ceftazidime
- Cefepime
- Piperacillin-tazobactam
plus
either a respiratory Fluoroquinolone
- Moxifloxacin or Levofloxacin
or
- Azithromycin
What are the HCAP broad spectrum antibiotics used for septic pts?
- Antipseudomonal carbapenem
- Imipenem, Doripenem
or
- Meropenem
or
- Cefepime
What are the Community UTI broad spectrum antibiotics used for septic pts?
- Antipseudomonal fluoroquinolone
- Ciprofloxacin or Levofloxacin
What are the medically care associated UTI broad spectrum antibiotics used for septic pts?
- Vancomycin
plus
- Imipenem
or
- Meropenem or Cefepime
What are the Soft tissue broad spectrum antibiotics used for septic pts?
- Vancomycin
or
- Daptomycin
plus
- Imipenem
or
- Meropenem
What are the two drugs added to broad spectrum antibiotic tx for septic pts if there is flu like symptoms or C. Diff?
- Oseltamivir (Flu tx)
- Vancomycin (C. Diff tx)
Hemodynamic support for septic pts consist of?
- Fluids with crystalloids
- Vasopressors to maintain a MAP
> 65mmHg
Norepi first choice
Glycemic control of septic pts consists of ?
- Glycemic control
BGL < 180 mg/dl
What must be done within 48 hours after admission into hospital?
- DVT prophylaxis
- Stress ulcer prophylaxis
- Nutrition (oral or enteral)
Why must you have a low threshold, high suspicion of sepsis in pt’s?
- Presentation is variable
- Elderly subtle signs and symptoms
What are some atypical signs and symptoms of elderly pt’s with sepsis?
- Delirium
- Urinary incontinence
- Weakness
- Anorexia
- Falls
- Afebrile
- Tachycardia
- Hypoxemia
T or F
Minor delays in sepsis tx with elderly pt’s increases the chances of death?
- True
- Higher mortality
Overall prognosis of Severe sepsis mortality and Septic shock mortality?
- Severe sepsis mortality 30%
- Septic shock mortality 70%
Septic shock pts mortality rate increases by ______ every ______ that _______ are delayed?
- 7%
- HOUR
- Antibiotics
True or False
Identifying septic pt’s early is crucial to treatment?
- True
Fluid resuscitation & Antibiotics should be delivered within ?
- 1 Hour
What is the earliest lab key finding in helping to dx sepsis in a pt?
- Lactate measurements
What are important steps in management of a septic pt?
- Aggressive IV resuscitation
- Laboratory and Imaging studies (Infection Identification)
- Initiating empiric broad-spectrum antimicrobial therapy
- Evaluation by ICU medical team
