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2. HDS Pulmonary > Sepsis and ARDS > Flashcards

Sepsis and ARDS Flashcards

1
Q

Sepsis

Epidemiology

A
  • High mortality rate ⇒ 2-25x risk of dying
  • Mortality 20-60% depending on severity
  • Costs ~ 50k per episode of sepsis
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2
Q

Infection

Definition

A

Invasional of normally sterile tissues by microorganisms.

Inflammatory response to the presence of microorganisms.

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3
Q

Bacteremia

A

The presence of viable bacteria in the blood.

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4
Q

Sepsis

Definition

A

Life-threatening organ dysfunction caused by a dysregulated host response to infection.

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5
Q

Septic Shock

Definition

A

A subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality.

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6
Q

Sepsis

Pathophysiology

A

Normal immune processes in response to infection results in host injury via tissue injury caused by hypoperfusion and immune dysregulation.

  • Invasion of infectious pathogen with evasion of immune defenses ⇒ invasive infection
  • Immune cells signaling via inflammatory cytokines, complement, and coagulation components
  • With uncontrolled infectious process, localized inflammation becomes uncontrolled
  • Endothelial membranes throughout the body becomes activated
  • Neutrophils and platelets adhere to activated surfaces
  • Released reactive oxygen radicals cause additional endothelial damage
  • NO released ⇒ vasodilation of capillary beds ⇒ ↑ permeability
  • Intravascular fluid leaks into interstitial space
  • Systemic hypotension develops
  • Can lead to organ dysfunction and death
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7
Q

Sepsis

Diagnostic Criteria

A

Two-step evaluation:

  • Possible sepsis
    The presence of infection plus at least 2 of the following:
    • SBP ≤ 100 mmHg
    • RR ≥ 22/min
    • AMS

If ≥ 2 present, go to next step to look for organ dysfunction.

  • Sepsis
    Exists if ≥ 2 of the following markers of organ dysfunction are present:
    • Respiratory ⇒ hypoxia
    • Coagulation ⇒ thrombocytopenia
    • Liver ⇒ ↑ bilirubin
    • Cardiovascular ⇒ ↓ MAP ± vasopressor requirement
    • CNS ⇒ ↓ me
    • Renal ⇒ ↑ serum creatinine or ↓ urine output
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8
Q

Septic Shock

Diagnostic Criteria

A

Hypotension (MAP < 65 mmHg) requiring vasopressors despite adequate fluid resusitation

AND

Elevated serum lactate > 2.0 mmol/L

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9
Q

Systemic Inflammatory Response Syndrome (SIRS)

Definition

A

The body’s response to inflammation from a variety of insults.

(Both infectious and non-infectious)

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10
Q

SIRS

Diagnostic Criteria

A

Defined as presence of ≥ 2 of the following criteria:

  • Temperature > 38°C or < 36°C
  • Heart rate > 90 bpm
  • RR > 20 rpm or PaCO2 < 32 mmHg
  • WBC count > 12,000 cells/mm3 or < 4,000 cells/mm3
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11
Q

SIRS

Non-infectious Etiologies

A
  • Pancreatitis
  • Severe trauma
  • Thermal burns
  • Toxins or environmental exposures
  • Anaphylaxis
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12
Q

Sepsis

Clinical History

A

Presentation can be variable ⇒ need a high index of suspicion.

  • Any specific risks for infection
  • Recent infection / abx use
  • Recent hospitalization, procedures, or invasive devices
  • Living situation (community vs nursing home)
  • Detailed ROS looking for signs of infection and organ dysfunction
    • General ⇒ fever, chills, lethargy
    • Specific ⇒ cough, dysuria, frequency, dec. urine output
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13
Q

Sepsis

Physical Exam

A

A thorough exam guided by history:

  • Vital signs ⇒ temp, HR, RR, BP, pulse ox
    • Hypothermia ⇒ a worse prognostic sign
  • Evidence of organ dysfunction
    • AMS
    • Jaundice / scleral icterus
    • Dec. bowel sounds
    • Edema
    • Petechiae or other signs of coagulopathy
  • Evidence of infection
    • Heart murmur
    • Pulmonary findings
    • Bladder or CVA tenderness
    • Skin findings
  • Septic shock is distributive shock
    • Extremities may be warm initially
    • Eventually vasoconstriction occurs
    • Extremities become cold and mottled (cyanotic)
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14
Q

Sepsis

Etiologies

A

Bacteria are the most common cause of sepsis:

  • S. aureus
  • Group A Strep
  • E. coli
  • Klebsiella spp
  • Enterobacter spp
  • P. aeruginosa
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15
Q

Sepsis

Risk Factors

A
  • Neutropenia
  • Asplemia
  • Cirrhosis
  • Alcohol abuse
  • DM
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16
Q

Multidrug-Resistant (MDR) Organsims

Risk Factors

A
  • Prolonged hospitalization / chronic facility stay
  • Recent abx use
  • Prior hospitalization
  • Prior colonization / infection w/ MDR organisms
17
Q

Sepsis

Initial Evaluation

A
  • Consider DDx for sepsis
    • Infection
    • SIRS due to non-infectious causes
  • History and physical exam
  • Lab evaluation
    • Blood cultures ⇒ at least 2 sets before starting abx
      • Unless this will cause > 45 min delay in treatment
      • ⊕ cultures ⇒ de-escalation of abx therapy
      • Also collect sample from IV catheter if present
    • Culture any site which may be source of infection
      • CNS, urine, wound, respiratory secretions
      • Pan culture not recommended
    • CBC ⇒ look for ∆ in WBC
    • CMP ⇒ look for e/o organ dysfunction
    • Serum lactate
    • DIC panel
  • Imaging as indicated
18
Q

Sepsis

Management

A

Medical emergencies ⇒ need early recognition and immediate treatment.

  • Maintain oxygen delivery / perfusion to tissues
    • Maintain BP ⇒ MAP ≥ 65 mmHg
      • IV fluid resuscitation
      • Vasopressor agents in septic shock
    • Monitor for signs of adequte perfusion
  • Control underlying infection
    • Empiric abx treatment ⇒ within 1 hour
      • Consider host factors and local microbiology
    • Source control
      • Remove IV devices if source/possible
      • Drain abscesses if present
      • Debride wounds if present
  • Mechanical ventilation
    • May be needed to maintain oxygenation
19
Q

Acute Respiratory Distress Syndrome

Definition

A

A clinical syndrome of severe dyspnea of rapid onset with hypoxemia and diffuse pulmonary infiltrates leading to respiratory failure.

20
Q

ARDS

Epidemiology

A
  • Risk factors:
    • Older age
    • Chronic ETOH abuse
    • Metabolic acidosis
    • Severity of underlying critical illness
  • Can be caused by diffuse lung injury from multiple medical or surgical issues
  • > 80% of cases caused by:
    • Sepsis or bacterial PNA ⇒ 40-50%
    • Trauma, multiple transfusions, aspiration of gastric contents, drug OD
21
Q

ARDS

Pathophysiology

A
  • Alveolar capillary endothelial and epithelial cells injured
  • Loss of tight alveolar barrier
  • Protein rich edema fluid accumulates in interstitial and alveolar spaces
  • Hyaline membranes form and pulmonary vascular injury occurs
  • Results in severe hypoxemia and hypercapnia
22
Q

ARDS

Clinical Manifestations

A
  • Dyspnea and sensation of inability to get enough air
  • Patient exhibits tachypnea, ↑ WOB, respiratory failure
23
Q

ARDS

Evaluation

A

CXR ⇒ alveolar and interstitial opacities involving at least 75% of lungs

∆ non-specific and can look like pulmonary edema

24
Q

ARDS

Management

A

Treat underlying cause of ARDS.

Supportive care including ventilator support.

25
Q

Sepsis & ARDS

Summary

A
  • Sepsis very common & has high risk for morbidity and mortality
  • Clinical presentation can be variable - need thorough hx and physical
  • Early recognition is key to reducing mortality
    • Consider sepsis if pt presents w/ sx, signs, and/or lab abnls compatible and not explained by alt. dx, even if BP nl
  • Early aggressive fluid resuscitation and supportive care can be life-saving
  • Early tx w/ broad spectrum abx improves outcomes
  • Need to also control source of infection if possible
  • ARDS is one potential complication of sepsis

2. HDS Pulmonary (28 decks)

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