Sepsis and Septic Shock

Question 1

Sepsis-3 Definition (2016)

Answer 1

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

Question 2

Septic Shock
(Distributive shock)

Answer 2

Subset of sepsis in which profound circulatory, cellular, and metabolic abnormalities are associated with a great risk of mortality
Need for vasopressor to maintain mean arterial pressure (MAP) ≥65 mmHg despite adequate fluid resuscitation
Lactate >2 mmol/L

Question 3

Fluid Resuscitation

Answer 3

Provide fluid therapy to increase intravascular volume and venous return
Crystalloids
Dynamic

Question 4

Fluid Resuscitation - Amount of fluid

Answer 4

30 mL/kg within the first 3 hours of resuscitation

Question 5

Fluid Resuscitation - Type of Fluid

Answer 5

First-line fluid for resuscitation = Crystalloids

Question 6

When to use albumin for fluid resuscitation?

Answer 6

Patients who already received a significant amount of crystalloids and at risk of volume overload

Question 7

Which crystalloid is suggested and why?

Answer 7

balanced crystalloids (lactated ringers)
Concern for normal saline and its potential harm related to hyperchloremic metabolic acidosis leading to renal failure

Question 8

Fluid Resuscitation - Assessment of Fluid Responsiveness

Answer 8

Passive leg raise - Allowing the blood from the legs to act as a fluid bolus back to the heart

Question 9

MAP

Answer 9

Mean Arterial Pressure
MAP ≥65 mmHg is needed for adequate perfusion
MAP = 1/3 SBP + 2/3 DBP

Question 10

Lactate

Answer 10

Blood Lactate
Metabolic product of anaerobic metabolism
Biomarker for global tissue hypoxia
Lactate > 2 mmol/L: global hypoperfusion

Question 11

Initial management of sepsis and septic shock

Answer 11

Surviving Sepsis Campaign (SSC) Hour-1 Bundle
Measure lactate level (Re-measure if initial lactate >2 mmol/L)
Obtain blood and other relevant cultures
Administer broad-spectrum antibiotics
Rapidly administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L
Start vasopressors if hypotensive during or after fluid resuscitation to maintain mean arterial pressure (MAP) ≥ 65 mmHg

Question 12

Alpha-1 (α1) Tissue

Answer 12

Vascular smooth muscle

Question 13

Alpha-1 (α1) Stimulation of Receptor

Answer 13

Vasoconstriction

Question 14

Beta-1 (ꞵ1) Tissue

Answer 14

Heart

Question 15

Beta-2 (ꞵ2) Tissue

Answer 15

Bronchial smooth muscle
Vascular smooth muscle

Question 16

Vasopressin-1 (V1) Tissue

Answer 16

Vascular smooth muscle

Question 17

Vasopressin-2 (V2) Tissue

Answer 17

Kidneys

Question 18

Angiotensin-1 (AT-1) Tissue

Answer 18

Vascular smooth muscle
Kidneys

Question 19

Beta-1 (ꞵ1) Stimulation of Receptor

Answer 19

Increased HR and contractility

Question 20

Beta-2 (ꞵ2) Stimulation of Receptor

Answer 20

Bronchodilation
Vasodilation

Question 21

Vasopressin-1 (V1) Stimulation of Receptor

Answer 21

Vasoconstriction

Question 22

Vasopressin-2 (V2) Stimulation of Receptor

Answer 22

Fluid retention

Question 23

Angiotensin-1 (AT-1) Stimulation of Receptor

Answer 23

Vasoconstriction
Fluid and sodium retention

Question 24

Norepinephrine Receptors

Answer 24

α1, ꞵ1

Question 25

First line Vasopressor

Answer 25

Norepinephrine

Question 26

Epinephrine Receptors

Answer 26

α1, ꞵ1, ꞵ2

Question 27

First alternative or an add-on to norepinephrine

Answer 27

Epinephrine

Question 28

Epinephrine adverse effects

Answer 28

Tachyarrhythmias (beta-1 stimulation) Lactic acidosis (beta-2 stimulation) Hyperglycemia (beta-2 stimulation)

Question 29

Dopamine Receptors

Answer 29

Dose-dependent activity Low dose (1-3 mcg/kg/min): DA Medium dose (3-10 mcg/kg/min): ꞵ1 High dose (10-20 mcg/kg/min): α1, ꞵ1

Question 30

Dopamine place in therapy

Answer 30

Not preferred (risk of arrhythmias)

Question 31

Phenylephrine Receptors

Answer 31

α1

Question 32

Phenylephrine place in therapy

Answer 32

In select patients who may not tolerate other vasopressors (e.g. tachyarrhythmia on norepinephrine) Mostly used as salvage therapy

Question 33

Vasopressin receptors

Answer 33

V1, V2

Question 34

Vasopressin place in therapy

Answer 34

Add-on to norepinephrine To further increase MAP to target To decrease norepinephrine requirements

Question 35

Angiotensin II

Answer 35

AT-1, AT-2

Question 36

Angiotension II place in therapy

Answer 36

Unclear; Reserved for only select patients Approved indication: septic/distributive shock

Question 37

Vasopressin Efficacy Monitoring Parameters

Answer 37

Mean arterial pressure (MAP) Heart rate (HR) Infusion rates Resolution of shock (signs and symptoms)

Question 38

Vasopressin Safety Monitoring Parameters

Answer 38

Line access (central vs. peripheral) Extravasation (antidote: phentolamine) Peripheral vasoconstriction Electrocardiogram (ECG) and telemetry Adverse events associated with each vasopressor

Question 39

Vasopressin Adjunct therapies

Answer 39

Corticosteroids Hydrocortisone 50 mg IV Q6H For septic shock not responsive to fluid resuscitation and increasing vasopressors IV Vitamin C Not Recommended

Question 40

Supportive Care

Answer 40

VTE Prophylaxis Stress Ulcer Prophylaxis Glucose Management Nutrition Support (Maybe add more or separate here)