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Therapeutics IV > Sepsis - Block 2 > Flashcards

Sepsis - Block 2 Flashcards

1
Q

What is sepsis?

A

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

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2
Q

What is sepsis-induced hypotentions?

A

SBP: 90
MAP: <70

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3
Q

How does septic shock diffeer from septic hypotension?

A

MAP <65 requiring vasopressor, elevated lactate >2 post adequate fluid resuscitation (30mL/kg of crystalloids)

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4
Q

What are the presentations of septic tissue hypoperfusion?

A
  1. Hypotension
  2. Elevated lactate
  3. Oliguria
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5
Q

What type of shock is septic?

A

Vasodilatory/distributive

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6
Q

What mediators are released due to septic shock?

A

Pro-inflammatory: TNF, IL1,6, 12
Anti-inflammatory: IL-ra, 4, 10

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7
Q

Describe the components the sepsis cascade?

A

Proinflammatory -> inflamed tissue -> endothelial cells allow granulocytes and plasma entering inflamed tissue leading to:
* Arterioles become less responsive VC to VD -> hypotension -> shock
* Multi-organ damage

TNF and pro-inflammatory facotrs promote pro-coag and antifibrinolytic -> DIC

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8
Q

Complications of sepsis?

A
  1. DIC
  2. Shock (hemodynamic effects)
  3. Multi-organ failure (AKI, ARDS-increased capillary permeability and alveolar epithelial cell injury -> edema and alveolar collapse)
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9
Q

RF of sepsis?

A

Young and advanced age
Pre-existing conditions:
1. HF
2. Diabetes
3. COPD
4. Cirrhosis
5. Alcohol dependence
6. ESRD
7. Immunocompromised

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10
Q

Pathogens associated with sepsis?

A
  1. E. coli
  2. Staph aureus
  3. Staph epidermis
  4. Enterococcus
  5. Candida albicans
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11
Q

What are factors that can determine the recovery time from sepsis?

A
  1. IA infection secondary to ischemic bowel
  2. Increased mortality rate:
    * Advance age
    * AKI (CKD3)
    * Cadidemia
    * Serum lactate >4 for >24hrs
    * Increased failing organs
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12
Q

Vitals associated with sepsis?

A
  1. > 100.4 or <96.8
  2. Tachycardia >90
  3. Hypotension: <90/70
  4. Tachypnea: >22
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13
Q

inflammatory variables associated with sepsis?

A

Leukocytosis: WBC >10
Leukopenia: WBC <4
Procalcitonin: >0.5

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14
Q

Coagulation labs associated with sepsis?

A

INR >1.5
Aptt >60s
Thyrombocytopenia <100,000

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15
Q

Tissue perfusion labs associated with sepsis?

A

Lactate >1
Capillary refill decrease

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16
Q

Presentations of kidney dysfunction due to sepsis?

A

AKI: Creatine increase >0.3 mg/dL or 1.5-1.9 x from the baseline; acute oliguria (urine output < 0.5 ml/kg/hour and > 2hours despite adequate fluid resuscitation)

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17
Q

Presentations of liver dysfunction due to sepsis?

A

Bilirubin >2
AST and ALT elevated

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18
Q

Presentations of lung dysfunction due to sepsis?

A

Arterial hypoxemia

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19
Q

Presentations of CNS dysfunction due to sepsis?

A

AMS Glasgow coma scale (6-15)

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20
Q

Describe the Glasgow coma scale score?

A

Best: 15
Severe: ≤8
Deep coma: 3

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21
Q

What is the screening tool used for sepsis using labs and organ functionality?

A

SOFA score

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22
Q

What are the components of qSOFA?

A
  1. AMS <15
  2. RR >22
  3. SBP <100

Sepsis -> ≥2

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23
Q

What are the components of a 1hr bundle?

A
  1. Measure lactate level -> repeat in 2hrs if >2
  2. Obtain cultures (blood, urine, sputum) prior to ABX
  3. Empiric ABX within 1 hr
  4. Rapid administration 30mL/kg crystalloid for hypotension or lactate ≥4
  5. Vasopressor during or post fluid resuscitation to maintain MAP >65
24
Q

What are the method used to identify a septic pathogen and diagnosis?

A
  1. Urine culture (UA first), Blood culture
  2. Xray
  3. Lumbar puncture
  4. CBC and serum lactate
  5. Urine output
25
Initial envaluation of LRT
Sputum, rapid influenza testing, urinary antigen testing, bronchoalveolar lavage
26
Initial envaluation of UT?
Urine culture
27
Initial envaluation of vascular catheters?
Blood culture, culture of catheter tip if removed
28
Initial envaluation of CNS?
CSF count, protein, glucose, Gram stain, culture
29
Initial envaluation of GI?
Stool culture for Salmonella, Shigella, or Campylobacter
30
Initial envaluation of IA?
Culture from percutaneuosly or surgically drained ab fluid collections
31
Initial envaluation of PD cath?
Cell count and culture of PD fluid
32
Initial envaluation of bone?
Blood cultures, MRI, bone cultures at surgery or interventional radiology
33
Initial envaluation of joint?
Arthrocentesis with cell counts, Gram stain, and culture
34
What are the treatment approaches for sepsis?
1. Initial resuscitation (MAP>65, lactate <2) - fluid and vasopressor 2. Infection control (empiric antimicrobial therapy +/- antifungal therapy) 3. Supportive care
35
How do you initiate fluid resuscitation in a patient?
In the presence of hypotension, initiate 30mL/kg (IBW) of IV crystalloids within 1 hr (copleted in first 3 hr) **Types of balanced crystalloids:** 1. NS (can cause acidosis through hyperchloremia) -> only in trauma brain edema 2. LR 3. Plasma-Lyte Colloid albumin for those who have already recieved large amounts of crystalloids and still require fluid
36
Dopamine activity?
**Low:** d **Med:** b1 **High:** a1
37
Epinephrine activity?
a1=b1>b2
38
Norepinephrine activity?
a1>b1>b2
39
Phenylephrine activity?
a1 | Can cause reflexive bradycardia
40
Describe the selection of vasopressors for sepsis?
**1st:** NE **2nd:** VP or E **3rd:** Hydrocortisone IV * **Alt** * PE (PV constriction reflective bradycardia) * Dopamine (arrythmia) **Refractory after max VP:** Giapreza (Angiotensin II)
41
Empiric coverage tx?
Vancomycin + Zosyn **(suspected intraabdominal, aspiration)** Vancomycin + cefepime **(not for aspiration and anaerobes)**
42
Empiric ABX for those with a hx of MDR?
**ESBL within 12 months:** Vancomycin + Carbapenem **PA within 3 months:** Vancomycin + Cefepime + different PA ABX class (FQ)
43
What do you do after confirming the infection type and site?
Deescalate/switch ABX to target site infection
44
Definitive tx for CA UT infection? HA?
Ceftriaxone
45
Definitive tx for CA RT infection? HA?
**CA:** ceftriaxone + azithromycin **HA:** Zosyn (if aspiration) or cefepime + Vanc
46
Definitive tx for CA Intra-ab infection? HA?
**CA:** * ZOsyn * Ceftriaxone + metronidazole * Cipro or Levo + metronidazole **HA:** * Zosyn * Cefepime + metronidazole
47
Definitive tx for CA skin soft infection? HA?
**CA:** Vancomycin **HA:** Vanc + zosyn in extensive wound
48
Definitive tx for CA catheter related infection? HA?
**CA:** none **HA:** vanc
49
What are the RF of fungal infection?
1. Febrile neutropenic pateints after 4-7 days of broad-spec ABX 2. Immunocompromised status 3. Fungal colonization 4. CS
50
What is the most common fungal infection?
Candidiasis
51
What are the antifungal parenteral agents?
1. Echinocandins 2. IV triazoles 3. A formulation of amphotericin B
52
What are the empiric antifungal tx for sepsis?
**Echinocandin:** anidulafungin, micafungin, caspofungin **Triazole (hemodynamical stable and not previous triazole exposure):** fluconazole, voriconazole
53
How often should ABX tx be assessed?
Daily for potential de-escalation
54
Duration of ABX tx?
**ABX:** 7-10 days **Fungal:** 10-14 days
55
What is the supportive tx for VTE prophylaxis?
1. Heparin 2. Enoxaparin (preferred)
56
What is the supportive tx for stress ulcer prophylaxis?
1. PPI (preferred) 2. H2RA
57
What is the supportive tx for glucose control?
Insulin when BG >180, targeting an upper BG <180

Therapeutics IV (39 decks)

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