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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
Q

Initial envaluation of LRT

A

Sputum, rapid influenza testing, urinary antigen testing, bronchoalveolar lavage

26
Q

Initial envaluation of UT?

A

Urine culture

27
Q

Initial envaluation of vascular catheters?

A

Blood culture, culture of catheter tip if removed

28
Q

Initial envaluation of CNS?

A

CSF count, protein, glucose, Gram stain, culture

29
Q

Initial envaluation of GI?

A

Stool culture for Salmonella, Shigella, or Campylobacter

30
Q

Initial envaluation of IA?

A

Culture from percutaneuosly or surgically drained ab fluid collections

31
Q

Initial envaluation of PD cath?

A

Cell count and culture of PD fluid

32
Q

Initial envaluation of bone?

A

Blood cultures, MRI, bone cultures at surgery or interventional radiology

33
Q

Initial envaluation of joint?

A

Arthrocentesis with cell counts, Gram stain, and culture

34
Q

What are the treatment approaches for sepsis?

A
  1. Initial resuscitation (MAP>65, lactate <2) - fluid and vasopressor
  2. Infection control (empiric antimicrobial therapy +/- antifungal therapy)
  3. Supportive care
35
Q

How do you initiate fluid resuscitation in a patient?

A

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
Q

Dopamine activity?

A

Low: d
Med: b1
High: a1

37
Q

Epinephrine activity?

A

a1=b1>b2

38
Q

Norepinephrine activity?

A

a1>b1>b2

39
Q

Phenylephrine activity?

A

a1

Can cause reflexive bradycardia

40
Q

Describe the selection of vasopressors for sepsis?

A

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
Q

Empiric coverage tx?

A

Vancomycin + Zosyn (suspected intraabdominal, aspiration)
Vancomycin + cefepime (not for aspiration and anaerobes)

42
Q

Empiric ABX for those with a hx of MDR?

A

ESBL within 12 months: Vancomycin + Carbapenem
PA within 3 months: Vancomycin + Cefepime + different PA ABX class (FQ)

43
Q

What do you do after confirming the infection type and site?

A

Deescalate/switch ABX to target site infection

44
Q

Definitive tx for CA UT infection? HA?

A

Ceftriaxone

45
Q

Definitive tx for CA RT infection? HA?

A

CA: ceftriaxone + azithromycin
HA: Zosyn (if aspiration) or cefepime + Vanc

46
Q

Definitive tx for CA Intra-ab infection? HA?

A

CA:
* ZOsyn
* Ceftriaxone + metronidazole
* Cipro or Levo + metronidazole

HA:
* Zosyn
* Cefepime + metronidazole

47
Q

Definitive tx for CA skin soft infection? HA?

A

CA: Vancomycin
HA: Vanc + zosyn in extensive wound

48
Q

Definitive tx for CA catheter related infection? HA?

A

CA: none
HA: vanc

49
Q

What are the RF of fungal infection?

A
  1. Febrile neutropenic pateints after 4-7 days of broad-spec ABX
  2. Immunocompromised status
  3. Fungal colonization
  4. CS
50
Q

What is the most common fungal infection?

A

Candidiasis

51
Q

What are the antifungal parenteral agents?

A
  1. Echinocandins
  2. IV triazoles
  3. A formulation of amphotericin B
52
Q

What are the empiric antifungal tx for sepsis?

A

Echinocandin: anidulafungin, micafungin, caspofungin
Triazole (hemodynamical stable and not previous triazole exposure): fluconazole, voriconazole

53
Q

How often should ABX tx be assessed?

A

Daily for potential de-escalation

54
Q

Duration of ABX tx?

A

ABX: 7-10 days
Fungal: 10-14 days

55
Q

What is the supportive tx for VTE prophylaxis?

A
  1. Heparin
  2. Enoxaparin (preferred)
56
Q

What is the supportive tx for stress ulcer prophylaxis?

A
  1. PPI (preferred)
  2. H2RA
57
Q

What is the supportive tx for glucose control?

A

Insulin when BG >180, targeting an upper BG <180

Therapeutics IV (39 decks)

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