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Boards: SIRS/sepsis/MODS > Sepsis CCM 7 + 90 > Flashcards

Sepsis CCM 7 + 90 Flashcards

1
Q

What is the incidence and mortality rate of sepsis in veterinary medicine?

A
  • the incidence rate is not established
  • mortality ranges from 20-68%
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2
Q

What is the definition of Bacteremia?

A

presence of live bacterial organisms in the bloodstream

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3
Q

What is the definition of sepsis?

A

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

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4
Q

What is the definition of septic shock?

A

a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality

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5
Q

How can patients with septic shock be identified?

A

patient with signs of sepsis

PLUS

persistent hypotension requiring vasopressors to maintain MAP at or above 65 mm Hg

PLUS

serum lactate > 2 mmol/L

… despite adequate volume resuscitation

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6
Q

what is the definition of Systemic inflammatory response syndrome (SIRS)?

A

The clinical signs of systemic inflammation in response to infectious or noninfectious insults (e.g., trauma, pancreatitis, burns, snakebites, neoplasia, and heat stroke).

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7
Q

what is the definition of multiple organ dysfunction syndrome (MODS)?

A

Physiologic derangements of the endothelial, cardiopulmonary, renal, nervous, endocrine, and gastrointestinal (GI) systems associated with the progression of uncontrolled systemic inflammation and disseminated intravascular coagulation (DIC).

  • two or more organs affected
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8
Q

What are the 4 hallmarks of sepsis

A
  1. Dysregulation of vasomotor tone
  2. Increased vascular permeability
  3. Dysfunctional microcirculation
  4. Coagulation abnormalities
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9
Q

What is PIRO?

A

a concept to stage sepsis, adopted after the 2001 international sepsis definition conference

to describe clinical manifestation of the infection and the host response to it

Predisposition, Insult or Infection, Response, Organ dysfunction

not yet adapted in vet med due to lack of advanced diagnostic techniques

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10
Q

What is the most common orignin of gram negative sepsis in cats and dogs?

A

gastrointestinal and genitourinary systems

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11
Q

What is the most common origin of gram positive sepsis in dogs and cats?

A

skins, injured soft tissue, IV catheters

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12
Q

What is the most important pathogen-associated molecular pattern of gram negative bacteria?

Explain how it leads to inflammation and what receptors/cytokines/cells are involved in this pathway

A

Lipopolysaccharide (LPS) > part of the gram-negative bacterial cell wall

  • binds to lipololysacchardie binding protein (LBP) > forms LPS-LBP complex
  • LPS-LBP complex binds to macrophage membrane-bound CD14
  • macrophage activation > Toll-like receptors > signaling transfuction to the nucleus > starts transcription of inflammatory cytokines

inflammatory cytokines:

  • tumor necrosis factor-alpha (TNF-alpha)
  • IL-1, IL-6, IL-8
  • interferon gamma
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13
Q

What does CARS stand for? List 3 of its cytokines.

A

compensatory anti-inflammatory response syndrome > counter-inflammatory mediators to reduce inflammatory response

IL-4, IL-10, IL-13

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14
Q

What are the most important pathogen-associated molecular patterns (PAMPs) of gram positive bacteria?

A

cell wall components:

  • lipoteichoic acid
  • peptidoglycan
  • peptidoglycan stem peptides

bacterial DNA

exotoxins

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15
Q

why are exotoxins of gram positive bacteria “superantigens”?

A

soluble bacterial exotoxins induce widespread T cell activation > inflammatory cytokines released:

  • interferon gamma
  • TNF-alpha
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16
Q

How can neutrophils lead to extensive host tissue damage?

A

release of:

  • ROS
  • proteases
  • lysozymes
  • lactoferrin
  • cathepsins
  • defensins
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17
Q

explain the main mechanism of sepsis leading to hypotension

A

bacterial endotoxins, cytokines like TNF-alpha and IL-1, and mediators like PAF (platelet activating factor) >

> lead to accumulation of iNOS (inducible nitric oxide synthase) >

> high levels of NO produced >

> potent smooth muscle relaxant >

> loss of vasomotor tone >

> septic shock

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18
Q

what are ways to quantify/measure the extent of NO production in dogs?

A

plasma nitrate and nitrite measurements

= breadown products of NO

have shown to be elevated in septic dogs with SIRS compared to healthy controls

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19
Q

Briefly summarize how inflammation leads to a hypercoagulable state

A

inflammatory cytokines > upregulate TF (tissue factor) levels > TF combines with VIIa > initate coagulation cascade

TF-VIIa complex and subsequent products trigger release of even more inflammatory cytokines and cause platelet activation

downregulation of anticoagulants

  • downregulation of antithrombin, tissue factor pathway inhibitor, tissue plasminogen activator (tPA)
  • inhibition of protein C/S pathway > less active protein C
  • increased plasminogen activator inhibitor (PAI-1)

+ platelet activation

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20
Q

Explain how sepsis can lead to cryptic shock

A

endothelial damage, increased vascular permeability, microcirculatory derangements from:

  • endothelial dysfunction
  • alteration and damage to the endothelial glycocalyx layer
  • rheologic changes to red blood cells
  • leukocyte activation
  • microthrombosis
  • loss of vascular smooth muscle autoregulation

=> decrased functional capillary density, heterogenous microvascular blood flow, increased O2 diffusion distance

⇒ decreased tissue oxygen extration ⇒ tissue hypoxia

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21
Q

What is cryptic shock?

A

microcirculatory disturbances despite normal macrohemodynamic variables

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22
Q

What is VEGF?

A

Vascular endothelial growth factor

  • hypoxia-responsive angiogenic factor associated with increasing vascular permeability
  • higher levels in septic dogs have been associated with increased mortality
23
Q

How does increased vascular permeability lead to tissue hypoxia?

A

increased vascular permeability ⇒ efflux of water, proteins, and solutes into the interstitial space ⇒ increased distance from RBC in capillaries to target cells and mitochondira

24
Q

what is cytopathic hypoxia?

A

primary mitochondiral dysfunction, e.g., from sepsis itself

25
Q

What are common bacteria causing sepsis from the peritoneal cavity/septic peritonitis (e.g., GI perforation)

A
  • Coagulase-negative Staphylococcus spp,
  • Enterococcus spp,
  • B-hemolytic Streptococcus spp,
  • Escherichia coli,
  • Klebsiella spp,
  • Enterobacter spp,
  • Pasteurella spp,
  • Corynebacterium spp
26
Q

What are common bacteria causing sepsis from the pulmonary parenchyma or pleura (e.g., pneumonia, pyothorax, …)

A
  • B-hemolytic Streptococcus spp,
  • E. coli,
  • Bordetella bronchiseptica,
  • Staphylococcus spp,
  • E. coli,
  • Klebsiella spp,
  • Pseudomonas spp,
  • Enterococcus faecalis,
  • Acinetobacter spp,
  • Pasteurella spp
27
Q

What are common bacteria causing sepsis from the GI tract (e.g., enterocolitis, bacterial translocartion)?

A

E. coli

28
Q

What are common bacteria causing sepsis from the reproductive tract? (e.g., pyometra, prostatitis)?

A
  • Group G Streptococcus spp,
  • Enterococcus spp,
  • B-hemolytic Streptococcus spp,
  • E. coli,
  • Klebsiella spp
29
Q

What are common bacteria causing sepsis from the urinary tract? (e.g., pyelonephritis, bacterial cystitis)

A
  • B-hemolytic Streptococcus spp,
  • E. coli,
  • Acinetobacter spp,
  • Enterococcus spp
30
Q

What are common bacteria causing sepsis from the soft tissue or bones (e.g., trauma, osteomyelitis, bite wounds)?

A
  • E. coli
  • Enterobacter spp.
31
Q

What are common bacteria causing sepsis from the cardiovascular system? (e.g., endocarditis)

A
  • Staphylococcus lugdunensis,
  • Bartonella spp,
  • S. aureus,
  • E. faecalis,
  • Granulicatella spp,
  • Streptococcus spp,
  • Brucella spp
32
Q

What are considerations to be made when chosing an empirical antimicrobial before culture results are available?

A
  • Location of the infection (and ability of antimicrobial to penetrate the site)
  • Suspected bacterial flora
  • Community versus nosocomial source
  • Duration of hospitalization à long hospitalization time makes likelihood of multidrug-resistant bacteriahigher à consider hospital antibiograms
  • Previous exposure to antimicrobials

bactericidal rather than bacteriostatic antimicrobials preferred

33
Q

How many mL of plasma are needed to raise the albumin by 0.5 g/dL?

A

22 mL/kg of plasma

34
Q

How could vasopressors worsen sepsis?

A
  • Vasopressors may also result in excessive vasoconstriction –> particularly splanchnic and renal circulation –> GI and renal ischemia
  • Splanchnic vasoconstriction may exacerbate septic state due to loss of gut barrier function and bacterial translocation
35
Q

What is the venous oxygen saturation reflective of?

A

the difference between DO2 and VO2

36
Q

what are the options for measuring venous oximetry?

A

blood sampling (blood gas)

co-oximetry

continuous fiberoptic measurement (spectrophotometry)

37
Q

Where should blood for SvO2 ideally be sampled from?

A

pulmonary artery

38
Q

By how much and why differ SvO2 and ScvO2?

A

ScvO2 is in health approximately 2-3% lower than SvO2

  • because of the high metabolic rate of the brain and the cranial part of the body
  • because of vascular circuits with low oxygen extraction (i.e., renal blood flow)
39
Q

How does the difference between the SvO2 and ScvO2 change during states of shock?

A

SvO2 becomes higher than ScvO2 due to prioritization of coronary and cerebral circulation as well as decrease in splanchnic circulation

40
Q

What ScvO2 and SvO2 target goals does the SSC recommend?

A

ScvO2 70% or greater

SvO2 65% or greater

41
Q

What is the current SSC recommendation on lactate measurement?

A

measure lactate within first hour of admission and if > 2.0 mmol/L recheck within 2-4 hours and until normalized

42
Q

In cats with septic peritonitis how many have gram positive versus gram negative infections>

A

Gram negative 55%
Gram positive 40%

43
Q

Describe the sensitivity and specificity of the SIRS criteria to identify sepsis in dogs with confirmed infection and systemic illness

A

350 hospitalized dogs, Hauptman et al, 1997

very sensitive 97%
but also positive in 1/3 of dogs without infection - poor specificity

44
Q

What can be added to a patients assessment to improve the accuracy of the SIRS criteria in dogs with confirmed parvovirus infection?

A

assessing for prolonged CRT or abnormal MM color

45
Q

How did SOFA scores predict mortalities in dogs undergoing surgery for septic peritonitis?

A

presence of any organ dysfunction increased odds of survival

1 organ - 6.73 increased odds ratio of mortality
4-5 organs - 18.7 odds ratio of mortality

46
Q

What is measured/assessed as part of the SOFA score?

A
  • respiratory: P/F ratio
  • hepatobilirary: total bilirubin
  • renal: creatinine
  • CNS: GCS
  • Coagulation: Platelet count
  • Cardiovascular: Hypotension

score 0-4 (5 point scale) for each category
2 or more - 10% mortality risk
less than 9 - under 33% mortality risk

47
Q

How is the qSOFA measured?

A

scale of 0-3

  • SAP < 100 mm Hg
  • RR 22 or higher
  • altered mentation

2 or higher –> increases likelihood of poor outcome, requires more investigation

48
Q

How does qSOFA perform in dogs?

A

hospitalized ICU patients - qSOFA not associated with survival - adding lactate improved sensitivity but the held true with just lactate alone

hspitalized SEPTIC dogs - qSOFA of 2 or higher –> seven-fold increased risk of death, increased risk of postop complications and length of hospitalization

49
Q

List the criteria measured in the canine Apple-full score

A
  • age
  • mentation score
  • RR
  • SpO2
  • WBC count
  • albumin
  • creatinine
  • tbili
  • lactate
50
Q

List the criteria measured in the canine Apple-fast score

A
  • glucose
  • albumin
  • lactate
  • PLT count
  • mentation score
51
Q

List the criteria measured in the feline Apple-full score

A
  • mentation
  • temperature
  • MAP
  • lactate
  • PCV
  • BUN
  • chloride
  • body cavity fluid score
52
Q

List the criteria measured in the feline Apple-fast score

A
  • mentation score
  • temperature
  • MAP
  • lactate
  • PCV
53
Q

What are the targets for EGDT?

A
  • CVP 8-12 mm Hg
  • MAP 65-90
  • ScvO2 at least 70%

Boards: SIRS/sepsis/MODS (9 decks)

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