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OU Module ID Fall 2018 > Sepsis Exam 4 > Flashcards

Sepsis Exam 4 Flashcards

1
Q

Epidemiology of sepsis and septic shock

A
  • Affects millions of patients per year
  • Potentially 5.3 million deaths annually
  • Mortality varies depending on definitions
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2
Q

risk factors for sepsis and septic shock

A
  • Age: <2yr or >55yr
  • Chronic / serious illness
  • Impaired immunity
  • Breach of natural barriers
  • Chronic infections
  • Protein calorie malnutrition
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3
Q

risk factors for sepsis and septic shock: Chronic / serious illness

A
  • Cancer
  • diabetes
  • COPD
  • cirrhosis or biliary obstruction
  • cystic fibrosis
  • CKD
  • CHF
  • collagen vascular disease
  • obesity
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4
Q

risk factors for sepsis and septic shock: Impaired immunity

A
  • Transplantation
  • chemotherapy
  • radiation therapy
  • drug-mediated immunosuppression
  • blood transfusions
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5
Q

risk factors for sepsis and septic shock: Breach of natural barriers

A
  • Trauma
  • surgery
  • catheterization
  • intubation
  • burns
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6
Q

risk factors for sepsis and septic shock: Chronic infections

A
  • HIV

- decubitus ulcers or non-healing wounds

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7
Q

Epidemiology of sepsis and septic shock: organisms

A
  • gram + becoming the major cause in recent years
  • gram - not far behind
  • fungi does cause it but not to the same extent
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8
Q

What is the APACHE II?

A
  • use APACHE II to make sure that we’re comparing pts on the same level
  • the higher the score, the higher risk of mortality
  • sees how sick a person is
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9
Q

What are the SIRS criteria?

A

Have to have >= 2 of the following:

  • T > 38.3⁰C (100.9⁰F) or <36⁰C (96.8⁰F)
  • HR > 90bpm or >2SD above ULN for age
  • RR > 20bpm or PaCO2 < 32mmHg
  • WBC >12,000/mm3 or < 4,000/mm3
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10
Q

Define Sepsis-2 for a person that has sepsis

A

SIRS PLUS suspected or documented infection

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11
Q

Define Sepsis-2 for a person that has severe sepsis

A

Sepsis PLUS organ dysfunction

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12
Q

Define Sepsis-2 for a person that has septic shock

A
  • Acute circulatory failure characterized by persistent arterial hypotension unexplained by other causes
  • Hypotension: SBP <90mmHg, MAP <60, or↓ SBP >40mmHg from baseline
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13
Q

Sepsis-2 Clinical Criteria: general variables

A
  • T > 38.3⁰C (100.9⁰F) or <36⁰C (96.8)
  • HR > 90bpm or >2SD above ULN for age)
  • RR > 20bpm or PaCO2 < 32mmHg
  • altered mental status
  • Significant edema or +fluid balance (>20ml/kg over 24hr)
  • hyperglycemia (>120mg/dL) in absence of diabetes
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14
Q

Sepsis-2 Clinical Criteria: inflammatory variables

A
  • WBC >12,000/mm3 or < 4,000/mm3
  • > 10% bands w/normal WBC
  • C-reactive protein (CRP) >2SD above normal
  • Procalcitonin (PCT) >2SD above normal
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15
Q

Sepsis-2 Clinical Criteria: hemodynamic variable

A
  • SBP <90mmHg, MAP < 60, ↓ SBP >40mmHg from baseline
  • SvO2 > 70%
  • CI > 3.5l/min/m^2
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16
Q

Sepsis-2 Clinical Criteria: organ dysfunction variables

A
  • Pao2/FIO2 ratio <300
  • UOP <0.5ml/kg/hr x ≥2hr
  • SCr ↑0.5mg/dL
  • INR >1.5 or aPTT > 60sec
  • Ileus
  • platelets <100,000/mcL
  • Tbili > 4mg/dL
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17
Q

Sepsis-2 Clinical Criteria: perfusion variables

A
  • Hyperlactatemia >1mmol/L

- decreased capillary refill or skin mottling

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18
Q

Who is qSOFA used for?

A

used on pts who are not in the ICU

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19
Q

What are the components of qSOFA?

A
  • Altered mental status
  • respiratory rate ≥22
  • SBP ≤100mmHg
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20
Q

How does sepsis 3 define sepsis?

A

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

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21
Q

Higher SOFA means higher…

A

mortality

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22
Q

According to sepsis 3, how do you define organ dysfunction?

A
  • Acute change in SOFA score ≥2 consequent to the infection
  • Baseline SOFA assumed to be 0 if no known preexisting organ dysfunction
  • SOFA ≥2 reflects an overall mortality risk of ~10% in a general hospital population w/suspected infection
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23
Q

According to sepsis 3, how do you define septic shock?

A
  • Subset of septic patients in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality
  • hypotension (MAP < 65mmHg) AND lactate > 2mmol/L
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24
Q

What does SOFA stand for?

A
  • sequential organ failure assessment score

- use THIS one for ICU pts

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25
Q

According to sepsis 3, how do you define sepsis?

A

Suspected or documented infection PLUS acute ↑ ≥2 SOFA points

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26
Q

What is the goal of fluid therapy in sepsis?

A
  • restore intravascular volume
  • ↑cardiac output (CO)
  • augment O2 delivery
  • improve tissue oxygenation
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27
Q

What is given for initial resuscitation fluid thearpy?

A
  • Crystalloids: cheap salts / sugars; as solutions of ions capable of crossing semipermeable membranes
  • Colloids: more expensive; suspensions of large plasma-derived or semi-synthetic molecules that cannot cross semipermeable membranes
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28
Q

Normal values of electrolytes in plasma

A
  • Na: 140mEq/L
  • Cl: 100mEq/L
  • K: 4mEq/L
  • Ca: 9.6mg/dL
  • Mg: 2.4mg/dL
  • HCO3-: 24mEq/L
29
Q

Normal osmolality of plasma

A

291 (275 - 295)

30
Q

Normal pH of plasma

A

7.35 - 7.45

31
Q

What does the Surviving Sepsis Campaign (SSC) recommend for sepsis induced hypoperfusion?

A

≥30ml/kg of IV crystalloid fluid within the first three hours

32
Q

What does the Surviving Sepsis Campaign (SSC) recommend for initial resuscitation and subsequent intravascular volume replacement in patients w/sepsis and septic shock?

A
  • crystalloids
  • weak: can give crystalloids or saline for fluid resuscitation
  • if pt needing large amount of crystalloids, can supplement with colloids
33
Q

What happens after initial resuscitation?

A
  • additional fluids should be guided by frequent reassessment of hemodynamic status
  • fluid challenge technique be applied where fluid administration is continued as long as hemodynamic factors continue to improve
34
Q

What are the ways in which you can check for fluid responsiveness?

A
  • Central Venous press. (CVP)
  • Stroke Vol. Variation (SVV)*
  • Pulse Press. Variation (PVV)*
  • Vena cava dimensions / collapsability
  • Passive leg raise (PLR)*
  • End-expiratory Occ. Test
  • Fluid challenge*
35
Q

Fluid Responsiveness: Central Venous press. (CVP)

A
  • debunked for the most part

- it’s never been shown that if the CVP is low, that the pt is responding to fluids; not used anymore

36
Q

Fluid Responsiveness: Stroke Vol. Variation (SVV)*

A
  • heart lung interaction when pt is on ventilator; apply pressure to keep the alveoli open; can also affect blood flow; keeps blood from venous return to right atrium; pts on mechanical ventilator (MV), if it shows that you have >12% increase in cardiac output, it shows that pt will response to fluid
  • Can’t be used if spontaneously breathing, arrhythmias, low tidal volumes (Tv)/lung compliance
37
Q

Fluid Responsiveness: Pulse Press. Variation (PVV)*

A
  • when pt is on mechanical ventilation, usually do what’s called positive pressure; when a critically ill pt breathes out, may not breathe that well and alveoli is probably collapsing -> have to push pressure to keep that alveoli open which could in turn affect blood flow in thoracic cavity; positive pressure applied at the end of expiratory breath (instead of inhalation like normal); this keeps blood from venous return to the right atrium; pts who are on MV (mechanical ventilator) who have a set RR (not taking any spontaneous breaths), you’ll see variations in pulse pressure and stroke volume, systolic and diastrolic throughout resp cycle; if you’re volumed up, shouldn’t see variation; if you’re seeing variation (>12% increase in cardiac output) between inspiration and expiration in the venous return (SV or PP), then that suggests that you’ll respond to fluid
  • Can’t be used if spontaneously breathing, arrhythmias, low tidal volumes (Tv)/lung compliance
38
Q

Fluid Responsiveness: Vena cava dimensions / collapsability

A
  • not recommended
  • Can’t be use if spontaneously breathing, low Tv/lung compliance
  • not useful because SVC requires TEE; look at ultrasound to see hwo much the vena cava collapsed
39
Q

Fluid Responsiveness: Passive leg raise (PLR)*

A
  • in your lower extremities, you actually have 300 mL of blood in your venous side esp if you’re lying flat; kick legs up and monitor CO; kind of like a fluid challenge
  • increase CO >10% shows response to fluid
40
Q

Fluid Responsiveness: End-expiratory Occ. Test

A
  • ecclude ventilator for 15 seconds and then see how CO changes
  • pts can’t tolerate this; not commonly done
  • increase in >5% CO shows response to fluid
41
Q

Fluid Responsiveness: Fluid challenge*

A
  • administer 100mL of fluid; if CO increases by >6% then shows response to fluid
  • administer 500mL of fluid; if CO increases by >15% then shows response to fluid
42
Q

Albumin ADE / comments

A
  • Theoretically risk of disease transmission

- Expensive vs. crystalloids AVOID in TBI

43
Q

NS ADE / comments

A
  • Hyperchloremic metabolic acidosis
  • Cl- content may lead to AKI
  • PREFERRED in TBI
44
Q

LR ADE / comments

A
  • Lower risk of hyperchloremic metabolic acidosis

- May have lower AKI risk vs. NS

45
Q

Plasmalyte ADE / comments

A
  • Lower risk of hyperchloremic metabolic acidosis

- May have lower AKI risk vs. NS

46
Q

In general, what are ADE’s of fluids?

A
  • increase in pulmonary edema
  • increased prolonged ventilation
  • increased tissue edema
  • poor wound healing
  • impaired contractility
  • abd compartment syndrome: bowel edema + inflammation already going on increases intra-abd pressure, decreases abd perfusion, lead to organ failure
  • hepatic congestion
  • over-stretched myocardium that falls off starling curve
47
Q

What can cause a pt to have increased Vd?

A
  • Sepsis
  • Trauma
  • Severe hypoalbuminemia
  • Fluid therapy
  • Parenteral nutrition
  • Reduced CO
  • Pleural effusion
  • Ascites
  • Mediastinitis
  • these conditions give an apparent increase in Vd (Post-surgical drainage, early phase burns)
48
Q

What can cause a pt to have increased clearance?

A
  • late phase burns
  • Acute Leukemia
  • Hyperdynamic sepsis phase
  • Increased CO
  • Poly-trauma
49
Q

What can cause a pt to have decreased clearance?

A
  • Renal failure

- >75yr

50
Q

When to administer antibiotic therapy?

A
  • if cultures do not delay administration, obtain a culture
  • initiate ASAP (within 1 hour of sepsis or septic shock)
  • for every hour that passes with lack of antibiotics after pt is hypotensive, you get a 8% decrease in survival
  • recommend empiric broad-spectrum to cover all likely pathogens
51
Q

How long should antibiotics be administered for?

A
  • 7-10 days (weak recommendation)
  • longer in these pts: Slow clinical response, undrainable foci of infection, bacteremia w/S. aureus, some fungal and viral infections, or immunological deficiencies
  • shorter in these pts: those w/rapid clinical resolution following effective source control of intra-abdominal or urinary sepsis and those w/anatomically normal pyelonephritis
52
Q

What are factors / considerations that will help guide empiric therapy?

A
  • Site of infection
  • Prevalence of pathogens within the community, hospital, and even specific unit/ward
  • Resistance patterns of the prevalent pathogens
  • Presence of immunodeficiencies, i.e. neutropenia, HIV, splenectomy, etc.
  • Age/patient comorbidities, organ function, presence of invasive devices
  • Pharmacokinetic / pharmacodynamic changes
53
Q

If your suspected source is pulmonary, which antibiotic would you use to treat?

A
  • VAP: Zosyn or cefepime ± vanc ± Cipro or aminoglycoside

- HAP: Zosyn, cefepime ± vanc ± cipro or aminoglycoside

54
Q

If your suspected source is intra-abdominal, which antibiotic would you use to treat?

A

Zosyn or cefepime / MTDZ, ± fluconazole or micafungin

55
Q

If your suspected source is genitourinary / kidneys, which antibiotic would you use to treat?

A
  • Community acquired: ceftriaxone

- CAUTI / Hosp. acquired: zosyn, cefepime

56
Q

If your suspected source are central lines, which antibiotic would you use to treat?

A
  • Zosyn ± vanc

- cefepime ± vanc

57
Q

If your suspected source is SSTI, which antibiotic would you use to treat?

A
  • Purulent: vancomycin
  • Non-purulent: zosyn ± vanc
  • Necrotizing: vanc + zosyn or cefepime/mtdz
  • Plus clindamycin if toxic shock suspected
58
Q

How do you calculate MAP?

A
  • CO * SVR
  • where CO = HR * stroke volume
  • OR (2DBP + SBP)/3
59
Q

Which vasopressor does the SSC recommend?

A
  • norepinephrine (NE) as first line
  • weak recommendation for adding vasopressin or epinephrine (EPI)
  • weak recommendation for starting dobutamine in pts w/ evidence of persistent hypoperfusion despite adequate volume loading + use of vasopressors
60
Q

Which vasopressor shouls you never use for septic shock?

A

dopamine

61
Q

What are vasopressors used for?

A

to help pt reach their perfusion goal

62
Q

SSC perfusion endpoints

A
  • initial target mean arterial pressure (MAP) of ≥65mmHg in patients with septic shock requiring vasopressors
  • Suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion
63
Q

What are the ways in which you can measure perfusion endpoints?

A
  • Physiologic
  • Hemodynamic
  • Metabolic
64
Q

Physiologic ways to measure perfusion endpoints

A
  • Heart rate goal < 90 – 100bpm

- Urine output(?) goal of >0.5ml/kg/hr

65
Q

Hemodynamic ways to measure perfusion endpoints

A
  • MAP goal of >65mmHg
  • Mixed venous oxygenation SvO2
  • Central venous oxygenation ScvO2
66
Q

Metabolic ways to measure perfusion endpoints

A
  • Lactate goal of < 2mmol/L or 10% decrease within initial 6hr
  • Base deficit
67
Q

Use of steroids in septic shock

A
  • Do not use if adequate fluid resuscitation and pressors are able to able to restore hemodynamic stability; if not then administer IV hydrocortisone 200mg/d
  • Use if not responsive to fluid and moderate-high dose vasopressors -> IV HC <400mg/day x ≥3 days
  • Pressor doses: >0.1 mcg/kg/min NE or equivalent pressor dose, EPI 0.1mcg/kg/min, PE 1mcg/kg/min, Vaso 0.04 units/min
68
Q

Metabolic resuscitation

A
  • pts have love levels of thiamine and Vitamin C if they are in septic shock
  • administer supplements
  • in his notes: IV thiamine 200mg IV q12 + Vit C 1500mg IV q6hr + HC 50mg IV q6hr

OU Module ID Fall 2018 (18 decks)

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