Sepsis Exam 4 Flashcards
Epidemiology of sepsis and septic shock
- Affects millions of patients per year
- Potentially 5.3 million deaths annually
- Mortality varies depending on definitions
risk factors for sepsis and septic shock
- Age: <2yr or >55yr
- Chronic / serious illness
- Impaired immunity
- Breach of natural barriers
- Chronic infections
- Protein calorie malnutrition
risk factors for sepsis and septic shock: Chronic / serious illness
- Cancer
- diabetes
- COPD
- cirrhosis or biliary obstruction
- cystic fibrosis
- CKD
- CHF
- collagen vascular disease
- obesity
risk factors for sepsis and septic shock: Impaired immunity
- Transplantation
- chemotherapy
- radiation therapy
- drug-mediated immunosuppression
- blood transfusions
risk factors for sepsis and septic shock: Breach of natural barriers
- Trauma
- surgery
- catheterization
- intubation
- burns
risk factors for sepsis and septic shock: Chronic infections
- HIV
- decubitus ulcers or non-healing wounds
Epidemiology of sepsis and septic shock: organisms
- gram + becoming the major cause in recent years
- gram - not far behind
- fungi does cause it but not to the same extent
What is the APACHE II?
- 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
What are the SIRS criteria?
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
Define Sepsis-2 for a person that has sepsis
SIRS PLUS suspected or documented infection
Define Sepsis-2 for a person that has severe sepsis
Sepsis PLUS organ dysfunction
Define Sepsis-2 for a person that has septic shock
- Acute circulatory failure characterized by persistent arterial hypotension unexplained by other causes
- Hypotension: SBP <90mmHg, MAP <60, or↓ SBP >40mmHg from baseline
Sepsis-2 Clinical Criteria: general variables
- 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
Sepsis-2 Clinical Criteria: inflammatory variables
- 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
Sepsis-2 Clinical Criteria: hemodynamic variable
- SBP <90mmHg, MAP < 60, ↓ SBP >40mmHg from baseline
- SvO2 > 70%
- CI > 3.5l/min/m^2
Sepsis-2 Clinical Criteria: organ dysfunction variables
- 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
Sepsis-2 Clinical Criteria: perfusion variables
- Hyperlactatemia >1mmol/L
- decreased capillary refill or skin mottling
Who is qSOFA used for?
used on pts who are not in the ICU
What are the components of qSOFA?
- Altered mental status
- respiratory rate ≥22
- SBP ≤100mmHg
How does sepsis 3 define sepsis?
life-threatening organ dysfunction caused by a dysregulated host response to infection
Higher SOFA means higher…
mortality
According to sepsis 3, how do you define organ dysfunction?
- 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
According to sepsis 3, how do you define septic shock?
- 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
What does SOFA stand for?
- sequential organ failure assessment score
- use THIS one for ICU pts
According to sepsis 3, how do you define sepsis?
Suspected or documented infection PLUS acute ↑ ≥2 SOFA points
What is the goal of fluid therapy in sepsis?
- restore intravascular volume
- ↑cardiac output (CO)
- augment O2 delivery
- improve tissue oxygenation
What is given for initial resuscitation fluid thearpy?
- 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
Normal values of electrolytes in plasma
- Na: 140mEq/L
- Cl: 100mEq/L
- K: 4mEq/L
- Ca: 9.6mg/dL
- Mg: 2.4mg/dL
- HCO3-: 24mEq/L
Normal osmolality of plasma
291 (275 - 295)
Normal pH of plasma
7.35 - 7.45
What does the Surviving Sepsis Campaign (SSC) recommend for sepsis induced hypoperfusion?
≥30ml/kg of IV crystalloid fluid within the first three hours
What does the Surviving Sepsis Campaign (SSC) recommend for initial resuscitation and subsequent intravascular volume replacement in patients w/sepsis and septic shock?
- crystalloids
- weak: can give crystalloids or saline for fluid resuscitation
- if pt needing large amount of crystalloids, can supplement with colloids
What happens after initial resuscitation?
- 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
What are the ways in which you can check for fluid responsiveness?
- 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*
Fluid Responsiveness: Central Venous press. (CVP)
- 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
Fluid Responsiveness: Stroke Vol. Variation (SVV)*
- 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
Fluid Responsiveness: Pulse Press. Variation (PVV)*
- 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
Fluid Responsiveness: Vena cava dimensions / collapsability
- 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
Fluid Responsiveness: Passive leg raise (PLR)*
- 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
Fluid Responsiveness: End-expiratory Occ. Test
- 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
Fluid Responsiveness: Fluid challenge*
- 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
Albumin ADE / comments
- Theoretically risk of disease transmission
- Expensive vs. crystalloids AVOID in TBI
NS ADE / comments
- Hyperchloremic metabolic acidosis
- Cl- content may lead to AKI
- PREFERRED in TBI
LR ADE / comments
- Lower risk of hyperchloremic metabolic acidosis
- May have lower AKI risk vs. NS
Plasmalyte ADE / comments
- Lower risk of hyperchloremic metabolic acidosis
- May have lower AKI risk vs. NS
In general, what are ADE’s of fluids?
- 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
What can cause a pt to have increased Vd?
- 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)
What can cause a pt to have increased clearance?
- late phase burns
- Acute Leukemia
- Hyperdynamic sepsis phase
- Increased CO
- Poly-trauma
What can cause a pt to have decreased clearance?
- Renal failure
- >75yr
When to administer antibiotic therapy?
- 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
How long should antibiotics be administered for?
- 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
What are factors / considerations that will help guide empiric therapy?
- 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
If your suspected source is pulmonary, which antibiotic would you use to treat?
- VAP: Zosyn or cefepime ± vanc ± Cipro or aminoglycoside
- HAP: Zosyn, cefepime ± vanc ± cipro or aminoglycoside
If your suspected source is intra-abdominal, which antibiotic would you use to treat?
Zosyn or cefepime / MTDZ, ± fluconazole or micafungin
If your suspected source is genitourinary / kidneys, which antibiotic would you use to treat?
- Community acquired: ceftriaxone
- CAUTI / Hosp. acquired: zosyn, cefepime
If your suspected source are central lines, which antibiotic would you use to treat?
- Zosyn ± vanc
- cefepime ± vanc
If your suspected source is SSTI, which antibiotic would you use to treat?
- Purulent: vancomycin
- Non-purulent: zosyn ± vanc
- Necrotizing: vanc + zosyn or cefepime/mtdz
- Plus clindamycin if toxic shock suspected
How do you calculate MAP?
- CO * SVR
- where CO = HR * stroke volume
- OR (2DBP + SBP)/3
Which vasopressor does the SSC recommend?
- 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
Which vasopressor shouls you never use for septic shock?
dopamine
What are vasopressors used for?
to help pt reach their perfusion goal
SSC perfusion endpoints
- 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
What are the ways in which you can measure perfusion endpoints?
- Physiologic
- Hemodynamic
- Metabolic
Physiologic ways to measure perfusion endpoints
- Heart rate goal < 90 – 100bpm
- Urine output(?) goal of >0.5ml/kg/hr
Hemodynamic ways to measure perfusion endpoints
- MAP goal of >65mmHg
- Mixed venous oxygenation SvO2
- Central venous oxygenation ScvO2
Metabolic ways to measure perfusion endpoints
- Lactate goal of < 2mmol/L or 10% decrease within initial 6hr
- Base deficit
Use of steroids in septic shock
- 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
Metabolic resuscitation
- 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
