Sepsis (Final) Flashcards
What is sepsis?
The consequence of a dysregulated inflammatory response to an infection. Gram-positive bacteria are the pathogens most commonly isolated from Pts with sepsis.
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection; organ dysfunction is defined as an increase of two or more points in the sequential (sepsis-related) organ failure assessment (SOFA) score.
What are the components of the SIRS criteria?
- Temp
- >100.4 F
- < 96.8F
- RR
- >20
- HR
- >90
- WBC
- >12,000
- <4,000
- >10% bands
- PCO2
- <32 mmHg
She said to know this!
Define sepsis using the SIRS criteria
- 2 SIRS criteria met
- +
- Confirmed or suspected infection
Define severe sepsis using the SIRS criteria
- Sepsis
- +
- Signs of end-organ damage
- +
- Hypotension (SBP < 90)
- +
- Lactate > 4 mmol
Define septic shock using the SIRS criteria
- Severe sepsis with persistent
- Signs of end-organ damage
- +
- Hypotension (SBP < 90)
- +
- Lactate > 4 mmol
- Signs of end-organ damage
What is the SOFA score used for?
- SOFA score is an illness-severity score used to predict mortality of critically ill patients
- Patients with suspected sepsis can be rapidly identified if they meet at least 2 of the three criteria of the qSOFA
Is lactate or qSOFA better for sepsis prognostication?
Lactate
Components of the qSOFA score
- Low blood pressure
- SBP ≤ 100 mmHg
- High respiratory rate
- RR ≥ 22 breaths/min
- Altered mentation
- GCS ≤ 14
Each is worth one point, a score of 2 or more indicates Pts who may have sepsis
Is qSOFA a screening tool or a diagnostic tool?
Screening tool
When is SOFA used (not qSOFA)
Great in the ICU setting but cumbersome in the ED
What is a problem with the SIRS criteria?
SIRS may over AND under diagnose
Risk factors for developing sepsis
- Advanced age
- Immunosuppression/steroid use/malnutrition
- DM/CA/HIV/Liver disease
- Recent abx use/drug-resistance
- Recent procedures or travel
- Alcohol/drug use
DDx for a fever
- Sepsis
- Drug reaction
- VTE
- Malignancy
- Rheumatological
Malignancy and rheumatological causes are often missed
WBC findings in sepsis
Greater than 12,000 or 140 mg/dL in the absence of diabetes
CRP findings in the setting of sepsis
CRP > 2.5 S.D. above normal
ABG findings in the setting of sepsis
Arterial hypoxemia
INR/aPTT findings in the setting of sepsis
- INR > 1.5
- or
- aPTT > 60s
Platelet findings in the setting of sepsis
Platelet count 4 mg/dL
Lactate findings in the setting of sepsis
Lactate > 2 mmol/L
Procalcitonin findings in the setting of sepsis
Procalcitonin > 2 S.D. above normal
Adrenal findings in the setting of sepsis
Adrenal insufficiency or euthyroid sick syndrome L
Pt is a 48 year old female with PMH of HIV who presented to the hospital with diarrhea for the last 5 days. She’s unable to tolerate anything PO. Vitals: temp 39.0, RR 15, HR 104, BP 90/70. On exam she had dry MM, tachy with a regular rhythm, tender abd, but no distention. Her labs are significant for an abnormal CBC with WBC at 19k. Abnormal BMP with cr of 2.1, Na 131, and K 3.0. ECG nml. UA nml.
What should you do next?
a. ) This patient meets sepsis criteria. Start IVF, identify source and get blood cultures
b) This patient does not meet sepsis criteria. Start IVF and Imodium
c. ) This patient meets sepsis criteria and is hemodynamically unstable Start IVF, broad-spectrum abx (Vanco, cefepime, and metronidazole), identify the source, and get blood cultures
d. ) The patient had diarrhea she can d/c home
c.) This patient meets sepsis criteria and is hemodynamically unstable Start IVF, broad-spectrum abx (Vanco, cefepime, and metronidazole), identify the source, and get blood cultures
Pt is a 48 year old female with PMH of HIV who presented to the hospital with diarrhea for the last 5 days. She’s unable to tolerate anything PO. Vitals: temp 39.0, RR 15, HR 104, BP 90/70. On exam she had dry MM, tachy with a regular rhythm, tender abd, but no distention. Her labs are significant for an abnormal CBC with WBC at 19k. Abnormal BMP with cr of 2.1, Na 131, and K 3.0. ECG nml. UA nml.
You decide to do a full sepsis work-up. What else should you consider in this Pt?
HIV status (What’s her most recent CD4 and viral load)?
Pt is a 48 year old female with PMH of HIV who presented to the hospital with diarrhea for the last 5 days. She’s unable to tolerate anything PO. Vitals: temp 39.0, RR 15, HR 104, BP 90/70. On exam she had dry MM, tachy with a regular rhythm, tender abd, but no distention. Her labs are significant for an abnormal CBC with WBC at 19k. Abnormal BMP with cr of 2.1, Na 131, and K 3.0. ECG nml. UA nml.
You decide to do a full work-up what all should be included in this?
- Blood cultures
- Chest X-ray
- UA (already have)
- Stool PCR (Since she is having diarrhea)
- CD4/Viral load
- CT-abdomen
Pt is a 48 year old female with PMH of HIV who presented to the hospital with diarrhea for the last 5 days. She’s unable to tolerate anything PO. Vitals: temp 39.0, RR 15, HR 104, BP 90/70. On exam she had dry MM, tachy with a regular rhythm, tender abd, but no distention. Her labs are significant for an abnormal CBC with WBC at 19k. Abnormal BMP with cr of 2.1, Na 131, and K 3.0. ECG nml. UA nml.
Her CD4 count comes back at 141 what should you do?
Start prophylaxis (Bactrim)
81 y.o. female with h/o of CVA who was admitted by home health agency due to decreased PO intake and altered mental status found to have a UTI
Vitals: 115/57, RR 17, HR 66, Pulse ox %100 on 3L
Gen: Appears ill, Dry MM, No evidence of volume overload
Labs: WBC 12.6, Macrocytic Anemia, Elevated Cr, Hyponatremia, elevated troponin
ECG: No evidence of ischemia UA: Positive
Does this patient meet sepsis criteria?
No, they only meet one SIRS criteria (Elevated WBC)
Name some of the Empiric IV antibiotics she listed. There’s a lot of them
- Ampicillin-sulbactam
- Piperacillin-tazobactam
- Ceftriaxone
- Cefepime
- Ertapenem
- Meropenem
- Aztreonam
- Gentamicin
- Ciprofloxacin
- Levofloxacin
- Azithromycin
- Doxycycline
- Cefazolin
- Vancomycin
- Daptomycin*
- Linezolid*
- Metronidazole
- Clindamycin
- Special situations:
- TMP-SMX
- Ampicillin
*require approval from ID before using
When selecting antibiotics which areas of coverage do you want to consider?
- Gram-positive
- Gram-negative
- Anaerobes
- Pseudomonas
- MRSA
- Atypical pneumonia
- Special situations
For IP empiric antibiotics you want to choose ones that cover what?
- Pseudomonas
- MRSA
- Anaerobes
- Special situations
62 year old female admitted for a UTI being treated with CTX develops hypotension overnight. You are called to bedside by the rapid response team. What should you do?
A.) IVF, Continue CTX, and Call ICU
B.) IVF, Switch to Vanco, and Call ICU
C.) IVF, Switch abx to pip-taz and vanco, and Call ICU
D.) Give her some cranberry juice for her UTI
C.) IVF, Switch abx to pip-taz and vanco, and Call ICU
Will cover both pseudomonas and MRSA
Name some antibiotics with pseudomonas coverage
- Cefepime
- Piperacillin-tazobactam
- Meropenem
- Gentamicin
- Aztreonam
- Ciprofloxacin
- Levofloxacin
Name some antibiotics with MRSA coverage
- Vancomycin
- Clindamycin
- TMP/SMX
- Doxycycline
Name some antibiotics with anaerobic coverage
- Ampicillin-sulbactam
- Piperacillin-tazobactam
- Meropenem
- Ertapenem
- Metronidazole
- Clindamycin
Name some organisms that cause atypical pneumonia
- Chlamydophila pneumoniae
- Legionella pneumonphilia
- Mycoplasma pneumoniae
71 y/o M hx alcohol abuse, T2DM, CAD, p/w cough and fever.
T: 39.0 deg C HR: 124 BP: 82/40 RR: 24 SpO2: 84% RA; 92% 2L NC
Standard initial workup: CBC, BMP +/- LFTs, Blood cultures, Lactate, UA, CXR
CBC: Plt 102, WBC 18k
CMP: Cr 1.2, BUN 26, T bili 1.6
Blood cultures drawn
Lactate: 4.2
UA: Neg
CXR: Right basilar infiltrate
Should this Pt be managed, inpatient or outpatient?
Inpatient, his CURB 65 score is 3 indicating high risk and need for admission.
Admit for PNA
Aspects of CURB-65
- Confusion
- BUN > 19
- RR ≥ 30
-
Blood pressure
- SBP < 90 or DBP ≤ 60
- Age ≥ 65
Each worth 1 point
A CURB-65 score of 0-1 indicates?
Pt can likely be managed outpatient
A CURB-65 score of 2 indicates?
Pt will likely need inpatient management
A CURB-65 score of 3+ indicates?
Pt will likely need ICU level care
Fluid replacement guide for sepsis
Initial crystalloid bolus of 30 mL/kg
Causes of Type A Lactic acidosis
- Tissue hypoperfusion from sepsis hypovolemia
- Shock
Causes of Type B Lactic acidosis
- Metformin
- DKA
- Alcohol abuse
- Liver disease
- HIV meds
Guide for treating hospital-acquired pneumonia
- Obtain respiratory specimen prior to the start of antibiotics when possible
- Non-invasive respiratory specimens such as sputum or tracheal aspirate should be interpreted with caution as there is possibility for contamination or colonization
- In Pts with septic shock, use dual gram-negative coverage pending culture results
- In MICU, serial procalcitonin levels may assist in the determination of duration of antibiotics therapy
In the inpatient setting, should patients with suspected aspiration pneumonia receive additional anaerobic coverage?
Not routinely (unless lung abscess or empyema)
Why is it important to recognize and treat sepsis ASAP?
- 30% die in first 30 days
- 50% die in the first 6 months
Common causes of sepsis
- PNA
- Bloodstream infections
- Including infective endocarditis
- Intravascular catheter-related sepsis
- Dialysis catheters are common source
- Intra-abdominal infections
- Urosepsis
- Surgical wound infections
Resuscitation goals in the treatment of sepsis
- Central venous pressure
- 8-12 mmHg
- Mean arterial pressure
- 65 mmHg
- Urine output
- 0.5 mL/kg/hr
- Central venous (superior vena cava) or mixed venous oxygen saturation
- 70%
When should IV antibiotics be started in the setting of severe sepsis
Within the first hour of recognition of severe sepsis, after appropriate cultures have been obtained
