Sepsis -Goya

Question 1

What is shock?

Answer 1

Failure to deliver oxygen and substrates to meet the metabolic demands of the tissue beds

supply < demand

oxygen delivery < oxygen consumption

Question 2

What are the 4 types of shock?

Answer 2

Hypovolemic shock - ex: hemorrhage, volume depletion, interstitial fluid redistribution

Cardiogenic shock - due to heart failure –> pump failing–> fluid back into lungs –> hypoxemic
-* need to improve heart function

Extra-cardiac obstructive shock
(Obstructive) - external pressure on the heart impair heart contraction or filling (tension pneumo, PE, aortic dissection, tamponade)

Distributive shock - loss of vasomotor control –> dilation ==> shunt blood away from the system

Question 3

What are the goals of treatment of shock?

Answer 3

decrease demand (treat hyperthermia, reduce work of breathing –> ventilation)

increase supply (improve preload (give fluid), improve contractility, dec after load, dec HR, improve O2)

treat the underlying cause

Question 4

What is the #1 cause of mortality from MIs?

Answer 4

cardiogenic shock

Question 5

What determines the treatment of cardiogenic shock?

Answer 5

where the heart is affected

LV =bypass, stent, intraaortic balloon pump

RV
fluid and inotropes with PA cath monitoring

Question 6

What determines the acuity of the obstructive shock? What are the treatments for tampanade vs. PE?

Answer 6

Rate of development of the obstruction (how fast the shock occurred)

tampanade–> pericardiocentesis

acute PE –> thrombolytic

Question 7

What is the classic feature of distributive shock? What is an example of this?

Answer 7

shunting

sepsis
SIRS–> Septic shock

Question 8

What is SIRS? What is sepsis?

Answer 8

Systemic Inflammatory Response Syndrome (SIRS): 2 or more of the following:

T>38C or 90
RR>20 (or PaCO212K, 10%bands

sepsis: Confirmed or suspected INFECTION accompanied by SIRS

Question 9

What is severe sepsis?

Answer 9

Presence of sepsis + organ hypoperfusion or dysfunction

Organ hypoperfusion:
Elevated lactic acid
Oliguria
Abnormal peripheral circulation
AMS

Organ dysfunction:
ARF		
ARDS
DIC
Delirium

Question 10

What is septic shock?

Answer 10

Presence of severe sepsis, plus refractory hypotension

SBP<65 or 40mmHg drop compared to baseline

Unresponsive to fluid challenge of 20-40ml/kg

Vasopressor dependency after adequate volume resuscitation

Question 11

What is the first priority in any pt with severe sepsis or septic shock?

Answer 11

stabilization of airway and breathing

Question 12

Can hypo perfusion occur in the absence of hypotension?

Answer 12

YES

over time this will get worse and develop Hypotension

Question 13

What are some signs of hypo-perfusion?

Answer 13

• Cool, vasoconstricted skin due redirection of blood flow to the core organs
• ->Patients with early sepsis may have warm, flushed skin
• Obtundation or restlessness
• Oiguria or anuria
• Elevated Lactic acid level
• may have normal BP

Question 14

SIRS criteria but cool and clammy and normal BP?

Answer 14

think pt may be going into septic shock

Question 15

Why is crystalloid or colloid fluid given to sepsis pts?

Answer 15

get the CVP > 12 mmHg

Question 16

When should antibiotics be given for sepsis? What type of antibiotic?

Answer 16

Broad-spectrum antibiotic within 1 hour recognition septic shock.

Blood cultures before antibiotics –> can adjust meds based on culture results

Question 17

What is the drug of choice for septic pt with hypotension?

Answer 17

norepinephrine (or epinephrine if NE doesn’t work)

only use dobutamine with low CO

Question 18

What are the signs to look for to determine adequacy of resuscitation?

Answer 18

Capillary refill < 2 sec

Adequate pulses

Warm limbs

Normal mental status

Urine output > 1 mL/kg/hr

Adequate blood pressure

Improved base deficit

Decreased lactate

SvO2 > 70%

Question 19

A 45-year-old man with acute cholecystitis is noted to have a fever of 38.3°C (101°F), hypotension, and altered sensorium. His hematocrit is noted to be 24%. Broad-spectrum antibiotics and intravenous saline are administered, and, although his Central Venous Pressure is 10 and his Mean Arterial Pressure is 80, his Scvo2 (mixed venous o2) remains

Answer 19

D. RBC Transfusion

hematocrit is 24–> super anemic –> give blood first

if hematocrit was higher, dobutamine would have been a good answer

Question 20

A 35-year old female is having panic attack and she is breathing at RR-28/min. Her ABG on room air shows pH 7.5, Paco2 of 29 and HCo3 of 24. What is her underlying acid base disorder?
A. acute respiratory alkalosis
B chronic respiratory alkalosis
C. Acute respiratory acidosis
D. Chronic respiratory acidosis

Answer 20

A. acute respiratory alkalosis

bicarb is normal –> NOT chronic