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PHM 703: Critical Care/Cancer > Sepsis management > Flashcards

Sepsis management Flashcards

1
Q

Sepsis definition

A

life threatening organ dysfunction in response to infection

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2
Q

Septic Shock

A

Subset of sepsis w. circulatory dysfunction and high mortality

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3
Q

Hemodynamic Shock Cause

Review

A

Identify source of loss - repair active bleeding w/ surgical hemostasis

Hemorrhage:
* replace blood (PRBCs or FFP)
* reverse anticoagulation

GI losses, burns, third spacing
* Fluids (crystalloids, albumin)

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4
Q

Cardiogenic shock causes

Review

A

MI: revascularization CABG
Arrythmias: achieve sinus rhythm
Advance methods: LVADs
* Intraaortic balloon pump
* Impella
* HeartMate and Tandem Heart

ECMO

left ventricular assist devices

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5
Q

Managing septic shock

A
  1. Correct underling cause
    * Abx
    * Source control
  2. Fluid
  3. Pressors
  4. Inotropes
  5. Corticosteroids
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6
Q

Identifying Sepsis

A
  1. qSOFA = rapid bedside score
  2. SIRS
  3. SOFA = stage organ dysfunction (for research)
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7
Q

qSOFA criteria

A

at least 2 of the following
* SBP < 100 mmHg
* RR > 22
* Altered mentation

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8
Q

SIRS criteria

A

at least two of the following
* Temp >38C or <36C
* HR >90
* RR > 20
* WBC >12 or <4

(+) sirs not = sepsis

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9
Q

Septic Shock 1 hour bundle

A
  1. Get initial lactate, if >2 re-measure
  2. Get blood culture asap
  3. Give broad spectrum abx
  4. Rapid bolus 30ml/kg crystalloid if hypotension or lactate ≥4
  5. Add pressors if hypotensive to maintain MAP ≥65
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10
Q

Why draw culture prior to abx admin?

A

Higher chance to ID bug – otherwise abx may “sterilize” the culture

Wait for culture b4 abx given as long as it doesn’t delay abx initiation
* delay abx = increased mortality

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11
Q

Harms of unnecessary abx use

A
  • allergic rxn
  • kidney injury
  • thrombocytopenia
  • C.diff
  • abx resistance
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12
Q

Importance of source control

A

Just abx alone not always enough
* Ventillator associated infection = clean vent
* infected hardware = surgery
* Necrotizing fascitis = debridement

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13
Q

If sepsis is possible but not in shock, when do you give abx?

A

assess infectious vs other cause of illness
give abx within 3 hours if infection concern persists

in all other circumstances give abx asap - ideally within 1 hr or recogn

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14
Q

MRSA patient specific risk factors

A
  • prior hx MRSA infection OR colonization
  • Recent IV abx use
  • Recent hospitalization
  • Hx recurrent skin infection/chronic wound
  • Presence of invasive devices
  • Hemodialysis
  • Severity of illness

Use VANCO or PipTazo coverage MRSA

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15
Q

MDR patient specific risk factors

use TWO gram negative agents to cover empirically

A
  • proven infection/colonization with resistant organism in the last year
  • broad spectrumm IV abx use last 90 days
  • Travel highly endemic country last 90 days
  • local prevalence of MDR
  • hospital acquired infection
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16
Q

Goal of fluid therapy

A

Increase stroke volume (depends on preload)
Increase cardiac output
Increase DO2 (delivery)

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17
Q

Fluid therapy

A

BOLUSES
30ml/kg over 15-30min
then 10ml/kg bolus prn

more conservative if HF, cardiogenic shock

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18
Q

LR vs NS vs Albumin

A
  1. LR
  2. NS
  3. Albumin (colloid)
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19
Q

LR considerations

A

may produce hyponatremia
lactate not an issue - metabolized rapidly

20
Q

NS considerations

A

may produce
* hypernatremia
* hypercholremia
* metabolic acidosis
* risk of increased AKI

21
Q

1 L crystalloid = ____ intravascular volume?

A

250 mL

Respectively, albumin 1L = 500-1000 mL intravascular

22
Q

Albumin considerations

A

available as 2 concentrations
efficacy equivalent to crystalloid
benefit not justified by cost
1L = 500-1000 mL intravascular
* SAFE trial: albumin for ICU = possible benefit for mortality
* ALBIOS trial: albumin for sepsis = no difference mortality

23
Q

Starches considerations

hetastarch, hydroxyethyl starch 6%

A

dont use it for septic shock
increased risk of mortality, AKI, bleed

24
Q

b1 agonism on organs

A

heart, GI, kidney, fat
* increased HR/contractility
* decreased GI tone/motility
* Increased renin secretion
* Lipolysis

no arteriole/lung/muscle/liver involvmement

25
Q

b2 agonist on organs

A

everything but kidney
* increased HR/contractility
* Arteriole dilation
* bronchial relaxation
* decreased GI tone/motility
* Glycogenolysis/gluconeogenesis
* Increased K+ uptake
* Lipolysis

b2 dilation - counteract in shock with other a1 agonism

26
Q

a1 agonism on organs

A
  • Arteriole constriction
  • decreased GI tone/motility
  • Decreased renin secretion
  • Glycogenolysis/gluconeogenesis
  • Lipolysis

arteriole, GI, kidney, liver, fat

27
Q

a2 agonism on organ

A
  • arteriole constriction
  • decreased Gi tone/motility
28
Q

V1 agonism

A

arteriole constirction

29
Q

V2 agonism

A

arteriole dilation
water reabsorption

30
Q

D1 agonism

A

artetriole dilation

31
Q

receptors w/ arteriole dilation

A

b2, v2, d1

32
Q

receptors with increased HR/contractility

A

b1, b2

33
Q

Receptors with arteriole constriction

A

a1,a2,v1

34
Q

decreased renin secretion

A

a1

35
Q

Increased renin secretion

A

b1

36
Q

water reabsorption

A

v2

37
Q

NE receptor affinity

A
  1. a1
  2. b2
    = increased SVR
38
Q

Dobutamine receptor affinity

A
  1. b1 =inotropic
  2. b2
    ±a1
    = increased CO
    decreased SVR

cardiogenic shock, pump failure

39
Q

EPI receptor affinity

A
  1. a1, b1
  2. b2
    = increased CO
    low dose = low SVR
    high dose = high SVR
40
Q

Dopamine receptor affinity

A

Low: d1>b1(CO)
med: d1=b1(CO,SVR)
high: a1=d1=b1(SVR)

41
Q

Catecholamine effects

A

a=more SVR (PE,, NE, EPI)
* distributibe
* hypovolemic
* code
middle = dopamine
b= more CO (Dobutamine, ISO)
* cardiogenic
* cardiomyopathy

42
Q

Pressors tx

A
  1. NE
  2. ADH
  3. EPI if previous not working
  4. Dobutamine: if need more CO (cardiogenic)
  5. AGII = vasoconstriction for refractory shock (distributive)
  6. PE: not used, purely alpha constriction
43
Q

use of steroids in sepsis

A

improves physiologic response to sepsis in refractory shock
1. regualtes inflammation
2. inhibits inducible NOS
3. reverses adrenergic receptor desensitization (pressor works better)
4. increases Na and water retention (increase volume) - MC

use when poor response to fluid+pressor

44
Q

Choosing steroid for septic shock

A
  1. Hydrocortisone 200 mg IV QD x 3-7 days
  2. Fludrocortisone 50mcg PO daily (MC effect only)

fludricortisone usually adjunct to HC for additional MC effect

45
Q
A

PHM 703: Critical Care/Cancer (17 decks)

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