Sepsis pt 2 Flashcards
1
Q
Procalcitonin: What is procalcitonin and how does it relate to assessing sepsis?
A
- Protein biomarker for bacterial infection
2
Q
Procalcitonin: How does the utilization of procalcitonin impact antibiotics?
A
- Can be utilized to deescalate antibiotics.
3
Q
Procalcitonin: A value above or equal to ___ ng/mL is highly suggestive of sepsis.
A
2
4
Q
National impact of severe sepsis: (T/F) Severe sepsis patients are likely to have high mortality rates.
A
- TRUE
5
Q
National impact of severe sepsis: Broadly describe the impact of severe sepsis patients with the hospital lengths of stay.
A
- Long lengths of stay
6
Q
National impact of severe sepsis: How do severe sepsis patients impact ventilator usage?
A
- High ventilator usage
7
Q
National impact of severe sepsis: (T/F) It’s super cheap and affordable to get sepsis. Don’t worry about it.
A
- False * High costs, * Lower payment-to-cost ratios
8
Q
Severe sepsis is common: How many cases of severe sepsis are there in the US annually?
A
- 750,000 to 1.5 million cases annually
9
Q
Severe sepsis is common: About what proportion of severe sepsis patients involve an ICU stay?
A
- > 50% of these cases
10
Q
Severe sepsis is common: How many deaths from severe sepsis occur annually in the US?
A
~210,000
11
Q
Severe sepsis is common: ___% of hospitalizations are due to sepsis in the US but account for >50% of deaths while hospitalized.
A
-10%
12
Q
Severe sepsis is common: Per ICU admission source data, where in the hospital do severe sepsis patients originate?
A
- ED: 37% - Floor: 32% - Post-op: 16% - Other hospital: 13% - Other: 2%
13
Q
Risk factors: Patients at higher risk for developing sepsis?
A
- All critically ill - Severe CAP - Intra-abdominal surgery - Meningitis - Chronic dz (DM, HF, CRF, COPD) - Immunocompromised - Cellulitis - UTI
14
Q
Risk factors: (T/F) A patient of __[a]__ (younger/older) age with an underlying comorbidity and at a __[b]__ (lower/higher) body weight is at greater risk of developing sepsis than most patients.
A
15
Q
Sepsis symptoms: SEPSIS is an acronym that can help you remember S/Sx. What does the first “S” stand for?
A
- S - Shivering, fever, or very cold
16
Q
Sepsis symptoms: SEPSIS is an acronym that can help you remember S/Sx. What does the “E” stand for?
A
- E - Extreme pain or general discomfort (“worst ever”)
17
Q
Sepsis symptoms: SEPSIS is an acronym that can help you remember S/Sx. What does the “P” stand for?
A
- P - Pale or discolored skin.
18
Q
Sepsis symptoms: SEPSIS is an acronym that can help you remember S/Sx. What does the second “S” stand for?
A
- S - Sleepy, difficult to wake up, confused
19
Q
Sepsis symptoms: SEPSIS is an acronym that can help you remember S/Sx. What does the “I” stand for?
A
- I - “I feel like I might die”
20
Q
Sepsis symptoms: SEPSIS is an acronym that can help you remember S/Sx. What does the third “S” stand for?
A
- S - Short of breath
21
Q
Recognizing Sepsis: What does SIRS stand for?
A
- Systemic inflammatory response syndrome (SIRS)
22
Q
Recognizing Sepsis: Describe SIRS.
A
- SIRS is a serious condition related to Systemic inflammation, organ dysfunction, and organ failure.
- It is a subset of cytokine storm, in which there is abnormal regulation of various cytokines.
- SIRS is also closely related to sepsis, in which patients satisfy criteria for SIRS and have a suspected or proven infection
23
Q
SIRS criteria: SIRS criteria involves four components. What are the four components?
A
- Temperature - Heart rate - Respiratory rate or PaCO2 - WBC
24
Q
SIRS criteria: SIRS criteria involves four components. How many of the components need to be positive for the patient to truly meet SIRS criteria?
A
- Greater than or equal to 2 positive components.
25
SIRS criteria: Temperature has to be above and below what levels to be considered a positive for SIRS criteria?
- Temp. > 38C (100.4F) - Temp. < 36C (96.8F)
26
SIRS criteria: RR has to be above what rate per minute to be considered a positive for SIRS criteria?
RR > 20
27
SIRS criteria: Heart rate has to be above what BPM to be considered a positive for SIRS criteria?
- HR > 90 BPM
28
SIRS criteria: PaCO2 has to be of what value to be a positive component for the SIRS criteria.
- PaCO2 < 32 mmHg
29
SIRS criteria: (T/F) For the respiratory to be positive, the PT needs to have an RR >20 *in addition to* their PaCO2 being < 32 mmHg.
- False - Either one indicates a positive. They don't need to coexist.
30
SIRS criteria: WBC needs to have what properties to be a positive component for the SIRS criteria?
- WBC > 12,000/mm^3 [or] - WBC < 4,000/mm^3 [or] - >10% bands *** First one is on the PPT, the other two are on MDcalc. Pick your poison.
31
SIRS: What GI conditions can mimic a systemic inflammatory response?
- Pancreatitis - GI bleed
32
SIRS: What endocrine conditions can mimic a systemic inflammatory response?
- DKA - Adrenal insufficiency
33
SIRS: What hypersensitivity reaction can mimic a systemic inflammatory response?
- Anaphylaxis
34
SIRS: What CV condition(s) can mimic a systemic inflammatory response?
- PE/DVT
35
SIRS: What autoimmune condition(s) can mimic a systemic inflammatory response?
- LSE flare
36
Sepsis with acute organ dysfunction: Dermatology appearance?
- Areas of mottled skin
37
Sepsis with acute organ dysfunction: Cap refill time?
- >- 3 seconds
38
Sepsis with acute organ dysfunction: Urine output?
- <0.5 mL/kg 1 hr or RRT
39
Sepsis with acute organ dysfunction: Lactate levels greater than what level?
> 2 mmol/L
40
Sepsis with acute organ dysfunction: Mental status?
- Abrupt change in mental status
41
Sepsis with acute organ dysfunction: Platelet levels?
< 100,000 [or] - DIC
42
Sepsis with acute organ dysfunction: Respiratory impact?
- Acute lung injury - ARDS
43
Sepsis with acute organ dysfunction: CV impact?
- Cardiac dysfunction
44
Severe sepsis: What is the MCC of severe sepsis?
- Pneumonia (~50% of cases)
45
Severe sepsis: Blood cultures are positive in ___ of PTs experiencing severe sepsis.
1/3
46
Severe sepsis: When blood cultures come back positive, the presence of a gram negative bacterial organism occurs in ___% of cases.
62%
47
Severe sepsis: When blood cultures come back positive, the presence of a gram positive bacterial organism occurs in ___% of cases.
47%
48
Severe sepsis: When blood cultures come back positive, the presence of a fungal organism occurs in ___% of cases.
19%
49
Severe sepsis: Per the traditional definition of sepsis, the trio of (i) infection, (ii) SIRS, and (iii) ___ combine to form a positive screen suggestive of severe sepsis.
- organ dysfunction
50
Sepsis - Tx: What are the three phases to sepsis treatment?
- Resuscitation phase - Initial management phase - Maintenance phase
51
Sepsis - Tx: What is the time frame that composes the resuscitation phase?
- 1st six hours
52
Sepsis - Tx: While the resuscitation phase is the first six hours, what should the actual goal be to initiate treatment?
- Strive for within first 3 hours
53
Sepsis - Tx: The initial management phase consists of what timeline?
- First 24 hours
54
Sepsis - Tx: The maintenance phase consists of what timeline?
> 24 hours
55
Sepsis - Tx: The resuscitation phase consists of many components. What are they?
- Airway (access and maintain) - Pan-culture - Initiate appropriate Abx therapy - IV fluids - Tight glycemic control - Vasopressors - Sedation - (+/-) Steroids
56
Sepsis - Tx: Discuss what "pan-culture" refers to in the resuscitation phase.
(?) - Cultures that test for both bacterial and fungal causes.
57
Sepsis - Tx: The initial volume of IV fluids should be 30 mL/kg under what conditions?
- MAP < 65 - Lactate > 4 mmol/L
58
Sepsis - Tx: "tight glycemic control" involves not only routinely assessing BGL but also treating the patient with what via IV?
- Continuous insulin drip
59
Sepsis - Tx: What are the vasopressors utilized in the resuscitation phase?
- Dobutamine - *norepinephrine* (1st line) - *dopamine* (use is discouraged) - phenylephrine - epinephrine - vasopressin
60
Sepsis - Tx: Why may steroids be a part of the treatment plan during the resuscitation phase?
- Adrenal insufficiency
61
Sepsis - Tx: The "Hour 1 Bundle" is the first hour within the resuscitation phase that a lot needs to happen. What are the five procedures/labs of this period?
1) Measure lactate level
2) Obtain blood cultures before administering Abx
3) Administer broad-spectrum antibiotics
4) Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate >- 4 mmol/L
5) Vasopressors
62
Sepsis - Tx: The vasopressors administered during the "Hour 1 Bundle" must be administered to maintain MAP greater than or equal to what value?
MAP >- 65 mmHg
63
Sepsis - Tx: You've measured a lactate level during the resuscitation phase. When would you consider measuring the lactate level again?
- Remeasure lactate if initial lactate is elevated (> 2mmol/L)
64
Sepsis - Tx: CVP goal during the resuscitation phase?
- CVP 8-12 mmHg
65
Sepsis - Tx: MAP goal during the resuscitation phase?
- MAP 65 mmHg
66
Sepsis - Tx: Formula for (approximate) MAP?
~ DBP + 1/3*(SBP - DBP)
67
Sepsis - Tx: When considering a patient's MAP, what is an alternative to calculating an approximate value?
- Direct invasive monitoring
68
Sepsis - Tx: Urine output goal during sepsis resuscitation?
0.5 mL/kg/hr
69
Sepsis - Tx: Central venous or mixed venous oxygen saturation goals?
- 70%, 65% respectively
70
Sepsis - Tx: What is the point of having goals for the CVP, MAP, urine output, and venous oxygen saturation?
- Maintaining a patient within these markers has been shown to reduce the 28-day mortality rate.
71
Vasopressors: What is the preferred first-line vasopressor?
- Norepinephrine
72
Vasopressors: How does the consideration of using dopamine compare to the other vasopressors?
- Dopamine is typically discouraged.
73
Vasopressors: When is phenylephrine considered as part of the vasopressor therapy?
- Commonly used as an add-on, but data is limited.
74
Vasopressors: While norepinephrine is the preferred first line vasopressors, what are two other common medications utilized for this purpose?
- Vasopressin - Epinephrine
75
Sepsis - Tx: What are the three main components of the initial management phase?
- Continue Resuscitation phase - Monitor cultures for targeting Abx therapy - Constant monitoring of Vasopressors & MAP
76
Sepsis - Respiratory: Respiratory support must be considered in the prevention of ARDS. What can we do for the patient to minimize their risk of ARDS?
- Elevate the head of the bed
| - Use mechanical ventilation weaning protocols
77
Sepsis - Respiratory: CXR appearance of ARDS?
- Bilateral diffuse fluffy infiltrates - Normal cardiac size - (+/-) Tracheostomy tube - (+/-) EKG wires
78
Sepsis - CNS Support: What are considerations and protocols in place for PT's CNS support?
- Sedation protocols
| - Avoid neuromuscular blockers if possible
79
Sepsis - CNS Support: When is it most difficult to avoid neuromuscular blockers?
- in PTs with ARDS
80
Sepsis - CNS Support: How do you compromise between appropriate neuromuscular Tx for ARDS support?
- Short course of neuromuscular blocker for patient with early, Severe ARDS.
81
Sepsis - Maintenance phase: If the patient of severe sepsis survives > 24 hours, special attention must be given to prevent ___ infections.
- nosocomial
82
Sepsis - Maintenance phase: Why might your antibiotic therapy of choice change in the maintenance phase compared to the resuscitation phase?
- Tailor Abx therapy as culture information becomes available.
83
Sepsis - Maintenance phase: When considering BGLs, your main goal is to keep blood glucose in what range?
< 180 mg/dL
84
Sepsis - Maintenance phase: What is an appropriate procedure for a patient who has experienced renal failure or fluid overload?
- Dialysis
85
Sepsis - Maintenance phase: What CV dz do you have to be especially aware of in a patient being treated for severe sepsis?
- DVT
| - Consider DVT prophylaxis
86
Sepsis - Maintenance phase: What GI complication may you consider prophylaxis for?
- Stress-ulcer
87
Sepsis - Maintenance phase: (T/F) Parenteral feeding is preferred over enteral feeding.
- FALSE - Enteral feeding if possible.
88
Sepsis - Causes: When considering causes of sepsis, what tissues or organs are you considering as the most likely initially impacted structures (the cause of the sepsis)?
- Lungs - Urinary tract - GI - skin and soft tissue
89
Sepsis - Causes: What bacteria are the MCCs of sepsis?
(?) - Staph - Strep - H. flu
