Sepsis/Septic Shock Flashcards
What is bacteremia?
Bacteria in the bloodstream
What is sepsis?
A systemic response to an infection leading to organ failure and death.
What is septic shock?
Subset of sepsis with circulatory and cellular/metabolic abnormalities
How can you monitor for organ dysfunction?
SOFA (sequential organ failure assessment) score
What is needed to calculate a SOFA score?
PaO2 Platelets Bilirubin MAP GCS score Cr and Urine output
A SOFA score greater than ___ reflects a mortality risk of 10% in a hospitalized patient.
2
SOFA scores cannot be done quickly at bedside. What assessment can be used quickly at bedside to assess for sepsis?
qSOFA
What are the components of the qSOFA?
Respiratory rate >/= 22
Altered mental status (GCS <13)
Systolic BP = 100mmhg
How many components of the qSOFA must be met to indicate a poor outcome?
2
What is the driving force of acute organ dysfunction in sepsis?
Coagulopathy
List 4 classic signs of inflammation.
Redness
Heat
Swelling
Pain
What is responsible for down regulation of the initial proinflammatory response?
Interleukin system (IL4 and IL10)
Severe sepsis disrupts homeostasis by activating ____ and _____, and suppressing ______.
Inflammation and coagulation
Finbrinolysis
What is the key inhibitor of fibrinolysis in sepsis?
Plasminogen activator inhibitor 1 (PAI-1)
PAI-1 is produced by?
Endothelial cells
______ released by gram negative rods increase activity of PAI-1
Endotoxins
What are the lab findings of DIC?
Elevated: PT, PTT, Fibrin monomers, D-dimer
Decreased: Protein C, Fibrinogen, Platelet count
What are the lab findings of sepsis?
Elevated: Cr, ALT AST T bili, Lactate, Procalcitonin.
What is procalcitonin?
Protein biomarker for bacterial infection
What is the normal level for procalcitonin?
What value suggests sepsis?
Normal is = 0.15 Values > 2.0 is suggestive of sepsis
Where do the majority of sepsis patients originate?
Emergency department (37%) and Floor (32%)
What are the effects of sepsis on the body?
- Decreased 02 delivery because of damaged to capillaries
- Decreased cardiac output (increase heart rate)
- increased anaerobic metabolism
- DIC
What is the most common cause of severe sepsis?
community acquired pneumonia
A lactate level greater than what indicates severe sepsis?
greater than 2mmol/L
What are the three phases of sepsis treatment?
- Resuscitation Phase ( 1st 6hours/sooner the better
- initial management phase (24 hours)
- Maintenance phase (>24 hours)
Do you assess and maintain airway during the resuscitation phase?
Yes
What elements are included in the resuscitation phase?
- Access and maintain airway
- Pan-culture
- Initiate appropriate antibiotic therapy
What is this? - IV fluids (If MAP <65 or lactate >4) initial volume 30ml/kg
- Tight glycemic control (continuous insulin drip)
- Vasopressors-dobutamine, norepinephrine, dopamine, phenylephrine, epinephrine, vasopressin
- Sedation
- Steroids possibly
What are the goals of sepsis resuscitation? (other than survival of course)
- CVP 8-12mm hg
- MAP 65mm Hg
- Urine output 0.5ml/kg/hr
- General venous or mixed venous O2 sat 70% or 65% (respectively)
Reduces 28-day mortality rate
What do you do during the hour 1 bundle: initial resuscitation
- Measure lactate level
- Obtain blood cultures before admin of antibiotics
- Administer broad spectrum antibiotics (vanco, pip/tazo/ carbapenems)
- begin rapid admin of 30ml/kg crystalloid for hypotension or lactate > 4
- Maintain MAP >/= 65mmhg (vasopressors)
Why would you administer vasopressor?
Vasopressors are used to stimulate vasoconstriction and increase blood pressure for pts in shock
What are some vasopressor medications?
- Norepinephrine- this is the preferred first line
- Vasopressin
- Epinephrine
- Phenylephrine- commonly used as add on
What vasopressor analog is discouraged from being used?
dopamine
What elements are apart of the “initial management phase”
- Continue the resuscitation phase
- Monitor cultures for targeting antibiotic therapy
- Constant monitoring of vasopressors (maintenance of MAP >65mmhg
What is a common respiratory problem and needs special attention to pressure and volumes?
ARDS
What will ARDS look like on X-ray?
Bilateral diffuse fluffy infiltrate, normal cardiac size
What type of medications should you avoid when giving central nervous system support?
Avoid neuromuscular blockers if possible (in pts without ARDS)
What type of protocol do you implement with central nervous system support?
Sedation protocol
What is involved with the maintenance phase?
- if survive >24 hours, attention to preventing nosocomial infections
- Restore premorbid condition
- Tailor antibiotic therapy as culture info available
What is involved with general supportive care for sepsis pts?
- Blood glucose management <180 mg/dl
- Dialysis for renal failure or fluid overload
- DVT prophylaxis- Low molecular weight heparin
- Stress-ulcer prophylaxis- commonly a PPI or H2 blocker
- Enteral feeding if possible
What causes sepsis?
- Lungs
- Urinary tract
- GI
- Skin and Soft tissue
What are most common bacteria for sepsis?
strep pneumo, staph and ecoli
