Sepsis, SIRS, MODS

Question 1

local inflammation reaction

Answer 1

tissue damage –> release of pro-inflammatory cytokines (TNF-a, IL-1, IL-6)

beneficial/protective mechanism for tissue healing as long as cytokines remain LOCAL

Question 2

cardinal signs of inflammation

Answer 2

1. heat
2. swelling
3. redness
4. pain
5. loss of function

caused by vasodilation, increased vascular permeability, and inflammatory mediators stimulating sensory nerve endings

Question 3

systemic inflammation reaction

Answer 3

severe/widespread tissue damage OR local inflammation spread systemically –> systemic release of TNF-a, IL-1, IL-6

NOT a beneficial/protective mechanism for tissue healing

results in SIRS

Question 4

systemic inflammatory response syndrome (SIRS)

Answer 4

systemic response to a non-infectious insult

caused by:
- heat stroke/burns
- trauma
- pancreatitis
- immune mediated disease
- neoplasia
- local infections spread systemically

Question 5

when can SIRS criteria be applied

Answer 5

in systemically ill patients only

Question 6

SIRS criteria

Answer 6

1. temperature
2. heart rate
3. respiratory rate
4. WBC count & %bands

Question 7

dog SIRS criteria

Answer 7

must meet 2/4

1. high or low temp
2. high HR
3. high RR
4. high or low WBC count, high bands

Question 8

cat SIRS criteria

Answer 8

must meet 3/4

1. high or low temp
2. high or low HR
3. high RR
4. high or low WBC count

Question 9

sepsis

Answer 9

SIRS that is caused by an infectious insult

must have infection AND systemic signs of inflammation

causes:
- septic peritonitis
- pneumonia
- pyothorax
- prostatitis
- pyelonephritis
- systemic mycoses
- viral/parasitic/protozoal infections

Question 10

multi organ dysfunction syndrome (MODS)

Answer 10

classified as two or more organs that become dysfunctional in a systemically ill patient to the point where they can no longer sustain the patient

subjective evaluation by clinician

Question 11

severe sepsis

Answer 11

SIRS + infection + MODS

can progress to septic shock

Question 12

septic shock

Answer 12

subset of sepsis that causes profound circulatory, cellular, and metabolic abnormalities

SIRS + infection + refractory hypotension

requires more therapy than just IV fluid bolus

Question 13

why does sepsis, severe sepsis, and septic shock need to be differentitated

Answer 13

variable prognosis

sepsis > severe sepsis > septic shock

Question 14

SIRS treatment steps

Answer 14

1. CV stabilization - ER
2. antimicrobials - ER, if suspected infection
3. source control - procedure
4. CV optimization - ICU
5. manage secondary organ dysfunction - ICU

Question 15

CV stabilization

Answer 15

fluid resuscitation
- isotonic crystalloid bolus at shock dose (start at 1/4 to 1/2)
- do NOT used synthetic colloids

want to reach endpoint (normalized perfusion parameters) within 6 HOURS of admission
- lactate < 2
- MAP > 65
- UOP: > 0.5 mL/kg/hr

Question 16

antimicrobial therapy

Answer 16

IV antibiotics in all patients that have SUSPECTED infection

want to administer within 1 HOUR of admission
- start with empiric than adjust once culture and susceptibility performed

1. Unasyn
2. Enrofloxacin

Question 17

source control

Answer 17

identify the anatomic site of infection and initiate source control (usually surgical)

want to remove the source of infection within 12 HOURS of stabilization
- always resuscitate patient first

Question 18

cardiovascular optimization

Answer 18

improve CV parameters by increasing SVR and HR

Question 19

CV optimization steps

Answer 19

ALWAYS give O2 supplementation

1. vasopressors
2. inotropic therapy
3. corticosteroids
4. antiarrhythmics

Question 20

vasopressors

Answer 20

norepinephrine
- a1 agonist –> vasoconstriction –> inc SVR –> inc BP

indications: MAP < 65 after fluid therapy
goal: MAP > 65

Question 21

inotropic therapy

Answer 21

dobutamine
- increases contractility

indications: MAP < 65 after fluids and vasopressors
goal: MAP > 65

Question 22

corticosteroids

Answer 22

hydrocortisone
- increases tissue perfusion + reduces inflammation

indications: MAP < 65 after fluids, vasopressors, dobutamine
goal: MAP > 65

Question 23

antiarrhythmics

Answer 23

lidocaine bolus followed by CRI
- stabilizes CV function

indications: hemodynamically relevant ECG (tachyarrhythmia, multiform, clinical collapse)

Question 24

how does infection affect the tree of life

Answer 24

infection –> decreased preload, contractility, HR, O2 saturation, and SVR

proinflammatory cytokines:
- vasodilation
- increased permeability
- decreased myocardial function

leads to hypotension, hypovolemia, systolic dysfunction –> hypoperfusion