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MHD > Sepsis Syndrome > Flashcards

Sepsis Syndrome Flashcards

1
Q

What are the criteria for SIRS (systemic inflammatory response syndrome)? How many do you need?

A

2

  1. HR >90f
  2. RR >20 or PaCO2 18,000 or 10% immature
  3. Temperature >38 or
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2
Q

What is sepsis?

A

SIRS + culture documented infection

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3
Q

What is severe sepsis?

A

sepsis + organ dysfunction or hypoperfusion

  • lactic acid
  • oliguria
  • acute alteration in mental status
  • hypoxemia
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4
Q

What is septic shock?

A

refractory hypotension

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5
Q

What is the mortality from sepsis? What are the causes?

A

18-30%

causes: bacterial, fungal, viral, parasitic infection and non-infection

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6
Q

What is the source of biologic activity in the gram negative outer membrane? What are other microbial factors that cause sepsis?

A

Lipid A

Microbial: LPS, cell wall, fungal and parasite components

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7
Q

How does the innate immune system play role in sepsis?

A

TLR

  • recognize PAMPs
  • intracellular signaling
  • transcription of proinflammatory cytokines, TNF alpha, IL-1
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8
Q

What role do macrophages play in the sepsis?

A

LBP-lipopolysaccharide binding protein
-acute phase reactant that binds to LPS
LPS-LBP complex binds to CD14 receptors and TLR4 dimer on inflammatory cells
activates genes for production of IL-1, TNF alpha and others

Soluble CD14-LPF-LBP complexes bind to endothelial cells

  • adhesion molecules
  • cytokines
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9
Q

What are the two major cytokines in sepsis syndrome?

A

TNF alpha
IL-1

proinflammatory : tnf alpha, il-1, 2, 6,8, 10
Anti inflammatory: IL 6, 10

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10
Q

What are the causes of DIC and Fibrinolysis in Sepsis?

A

DIC:

  1. Coagulation cascade
    a. Extrinsic-TNF: Increase expression of tissue factor on monocyte
    b. Intrinsic-Factor 12 activated by microbial components including peptidoglycan, teichoic acid, and LPS

FIbrinolysis-TNF activation of plasminogen activator

–>result is DIC with microvascular thrombi and consumption coagulopathy

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11
Q

What are potential mediators of vasodilation in sepsis?

A
  1. Kinin system activated through factor 12 conversion of prekallikrein to kallikrein
  2. NO-inducible NO synthesis by LPS, IL1, TNF
  3. Impaired secretion of antidiuretic hormone (vasopressin)

Result is hypotension

  • redistribution of intravascular fluid volume
  • increased endothelial permeability
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12
Q

What causes cell injury in sepsis ?

A
  1. Ischemia
    - microcirculatory lesions disrupts oxygenation
    - receptor mediated neutrophil-endothelial adherence
  2. Direct Cytotoxicity
    - LPS, TNF alpha, NO damage mitochondria
  3. Apoptosis
    - Enhanced in epithelium, T and B cells, lung
    - Delayed in macrophages and neutrophils
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13
Q

What are the three components of shock?

A
  1. System arterial Hypotension

- systolic 1.5 mmol/L

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14
Q

What are the key concepts in sepsis recognition?

A
  1. Hypotension
  2. Exam: skin, RR, urine output, mental status
  3. SIRS findings
  4. Lab:
    - WBC, decreased platelets
    - decreased pO2 or SaO2
    - elevated creatinine, bilirubin, INR
    - elevated lactate
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15
Q

How do you manage sepsis?

A
  1. Resuscitation
    -Airway
    -Oxygen
    -Fluid Replacement-500ml/30 minutes
    30mL/Kg within the first 3 hours
    crystalloid
    CVP preferred
  2. Monitor tissue perfusion
  3. Evaluation of source
  4. Imaging
  5. Antimicrobial therapy* within first hour
  6. Vasopressors
    -Norepinephrine-b and alpha adrenergic
    -Vasopressin (antidiuretic hormone)
  7. Support failing organ systems
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16
Q 
Goal directed fluid resuscitation 
CVP
MAP
Urine output
SCVO2
Lactate
A

CVP: 8-12
MAP> or equal to 65
Urine output > equal .5
SCVO2 70% or mixed oxygen saturation SVO2 65%
Normalized lactate in patients with elevated lactate levels

17
Q

What is in the first 3 hours of sepsis bundles?

A

1) measure lactate level
2) obtain blood cultures and administer antibiotics
3) administer 30mL/kg crystalloid for hypotension or lactate>4mmol/L

18
Q

What needs to be done within the first 6 hours?

A
  1. apply vasopressor
  2. measure CVP ScVO2
  3. remeasure lactate
19
Q

When do you give corticosteroids in septic shock?

A

Hydrocortisone (200mg/day) in patients whom hypotension persists despite adequate resuscitation and vasopressor therapy

MHD (81 decks)

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