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Clinical Decision Making II-Fall 21' > Sepsis-Van Bockern > Flashcards

Sepsis-Van Bockern Flashcards

1
Q

Sepsis is the consequence of a dysregulated __________

A

inflammatory response to an infection

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2
Q

Gram ______ bacteria are the pathogens that are most commonly isolated from patients with sepsis.

A

positive

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3
Q

SIRS criteria

A

t: >100.4
RR: >20
HR: >90
WBC: >12,000, <4,000, >10% bands, PCO2 <32 mmHg

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4
Q

Sepsis is diagnosed when how many SIRS criteria are met?

A

-2 SIRS + Confirmed or Suspected infection

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5
Q

Severe Sepsis is defined as:

A

Sepsis + Signs of end organ damage + Hypotension (SBP <90) + Lactate >4mmol

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6
Q

Septic shock= Severe Sepsis with persistent _________

A

Signs of end organ damage, hypotension (SBP <90), Lactate >4mmol

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7
Q

Sepsis is defined as life-threatening organ dysfunction caused by _________

A

a dysregulated host response to infection; organ dysfunction is defined as an increase of two or more points in the sequential (sepsis-related) organ failure assessment (SOFA) score.

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8
Q

QSOFA:

SOFA score is an illness-severity score used to predict _______

A
  • mortality of critically ill Pts (used in the ICU), SIRS is used on the floor
  • Patients with suspected sepsis can be rapidly identified if they meet at least 2 of three criteria of the score.
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9
Q

T/F: Lactate is superior to qSOFA for sepsis prognostication.

A

T!

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10
Q

QSOFA score criteria:

A
  • low BP (SBP < or equal to 100)
  • high RR (> or equal to 22/min )
  • altered mental status (GCS less than or equal to 14)

(1 point for each of the criteria met)

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11
Q

Take home points regarding Sepsis

A
  • SIRS may over AND under diagnose but still has a role to play
  • SOFA is cumbersome in the ED but great for ICU patients
  • qSOFA is a screening tool NOT a diagnostic tool
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12
Q

List Sepsis Risk factors

A
  • advanced age
  • Immunosuppression/steroid use/malnutrition
  • DM/CA/HIV/liver disease
  • Recent abx/drug-resistance
  • Alcohol/drug use
  • Recent procedures or travel
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13
Q

DDx: fever

A
  • sepsis
  • Drug Rxn
  • VTE
  • Malignancy**
  • Rheumatological**
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14
Q

Lab findings in Sepsis

A
  • WBC >12,000 or 140 mg/dL in the absence of diabetes.
  • CRP >2 S.D. above normal
  • Arterial hypoxemia
  • INR >1.5 or aPTT >60 s
  • Platelet count 4 mg/dL
  • lactate >2 mmol/L
  • Procalcitonin >2 S.D. above normal
  • adrenal insufficiency or euthyroid sick syndrome L
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15
Q

Sepsis Case Study: Pt 1
Pt is a 48 year old female with PMH of HIV who presented to the hospital with diarrhea for the last 5 days. She’s unable to tolerate anything PO. Vitals: temp 39.0, RR 15, HR 104, BP 90/70. On exam she had dry MM, tachy with a regular rhythm, tender abd, but no distention. Her labs are significant for an abnormal CBC with WBC at 19k. Abnormal BMP with cr of 2.1, Na 131, and K 3.0. ECG nml. UA nml.

What should you do next?
a) This patient meets sepsis criteria. Start IVF, identify source, and get blood cultures

b) This patient does not meet sepsis criteria. Start IVF and Imodium
c. ) This patient meets sepsis criteria and is hemodynamically unstable Start IVF, broad spectrum abd (Vanco, cefepime, and metronidazole), identify source, and get blood cultures
d. ) The patient had diarrhea she can d/c home

A

c.) This patient meets sepsis criteria and is hemodynamically unstable Start IVF, broad spectrum abd (Vanco, cefepime, and metronidazole), identify source, and get blood cultures

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16
Q

What should be included in her sepsis work up? (full sepsis w/u)

A
  • blood cultures
  • CXR
  • UA
  • Stool PCR (IF Pt is having diarrhea)
  • Cd4/viral load
  • CT-abd
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17
Q

Sepsis: Pt 1
-Pt’s CD4 trend went from 381 to 141 (**emergent)

-what should the Pt be started on prophylactically?

A

bactrim– proph for Pneumo J

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18
Q

Sepsis Pt 1: Putting it all together
#Sepsis 2/2–> Salmonella Enteritis with
#Salmonella Bacteremia: Pt initially met sepsis criteria with temp, tachycardia, RR, and elevated WBC. Stool PCR + salmonella. 1/2 blood cultures with enterobacteriaceae suspected salmonella. CT with new pancolitis and mild terminal ileitis.
-Continue _______ 750mg daily (stop date 10/27)
–Supportive care with ______

A
  • levofloxacin (for 14 days)
  • -Repeat blood cultures pending
  • -Supportive care=antiemetics, IVF, and APAP
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19
Q

Sepsis Pt 2:
81 y.o.femalewith h/o of CVA who was admitted by home health agency due to decreased PO intake and altered mental status found to have a UTI
Vitals: 115/57, RR 17, HR 66, Pulse ox %100 on 3L
Gen: Appears ill, Dry MM, No evidence of volume overload
Labs: WBC 12.6, Macrocytic Anemia, Elevated Cr, Hyponatremia, elevated troponin
ECG: No evidence of ischemia UA: Positive
Does this patient meet sepsis criteria?

A

no she does not meet sepsis criteria–her V/S are normal and she just has an elevated WBC

  • address elevated troponin in your note, document all abnormal lab values: elevated Cr, hyponatremia, and elevated troponin– could be AKI
  • AKI—she definitely has since her Cr is elevated

Cr- 2.1

AKI: must determine:

  • Pre Renal
  • post renal
  • Intrinsic

Calculate FeNa— for this Pt must add on urine sodium and urine Cr and urine osmolality- this calculation will tell you her cause is pre renal

-with hyponatremia– always get urine sodium and urine osmo

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20
Q

Causes of megaloblastic anemia?

A

-Vit B12, Folate, ETOH!!!!!

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21
Q 
Sepsis case: Pt #2
#Acute UTI with Leukocytosis:Urine culture resulted with Enterococcus. 
-Pt was switched to fosfomycin last night. 
-Discussed with pharmacy and given pt susceptibilities, allergies, Qtc prolongation risk, and age IP pharmacy recommended Vanco x 3 days (end date 11/6). 
-IVF as needed
A

Cant put her on amiodarone cuz she is high risk for QTc prolongation
-allergies—allergic to fluoroquinolones

-Pharmacy recommended starting her on vanco

Type 1 MI: STEMI
Type 2 MI: Demand/sepsis, heart failure, volume overload (cirrhosis)

DON’T ASSUME Pt is having an MI just cuz their troponin is elevated, start thinking MI if they are having CP

-megaloblas

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22
Q

Empiric IV Antibiotics (list ex’s)

A

-Ampicillin-sulbactam
-Piperacillin-tazobactam
-CeftriaxoneCefepime
-Ertapenem Meropenem
-Aztreonam
-Gentamicin
-CiprofloxacinLevofloxacin
Azithromycin
Doxycycline
Cefazolin
Vancomycin
Daptomycin
Linezolid
Metronidazole
Clindamycin

Special situations:TMP-SMX,Ampicillin

23
Q

Coverage selection (Abx) are based on:

A
  • gram +
  • gram -
  • anaerobes
  • pseudo
  • MRSA
  • Atypical PNA
  • Special situations
24
Q

Empiric Inpatient coverage (list 4 main ones)

A
  • pseudomonas
  • MRSA
  • Anaerobes
  • Special situations
25
Q

Sepsis Patient 3 –Empiric Coverage:
62 year old female admitted for a UTI being treated with CTX develops hypotension overnight. You are called to bedside by the rapid response team. What should you do?
A.) IVF, Continue CTX, and Call ICU
B.) IVF, Switch to Vanco, and Call ICU
C.) IVF, Switch abx to pip-taz and vanco, and Call ICU
D.) Give her some cranberry juice for her UTI

A

C.) IVF, Switch abx to pip-taz and vanco, and Call ICU

26
Q

List Abx that cover for pseudomonas

A 
Cefepime
Piperacillin-tazobactam
Meropenem
Gentamicin
Aztreonam
Ciprofloxacin, levofloxacin
27
Q

List Abx that cover MRSA

A

Vancomycin
Clindamycin
TMP/SMX
Doxycycline

28
Q

List Abx that cover anaerobes

A 
Ampicillin-sulbactam
Piperacillin-tazobactam
Meropenem, ertapenem
Metronidazole**
Clindamycin

(Abdominal infections for anaerobic coverage prescribe metronidazole!! )

29
Q

Atypical Pneumonia Coverage (organisms)

A

Chlamydophila pneumoniae
Legionella pneumophila
Mycoplasma pneumoniae

30
Q

Sepsis- Patient 4
71 y/o M hx alcohol abuse, T2DM, CAD, p/w cough and fever.
T: 39.0 deg C HR: 124 BP: 82/40 RR: 24 SpO2: 84% RA; 92% 2L NC
Standard initial workup: ?

A

CBC, BMP +/- LFTs, Blood cultures, Lactate, UA, CXR

31
Q 
Sepsis Pt 4: initial w/u 
-CBC: Plt 102, WBC 18k
-CMP: Cr 1.2, BUN 26, T bili 1.6
-Blood cultures drawn
--lactate: 4.2
UA-neg
-CXR: right basilar infiltrate

Should this Pt be inpatient or outpatient?
–what is his CURB-65 score?

A

inpatient!!!

use CURB-65

-confusion +- 1
-BUN >19
RR > or equal to 30
SBP < 90 or DBP ≤ 60
Age >65

score of 5

32
Q

___ days is always recommended for CAP abx tx

A

5

33
Q

Patient 4 –CURB 65

-when is a Pt considered high risk?

A

BUN > 19, SBP < 90 or DBP ≤ 60, Age > 65
–> 3 risk factors; high risk
Admit for PNA

34
Q

slide 40

A

slide 40

35
Q

Case 4: tx started
You give ceftriaxone, azithromycin, and a 30 cc/kg fluid bolus.
After initial treatment, the serum lactate is 2.4, and BP is 102/80.
What type of Lactic Acidosis did this patient have?

A

type A

36
Q

Lactate Acidosis is a measure of _______

A

**tissue hypoperfusion

37
Q

Lactate acidosis:

-Type A=

A
  • Tissue hypoperfusion from sepsis hypovolemia

- Shock

38
Q

Lactate acidosis:

-Type B=

A 
Metformin
DKA
Alcohol abuse
Liver disease
HIV meds
39
Q

Case 4 Continued:
Your patient then starts to develop EtOH withdrawal
He develops delirium tremens and is admitted to ICU and placed on a ______

A

dexmedetomidine (Precedex) drip and scheduled lorazepam.

40
Q

Case 4 cont:
On hospital day 4, he develops a temperature of 39 deg C, HR of 120, RR of 32, and BP of 98/50. WBCs trend up to 16k. Lactate is 3.4. CXR shows bibasilar infiltrates. COVID: negative.
–Abx selection?

A

HAP: cover MRSA and Pseudomonas

–Cefepime 2g IV Q8hr

41
Q

Hospital Acquired Pneumonia:

-obtain ______

A
  • Obtain respiratory specimen prior to the start of antibiotics when possible
  • Non-invasive respiratory specimens such as sputum or tracheal aspirate should be interpreted with caution as there is possibility for contamination or colonization

•In patients with septic shock, use dual gram-negative coverage pending culture results

42
Q

In MICU, serial _______ levels may assist in the determination of duration of antibiotic therapy

A

procalcitonin

43
Q

HCAP flow-sheet:

-PNA developed within ______ hours after hospital admission or while Pt was on a ventilator

A

equal to or greater than 48 hours–> IF not, follow CAP guidelines

44
Q

HCAP: work-up?

A
  • blood cultures x2 prior to abx tx
  • Resp specimen for culture prior to abx tx, if possible
  • Influenza PCR–if influenza season
  • MICU only: urine strep PNA and procalcitonin
45
Q

HCAP: empiric abx therapy?

A

-cefepime 2g IV q8hrs
(for serious type 1 PCN allergy–> give Levo 750 mg PO/IV daily)
-

46
Q

For ventilator assoc. PNA Pts with hx of MRSA or use of IV abx in the last 90 days tx with—>

A

add vanco (to cefepime for HCAP tx)

–and for severely ill Pts with septic shock 2/2 PNA: add vanco and amikacin

47
Q

Aspiration PNA: what is the big Question?

A

In the inpatient setting, should patients with suspected aspiration pneumonia receive additional anaerobic coverage?
–Not routinely (unless lung abscess or empyema)

48
Q

Sepsis:
___% die in first 30 days
-___% die in the first 6 months

A
  • 30%
  • 50%

**Important to recognize and treat quickly.

49
Q

The usual suspects:

A

PNA, bloodstream infxns (infective endocarditis), intravasc catheter-related sepsis, intra-abd infections, urosepsis, surgical wound infxns

50
Q

Resuscitation Goals: for septic Pts

A
  • central venous pressure: 8-12
  • MAP: 65
  • Urine output: 0.5 mL/kg1/hr
  • CVP (superior vena cava or mixed venous O2 sat–70%
51
Q

Intravenous antibiotic therapy should be started within________ of recognition of severe sepsis, after appropriate cultures have been obtained

A

the first hour

52
Q

Case study: 42 yo M with cirrhosis coming in with melena
-V/S: 90/70, Hr-90, 95% on RA, 37.8-T, RR-16
Melena UGIB, IV PPI

Assessment and Plan: ?

A

suspected UGIB, start IV PPI, Q4hrs CBC, Octreotide, CTX (ceftriaxone—for SBP ppx)

–consult GI get on scheduled EGD

-Hgb: 6.8–> <7 transfuse STAT EGD —
Needs a stat EGD since he is likely bleeding—varice

-put clips on varice–> to stop the bleeding

53
Q

Case 2:
66 yo M coming in w SOB and orthopnea x 2 weeks, no chest pain, no N/V, no fever

Vitals: 142/90, 15, 92, 88% on RA, 37.5-T
-PE: elevated JVP, pitting edema, crackles

-Diagnostics?

A

CXR, BMP, BNP, Trop!!!! Since he has SOB/orthopnea
-EKG, TTE

Results:

  • CXR—shows pulm edema, cardiomegaly
  • BMP–> K: 3.6, Bicarb-ok, Cr: 2.1, Na: 130,

-BNP: super elevated at 12,000

Trop: mildly elevated
EKG: sinus with LVH, and no ST changes

A/P: #volume overload 2/2 suspected new onset HF—(wont know until echo results)
-Start Pt on Lasix 20mg IV, I/O and daily weight, TTE, supplemental O2,
#AKI: –> get UA so you can determine FeNa, and urine lytes: urine Na, Cr, K, osmo
#Hypervolemic hyponatremia Lasix, check urine sodium 2hrs after starting Lasix to determine if the Pt is responding to the current dose of Lasix (goal for urine sodium is b/w 60-80)
#Type 2 trop elev: Ekg and trop re check in 4 hours

Day 2: EF 38% and Pt has wall motion abnormalities, and diastolic dysfunction
#Acute decompensated biventricular HF
BP: 150/90, 90, 15, 92% 2L, no fever
Cr: 1.8, Na: 132,
–cant start the Pt on an ACEI due to Cr being at 1.8
-PT is still volume overloaded– increase Lasix to 40 mg BID– check urine Na 2 hours after
Systolic HF–> can be 2/2 MI–> consult cardiology
Treatment goals: BB and ACEI once Cr is stable

Clinical Decision Making II-Fall 21' (5 decks)

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