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

- sepsis - Drug Rxn - VTE - Malignancy - Rheumatological

Sepsis-Van Bockern Flashcards by Sammy B

Sepsis is the consequence of a dysregulated __________

inflammatory response to an infection

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

positive

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SIRS criteria

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

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Sepsis is diagnosed when how many SIRS criteria are met?

-2 SIRS + Confirmed or Suspected infection

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Severe Sepsis is defined as:

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

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Septic shock= Severe Sepsis with persistent _________

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

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

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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QSOFA:

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

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

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QSOFA score criteria:

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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Take home points regarding Sepsis

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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List Sepsis Risk factors

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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DDx: fever

sepsis
Drug Rxn
VTE
Malignancy**
Rheumatological**

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Lab findings in Sepsis

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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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

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

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

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

-what should the Pt be started on prophylactically?

bactrim– proph for Pneumo J

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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 ______

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

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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?

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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Causes of megaloblastic anemia?

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

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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

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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Empiric IV Antibiotics (list ex’s)

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

Special situations:TMP-SMX,Ampicillin

Coverage selection (Abx) are based on:

gram +
gram -
anaerobes
pseudo
MRSA
Atypical PNA
Special situations

Empiric Inpatient coverage (list 4 main ones)

pseudomonas
MRSA
Anaerobes
Special situations

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

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

List Abx that cover for pseudomonas

``` Cefepime Piperacillin-tazobactam Meropenem Gentamicin Aztreonam Ciprofloxacin, levofloxacin ```

List Abx that cover MRSA

Vancomycin Clindamycin TMP/SMX Doxycycline

List Abx that cover anaerobes

``` Ampicillin-sulbactam Piperacillin-tazobactam Meropenem, ertapenem Metronidazole** Clindamycin ``` (Abdominal infections for anaerobic coverage prescribe metronidazole!! )

Atypical Pneumonia Coverage (organisms)

Chlamydophila pneumoniae Legionella pneumophila Mycoplasma pneumoniae

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: ?

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

``` 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?

inpatient!!! use CURB-65 -confusion +- 1 -BUN >19 RR > or equal to 30 SBP < 90 or DBP ≤ 60 Age >65 score of 5

___ days is always recommended for CAP abx tx

Patient 4 –CURB 65 -when is a Pt considered high risk?

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

slide 40

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?

type A

Lactate Acidosis is a measure of _______

**tissue hypoperfusion

Lactate acidosis: | -Type A=

- Tissue hypoperfusion from sepsis hypovolemia | - Shock

Lactate acidosis: | -Type B=

``` Metformin DKA Alcohol abuse Liver disease HIV meds ```

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

dexmedetomidine (Precedex) drip and scheduled lorazepam.

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?

HAP: cover MRSA and Pseudomonas --Cefepime 2g IV Q8hr

Hospital Acquired Pneumonia: | -obtain ______

- 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

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

procalcitonin

HCAP flow-sheet: | -PNA developed within ______ hours after hospital admission or while Pt was on a ventilator

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

HCAP: work-up?

- 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

HCAP: empiric abx therapy?

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

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

add vanco (to cefepime for HCAP tx) --and for severely ill Pts with septic shock 2/2 PNA: add vanco and amikacin

Aspiration PNA: what is the big Question?

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

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

- 30% - 50% **Important to recognize and treat quickly.

The usual suspects:

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

Resuscitation Goals: for septic Pts

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

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

the first hour

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: ?

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

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?

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