Septic shock Flashcards
What does SIRS Stand for?
Systemic Inflammatory Response Syndrome
What are the 4 criteria for SIRS?
- Temperature
- Heart Rate
- Respiratory Rate
- WBC
What temperatures would indicate SIRS/
> 38C (100.4F)
<36 C (96.8)
What heart rate would lead you to suspect SIRS?
> 90bpm
What respiratory rate would indicate SIRS?
> 20rpm (pCO2 < 32)
What WBC would indicate SIRS?
> 12,000K/ul or <4000
Or >10% bands (immature forms)
In order to have SIRS, how many of the criteria do you have to have?
At least 2
According to ACCP/SCCM what is an infection?
-Inflammatory response to microorganisms
or
-Invasion of normally sterile tissues
What is the ACCP/SCCM definition of SIRS?
Systemic response to a variety of processes
What is the ACCP/SCCM definition of sepsis?
-Infection plus two or more SIRS criteria
What is the ACCP/SCCM definition of Severe Sepsis?
- Sepsis
- Organ Dysfunction
What is the ACCP/SCCM definition of Septic Shock?
- Sepsis
- Hypotension despite fluid resuscitation
What is the ACCP/SCCM definition of Multiple Organ Dysfunction Syndrome?
- Altered organ function in an acutely ill patient
- Homeostasis cannot be maintained without intervention
What does MODS stand for?
Multiple Organ Dysfunction Syndrome
T/F Anyone can present with sepsis and severe sepsis
True
Who are those who most often present with sepsis?
Those with pre-existing diseases such as:
- Cirrhosis
- Malignancy
- AIDS
- COPD
- Diabetes
- Cancer Therapy
What is the worldwide breakdown of organisms that cause sepsis today?
62% gram negative
47% gram positive
19% fungal
Hypotension in septic shock is defined as ________
<90 mmHg systolic
- or MAP of 70mmHG
- or reduction of SBP of 40mmHg from baseline
What are the differential diagnosis for shock/hypotension?
- Endocrine
- Neurogenic, anaphylactic
- Drugs, Distributive
- Septic
- Hypovolemia
- Overdose, Obstruction
- Cardiogenic
- Kills–all of these things will kill you if you don’t figure out what is going on to treat them
What is sepsis?
The clinical syndrome that results from a dysregulated inflammatory response to infection
Hypotension is often associated with ______
Organ damage or dysfunction
Secondary Multiple organ dysfunction is due to what?
- NOT due to infection itself
- Due to the host’s response
*Possibly dysregulation of the innate immune system
Primary multiple organ dysfunction is due to what?
- Result of well-defined insult.
- Renal failure from muscle to breakdown products
What is Rhabdomyolysis?
the destruction of striated muscle cells
What are the 3 mechanisms of tissue injury?
- Ischemia
- Cytopathic injury
- Increased apoptosis
What is ischemia?
Decreased O2 givien tissue needs
*often an uptake and not just delivery problem
What is Cytopathic injury?
Inflammatory mediators cause damage (direct and indirect)
What is apoptosis?
Programmed cell death
What does PIRO stand for?
Predisposition
Insult
Response
Organ Dysfunction
What is involved in the treatment of Sepsis?
- Gather data
- ABCs as normal
- Monitor Tissue perfusion
- Goal to restore tissue perefusion- Fluids > vasopressors
- Source control
- Monitor response to therapy
- Begin ICU prophylaxis, nutrition, PT etc.
What is some data your would gather to treat sepsis?
- Cultures
- CBC
- Chemistries
- Coags
- U/A
- EKG
- CXR
- ABG
What are some methods of source control in sepsis?
- Antibiotics
- Debridement
- Surgery
What is the 6 hour Resucitation bundle?
- Early Identification
- Early Antibiotics and Cultures
- Early Goal Directed Therapy
What signs in the CNS might indicate acute organ dysfunction as a marker of severe sepsis?
- Altered Consciousness
- Confusion
- Psychosis
- Delirium
What signs in the respiratory system might indicate acute organ dysfunction as a marker of severe sepsis?
- Tachypnea
- Hypoxemia
- Oxygen saturation <90%
- Decreased ratio of arterial oxygen vs. inspired oxygen
What signs in the liver might indicate acute organ dysfunction as a marker of severe sepsis?
- Jaundice
- Increased liver enzymes
- Hypoalbuninemia
- Increased prothrombin time
What signs in the Cardiovascular system might indicate acute organ dysfunction as a marker of severe sepsis?
- Tachycardia
- Hypotension
- Increased central venous pressure
- Increased pulmonary artery occlusive pressure
What signs in the Kidney might indicate acute organ dysfunction as a marker of severe sepsis?
- Oliguria
- Anuria
- Increased creatine
What hematological signs might indicate acute organ dysfunction as a marker of severe sepsis?
- Thrombocytopenia
- Abnormal Coagulation tests
- Decreased levels of Protein C
- Increased D-Dimers
In PIRO, what are things involved in predisposition?
- Host factors
- Co-morbidities
- Genetics
In PIRO, what are things involved in Insult?
- Specific infecting organism with special weapons (PAMPS)
Examples:
- Ebola - Gram negative with LPS - MRSA with cytolytic toxins
In PIRO, what is involved with Response?
Activation of the immune system (DAMPs)
In PIRO what is the organ dysfunction?
collateral damage
In monitoring tissue perfusion, what does the clinical assessment involve?
- Skin
- Urine output
- MSE
- etc.
In monitoring tissue perfusion, the pH and lactate have 2 mechanisms. What are they?
- Hypoxic
2. Non hypoxic
Describe the hypoxic mechanism
Anerobic production of lactate
*global with shock or local with bowel infarction
Describe the non hypoxic mechanism
Decreased clearance of lactate or accelerated aerobic glycolysis
What is the historic survival of sepsis if lactate is greater than 10?
less than 10%
