Septic Shock

Question 1

What is sepsis-3

Answer 1

Life threatening ORGAN DYSFUNCTION OR DAMAGE (SOFA greater than 2) due to disregulated host response to INFECTION

Question 2

What is shock

Answer 2

A state in which there is failure of the circulatory system to maintain adequate cellular perfusion and/or oxygen delivery

Question 3

What are the three vital components of shock

Answer 3

Arterial hypotension (absolute or relative/ MAP less than 65), clinical signs of hypoperfusion, abnormal cellular oxygen metabolism (hyperlactatemia)

Question 4

What is the major criteria of the Systemic Inflammatory Response Syndrome (Hint: two or more of the following

Answer 4

Temperature greater than 100.4F (38.3C) OR less than 98.6F (36C)
Heart Rate greater than 90 beats per min
Respiratory rate greater than 20 breaths per min or PaCO2 less than 32 mmHg
WBC greater than 12,000 OR less than 4000 OR greater than 10% are bands

Question 5

What is the most likely cause of SIRS

Answer 5

Infection

Question 6

What is Septic shock

Answer 6

Sepsis that currently causes ORGAN DAMAGE PLUS VASOPRESSORS given to maintain MAP greater than 65mmHg PLUS serum lactate greater than 2 mmol/L

Question 7

What are vasopressors

Answer 7

Medications that contract blood vessels and raise blood pressure used to treat severely low blood pressure for those who are critically ill

Question 8

What are the two biggest culprits for organisms that lead to sepsis, what comes in as a faraway 3rd

Answer 8

Gram positive and gram negative organisms, fungi

Question 9

T/F: Patients will have an extremely high chance of dying from septic shock if there are more than two organ systems that are in dysfunction

Answer 9

True

Question 10

What is the KEY difference between septic shock and other shocks

Answer 10

Septic shock DOESN’T have an initial decrease in Cardiac Output (high output shock state)

Question 11

What is the disease continumm of septic shock and the mortality associated

Answer 11

Infection (no SiRS): 20%/ SiRS plus suspected infection: 20%/ Sepsis with organ damage: 30%/ Septic shock: 50%

Question 12

In Sepsis what causes the immune system to defend and what is the consequence with regards to blood

Answer 12

Infection releases endotoxins that causes the immune and inflammatory response, the inflammatory response then causes the procoagulation pathway to be activated increasing the amount of microvascular thrombi

Question 13

How does the increase in thrombin lead to more targeted organ damage (Hint: method, and direct 3 consqeuences)

Answer 13

Fibronolytic response tries to reduce the procoagulation but the anti-fibronolytic stumps this response leading to more clotting causing less blood to the organs/ enhanced formation of clots, thrombosis of small vessels, impaired tissue perfusion

Question 14

What are the two proteins that causes thrombi to not be broken down in the anti-fibronolytic stage of sepsis

Answer 14

Thrombin-activatable fibrinolysis inhibitor (TAFI) and Plasminogen activator inhibitor 1 (PAI-1)

Question 15

What is the biggest hemodynamic change in Septic shock why

Answer 15

Systemic vascular resistance reduced due to the inflammatory response in the body

Question 16

What are the other hemodynamic compensations for Septic shock

Answer 16

Increased Heart rate, Cardiac output early is increasing but late it decreases, decreased preload

Question 17

What is the most important fact about antimictrobial therapy for sepsis

Answer 17

Administration of effective antibiotics within the first hour of recognition

Question 18

What are the early goal directed therapy for paitents with Septic Shock

Answer 18

Volume resuscitate the patient (check if CVP 8-12 mmHg), check the arterial pressure (MAP greater than 65), check for organ malperfusion

Question 19

Which crystalloids would go into the intravascular space as needed

Answer 19

Normal Saline, Lactated Ringers, and Plasmalyte/ 30mL/kg IV bolus using total body weight

Question 20

T/F: Colloids, such as albumin, are first line for giving volume to patients with Septic shock

Answer 20

False: Crystalloids are first line

Question 21

When would patients recieve colloids instead of crystalloids

Answer 21

Patient starts to have pulmonary edema, renal failure, liver failure, unable to remove the excess fluid

Question 22

What is the order for vasopressors used in Septic shock, which have little to not great data, what should never be used and why

Answer 22

Norepinephrine, vasopressin, epinephrine/ Angiotensin 2 and phenlyepherine/ dopamine

Question 23

What receptors are needed to be activated when using vasopressors

Answer 23

Alpha 1 agonist

Question 24

When would an ionotrope be given in Septic shock, what is the risk

Answer 24

If the patient still has organ failure after adequate volume resuscitation, Dobutamine, arrhythmias

Question 25

In shock what should be elevated due to it being a stessful enviornment

Answer 25

Cortisol

Question 26

When can it be determined that a patient has adrenal insufficiency in Septic Shock, what is this called

Answer 26

Patient hypotension resonds poorly to adequate fluid resuscitation and vasopressors (often 2 vasopressors) Catecholamine refreactory septic shock

Question 27

Which corticosteroids would be given for catecholamine refreractory septic shock, benefits

Answer 27

Hydrocortisone 200-300 mg/day, gets patient off vasopressors quicker and improves mortality

Question 28

What are the parameters of the quick Sofa score

Answer 28

SBP less than 100 mmHG (low blood pressure), Respiratory rate greater than 22 breaths per minute (fast respiratory rate), Glascow coma score less than 15 (altered mental status)

Question 29

What are other things patients need for if sent to the ICU

Answer 29

VTE prophylaxis, insulin, stress ulcer prophylaxis