SIRS/Sepsis Flashcards
In regards to sepsis, explain the role/method of fluid resuscitation.
volume resuscitation using crystalloids or colloids should be used initially aiming at: CVP 8-12 mmHg, mean arterial pressure 65 mmHg, urine output 0.5ml/kg, central venous oxygen saturation 70%
Discuss the role of vasopressors and inotropes in the management of sepsis.
vasopressor support with norepinephrine may be considered even before optimal fluid loading has been achieved. Low dose vasopressin can be added to reduce requirement for high dose norepinephrine alone; inotropes are added to volume resuscitation and vasopressors, if there is evidence of continued low cardiac output despite adequate cardiac filling and fluid resuscitation
At what point should further IV fluid administration be stopped?
when filling pressures are high and no further improvement is seen in tissue perfusion
What happens to the MAC of inhalational anesthetics during severe sepsis?
reduction in MAC requirement
What is the goal of mechanical ventilation in patients with severe sepsis?
to use sufficiently high FiO2 concentration to maintain adequate oxygenation; strong evidence supports the use of low tidal volume strategy to minimize overall impact of positive pressure ventilation on lung tissue….. and venous return…. and cardiac output
What % of patients with sepsis will develop septic shock?
~50%
What is the relationship between sepsis and SIRS?
sepsis is defined as SIRS in response to an infectious process; sepsis is a potentially fatal whole body inflammation caused by severe infection that is now in the blood stream; sepsis can continue even after the infection is gone
What are the 3 levels of sepsis?
SIRS, severe sepsis, septic shock
What is the criteria for SIRS?
manifestation of 2 or more of the following: abnormal temp (>38 or 90, RR >20 or PaCO2 12,000 or 10% immature (band) forms
What is sepsis?
sepsis is a systemic inflammatory response (SIRS) in response to an insult to a host…. in association with infection; manifestations are the same as those described for SIRS; so you must have a DOCUMENTED INFECTION in conjunction with 2 or more: abnormal temp, tachycardia, tachypnea or hyperventilation, or abnormal WBC (>12 or 10% immature “band” forms)
What is severe sepsis?
in simple terms: sepsis complicated by organ dysfunction
severe sepsis is sepsis that is associated with organ dysfunction or hypotension; hypoperfusion and perfusion abnormalities may include lactic acidosis, oliguria, or acute alteration in mental status
may see hypoxemia 1.5, hyperglycemia in absence of diabetes (stress response)
What is septic shock?
sepsis complicated by high lactate level or by shock that doesn’t improve after fluid resuscitation
What is MODS?
multiple organ dysfunction syndrome that may occur with severe sepsis or septic shock; perfusion is compromised, ischemia and hypoxia of organs
What are organ system specific indicators of MODS?
Cardio: heart failure (need for inotropes despite fluid resuscitation), Neuro: change in LOC, Pulmonary: ARDS, Renal: ARF, Metabolic: acidosis, Hepatic: liver failure, Hematologic: disseminated intravascular clotting
What are potential stimuli for activation of an inflammatory response?
trauma, surgery, organ dysfunction, infection with microorganisms or viruses
With SIRS there is an activation of inflammatory response: cytokines, TNF-alpha, IL-1, IL-6, IL-8, PAF, prostaglandins, leukotrienes, neutrophil activation, complement system, vascular endothelial cells, activation of clotting and kinin cascades, thromboxane, prostacylin, prostaglandin.
What are clinical manifestations seen after this response?
vasodilation, increased capillary permeability, cellular activation, coagulopathy
What is lactic acid?
it is the end point of anaerobic breakdown of glucose in the tissues
Why is there an increase of lactate level in sepsis?
in sepsis, the adrenergic state and cytokine storm changes glucose metabolism, lactate metabolism, and lactate use; the heart and brain can take up lactate and use it for energy…. so lactate generation is probably an adaptive response to stress situations
Basic thinking is as oxygen to the tissues decreases, lactate increases… but this isn’t entirely true b\c in sepsis there may be good global oxygen delivery