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Surviving Sepsis Campaign > Surviving Sepsis > Flashcards

Surviving Sepsis Flashcards

1
Q

Sepsis

A

life-threatening organ dysfunction caused by a dysregulated host response to infection

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2
Q

Septic shock

A

subset of sepsis with circulatory and cellular/metabolic dysfunction associated
with a higher risk of mortality

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3
Q

Initial resuscitation

A

Recommend that treatment and resuscitation begin immediately

Early effective fluid resuscitation for stabilization of sepsis induced tissue hypoperfusion or spetic shock

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4
Q

What is the recommended human dose of crystalloids for sepsis induced tissue hypoperfusion?

A

At least 30 mL/kg of IV crystalloid fluid be given within the first 3 hours

a. Fixed volume of fluid enables initiation of resuscitation while obtaining more specific information and while awaiting more precise measurements of hemodynamic status (PROCESS and ARISE, 2 L in PROMISE Trial)
b. little literature includes controlled data to support this volume of fluid

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5
Q

What is the recommendation following initial fluid resuscitation?

A

Additional fluids be given and guided by frequent reassessment of hemodynamic status
a. Reassessment should include a thorough clinical examination and evaluation of available physiologic variables (heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output, and others, as available) as well as other noninvasive or invasive monitoring

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6
Q

What is the recommendation if the type of shock is not elucidated from reassessment?

A

Further hemodynamic assessment (such as assessing cardiac function) to determine the type of shock
Ex- echocardiography

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7
Q

Are dynamic variables recommended over static to predict fluid responsiveness?

A

NO, It is only suggested that dynamic over static variables be used to predict fluid responsiveness, when available

a. CVP no longer justified (static)
b. Dynamic measures demonstrated better diagnostic accuracy at predicting those patients who are likely to respond to a fluid challenge by increasing SV
i. Fluid challenges against stroke volume measurements or the variations in systolic pressure, pulse pressure in mechanically ventilated patients

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8
Q

What is the recommended initial target MAP in patients with septic shock requiring vasopressors?

A

65 mm Hg
-Human studies comparing MAP of 65 mmHg to 85 mmHg revealed improved cardiac index, but did no change in renal function, arterial lactate levels or oxygen consumption, 1 study had mortality as primary outcome and there was no significant difference in mortality at 28 or 90 days; higher risk of arrhythmias at maintaining MAP at 85 mmHg; Subgroup of older patients (>75 years) had reduced mortality at MAP of 65 mmHg

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9
Q

True or false: It is recommended to guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion

A

False–> Suggested

a. NOT A DIRECT MEASURE OF TISSUE PERFUSION→ surrogate
b. A significant reduction in mortality was seen in lactate-guided resuscitation compared to resuscitation without lactate monitoring, but no evidence for difference in ICU length of stay

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10
Q

What is normal MAP for dogs and cats?

A

60-100 mmHg

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11
Q

What is normal SAP for dogs and cats?

A

90-140 mmHg (D)

80-140 mmHg (C)

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12
Q

What is normal DAP for dogs and cats?

A

50-80 mmHg (D)

55-75 mmHg (C)

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13
Q

What is the recommendation for screening for sepsis and performance improvement?

A

Recommend that hospitals and hospital systems have a performance improvement program for sepsis, including sepsis screening for acutely ill, high-risk patients

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14
Q

True or false: Sepsis screening has been associated with decreased mortality

A

True
Due to IMPLEMENTATION of “BUNDLE” (core set of recommendations- separate development)
-Vary widely, but use of performance improvement programs with sepsis bundling and practice guidelines such as SSC were associated with significant increase in compliance and reduction in mortality

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15
Q

Overall hospital mortality rate has decreased by how much for every 3 months a hospital participated in the SSC?

A

Mortality decreased 0.7% for every 3 months a hospital participated in the SSC

Associated with a 4% decreased LOS for every 10% improvement in compliance with bundles
i. Study of 1800 patients with sepsis or septic shock demonstrated a 36%–40% reduction of the odds of dying in the hospital with compliance with either the 3 or 6 hour SSC bundles

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16
Q

True or false: Recommend that appropriate routine microbiologic cultures be obtained before starting antimicrobial therapy in patients with suspected sepsis or septic shock

A

True
If doing so results in no substantial delay in the start of antimicrobials
Sterilization of cultures can occur within minutes to hours after the first dose of an appropriate antimicrobial

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17
Q

True or false: Appropriate routine microbiologic cultures always include at least two sets of blood cultures (aerobic and anaerobic)

A

True

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18
Q

True or false: Pan culture of all sites that could potentially be cultured should be discouraged because this practice can lead to inappropriate antimicrobial use

A

True

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19
Q

How long of a time frame can be considered to be no substantial delay in the initiation of antimicrobial therapy while cultures are being obtained?

A

45 minutes

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20
Q

What is the mainstay of antibiotic stewardship programs and is associated with less resistant microorganisms, fewer side effects, and lower costs?

A

Antibiotic de-escalation

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21
Q

In potentially septic patients in whom a site of infection is not clinically apparent, what should be evaluated and where should at least one blood culture set should be obtained from?

A 
Evaluate IVC (in place > 48 hours) should be removed in whom a site of infection is not clinically apparent or a suspicion of IVC-associated infection exists
At least one blood culture set should be obtained from the IVC
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22
Q

True or false: Without suspicion of catheter-associated infection and in whom another clinical infection site is suspected, at least one blood culture should be obtained peripherally

A

True
No recommendation can be made as to where additional blood cultures should be drawn.
Options include:
a) all cultures drawn peripherally via venipuncture
b) cultures drawn through each separate IV device but not through multiple lumens of the same IVC or
c) cultures drawn through multiple lumens in an intravascular device

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23
Q

Administration of IV antimicrobials should be initiated as soon as possible after recognition and within how long for both sepsis and septic shock?

A

1 hour

Mortality increases by 7.6% for every hour without antimicrobials

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24
Q

What are causes of delays to antimicrobials?

A

High frequency of failure to recognize potential existence of sepsis or septic shock and of inappropriate empiric antimicrobial initiation

25
Q

What are possible solutions to delays in antimicrobial initiation?

A

Use of “stat” orders or including a minimal time element in antimicrobial orders, communication, addressing delays in obtaining blood and site cultures pending antimicrobial administration, and sequencing antimicrobial delivery optimally or using simultaneous delivery of key antimicrobials
i. Expedited IV access→ IO catheters, IM drugs

26
Q

It is recommended that empiric broad-spectrum therapy with one or more antimicrobials for patients presenting with sepsis or septic shock be initiated. What drives choice of antimicrobials?

A

Choice of empiric antimicrobial therapy depends on complex issues related to the patient’s history, clinical status, and local epidemiologic factors

27
Q

Because of the high mortality associated with inappropriate initial therapy, empiric regimens should err on the side of over-inclusiveness; What factors must be assessed and used in determining the appropriate antimicrobial regimen at each medical center and for each patient?

A

ia) Anatomic site of infection with respect to typical pathogen profile and to the properties of individual antimicrobials to penetrate that site
b) Prevalent pathogens within the community, hospital, and even hospital ward
c) Resistance patterns of those prevalent pathogens
d) Presence of specific immune defects (neutropenia, splenectomy and acquired or congenital defects of immunoglobulin, complement or leukocyte function or production
e) Age and patient comorbidities including chronic illness (e.g., diabetes) and chronic organ dysfunction (e.g., liver or renal failure), presence of invasive devices that compromise the defense to infection

28
Q

What risk factors should be assessed for infection with MDR pathogens?

A

Prolonged hospital/chronic facility stay, recent antimicrobial use, prior hospitalization, and prior colonization or infection with MDR organisms

29
Q

What can improve outcome in some circumstances regarding acquired pathogens?

A

Early involvement of infectious diseases specialists

30
Q

What is recommended once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted?

A

Recommend that empiric antimicrobial therapy be narrowed
Important strategy to reduce both the development of pathogen resistance and cost
Spectrum of coverage should be narrowed by eliminating unneeded antimicrobials and replacing broad-spectrum agents with more specific agents (de-escalation)

31
Q

How many patients with sepsis DO NOT have a causative pathogen identified?

A

~ ⅓ of patients

32
Q

Why is it recommended against use of sustained systemic antimicrobial prophylaxis in patients with severe inflammatory states of noninfectious origin (e.g., severe pancreatitis, burn injury)?

A

Sustained systemic antimicrobial therapy in the absence of suspected infection should be avoided in order to minimize likelihood that patient will become infected with an antimicrobial-resistant pathogen or will develop a drug related adverse effect
i. Meta-analyses demonstrate no clinical advantage of prophylactic antibiotics that would outweigh their long-term adverse effects

33
Q

True or false: Recommend that dosing strategies of antimicrobials be optimized based on accepted pharmacokinetic/pharmacodynamic principles and specific drug properties in patients with sepsis or septic shock

A

True
Clinical success rate for treatment of serious infections correlates with higher peak blood levels
i. Fluoroquinolones, aminoglycosides, B-lactams
ii. B-lactams can have increase in T>MIC if used increased dosing or utilize CRI over a few hours rather than 30 minutes (rec by some)
-Some meta-analyses suggest that extended/continuous infusion of β-lactams may be more effective than intermittent rapid infusion, particularly for relatively resistant organisms and in critically ill patients with sepsis

34
Q

What are physiologic perturbations that dramatically alter antimicrobial pharmacokinetics?

A
  1. Unstable hemodynamics, increased cardiac output, increased extracellular volume (markedly increasing volume of distribution), variable kidney and hepatic perfusion (affecting drug clearance) and altered drug binding due to reduced serum albumin
    ii. Augmented renal clearance is a recently described phenomenon→ may lead to decreased serum antimicrobial levels in the early phase of sepsis
35
Q

True or false: It is recommended against use of combination therapy for the routine treatment of neutropenic sepsis/bacteremia?

A

True
This does not preclude the use of multidrug therapy to broaden antimicrobial activity
-Meta-analysis/metaregression analysis have demonstrated that combination therapy produces HIGHER SURVIVAL in severely ill SEPTIC PATIENTS with a high risk of death (septic shock); also suggests possibility of increased mortality risk with combo therapy in LOW RISK patients without septic shock
-Direct evidence from adequately powered RCTs is not available to validate this approach definitively

36
Q

If combination therapy is initially used for septic shock, we recommend de-escalation with discontinuation of combination therapy within the first few days in response to clinical improvement and/or evidence of infection resolution. What are recommended approaches?

A

a) clinical progress (shock resolution, decrease in vasopressor requirement, etc.)
b) infection resolution as indicated by biomarkers (especially procalcitonin)
c) a relatively fixed duration of combination therapy

37
Q

True or false: It is recommended that an antimicrobial treatment duration of 7 to 10 days is adequate for most serious infections associated with sepsis and septic shock

A

False- Only suggested
Subgroup analysis of the most critically ill subjects (APACHE II score greater than either 15 or 20) in the short course of antimicrobials in the intra-abdominal sepsis study of Sawyer et al demonstrated no difference in outcome based on duration of therapy

38
Q

How often should patients be assessed for de-escalation of antimicrobial therapy in patients with sepsis and septic shock?

A

Daily

39
Q

True or false: Suggest that measurement of procalcitonin levels can be used to support shortening the duration of antimicrobial therapy in sepsis patients

A

True
Randomized trial on procalcitonin use in critically ill patients with presumed bacterial infection demonstrated evidence of a reduction in duration of treatment and daily defined doses of antimicrobials; PC group also showed decrease in mortality; HOWEVER other meta-analysis RCTs of de-escalation failed to demonstrate similar findings

40
Q

True or false: Decisions on initiating, altering, or discontinuing antimicrobial therapy should never be made solely on the basis of changes in any biomarker

A

TRUE

41
Q

Recommend that a specific anatomic diagnosis of infection requiring emergent source control be identified or excluded as rapidly as possible in patients with sepsis or septic shock, and that any required source control intervention be implemented as soon as medically and logistically practical after the diagnosis is made. What is the time frame for surgical source control?

A

TARGET OF NO MORE THAN 6-12 HOURS (small studies so not a definitive number)

42
Q

True or false: Recommend prompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established

A

True

43
Q

Recommend that a fluid challenge technique be applied where fluid administration is continued as long as hemodynamic factors continue to improve in order to avoid what?

A

Want to avoid sustained positive fluid balance during ICU stay as it is harmful so reassess in order to determine if additional fluid is needed

44
Q

What fluid type is recommended as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock?

A

Crystalloids

Although, absence of any clear benefit following administration of colloid compared to crystalloid solutions

45
Q

Although the guidelines are unable to recommend one crystalloid solution over another as no direct comparisons have been made between isotonic saline and balanced salt solution. However, what fluid type should be avoided?

A

Chloride-restrictive strategy as this can cause AKI

46
Q

Is it recommended to use albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement when patients require substantial amounts of crystalloids?

A

No, only suggested

a. SAFE study indicated that albumin administration was safe and equally effective as 0.9% saline in ICU patients requiring fluid administration
i. Albumin-treated patients vs crystalloids→ odds ratio of dying was significantly reduced for albumin-treated patients
ii. Xu et al→ reduced septic shock 90-day mortality and trended toward reduced 90-day mortality in sepsis
iii. Jiang et al→ mortality reduction trend reported when given <6 hours from sepsis ID
iv. Similar findings in Patel et al, BUT not consistent across individual severity subgroups
v. Rochwerg et al→ meta-analysis (~19,000 people) demonstrated no significant reduction in mortality
vi. ALBIOS trial→ No significant mortality benefit for alb vs crystalloids

47
Q

What colloid is NOT recommended for intravascular volume replacement in patients with sepsis or septic shock?

A

Hydroxyethyl starches (HESs)

a. Meta-analysis of nine trials comparing 6% HES 130/0.38–0.45 solutions to crystalloids or albumin in patients with sepsis showed no difference in all-cause mortality
i. Resulted in higher risk of death compared to other fluids (low risk bias)–> 34 more deaths per 1,000 people
ii. Led to higher risk of need for RRT
b. Albumin vs HES resulted in lower risk of death and trend toward less of a need for RRT

48
Q

What is the recommended first-choice vasopressor?

A

Norepinephrine

a. Increases MAP due to its vasoconstrictive effects, with little change in heart rate and less increase in stroke volume compared with dopamine (NE more potent)
i. Lower mortality and less arrhythmogenic than dopamine

49
Q

Suggest adding either vasopressin or epinephrine to norepinephrine with intent of raising MAP to target, or adding vasopressin to decrease norepinephrine dosage. What is the evidence?

A

a. Epinephrine may have deleterious effects on the splanchnic circulation and produces hyperlactatemia, BUT RCTs did not show worse clinical outcomes
i. Norepinephrine vs epinephrine demonstrated increase in adverse drug-related events with epi
ii. Epi increases aerobic lactate production via stimulation of skeletal muscle β2-adrenergic receptors so may preclude use of lactate clearance to guide resuscitation
b. Low doses of vasopressin may be effective in raising blood pressure in patients refractory to other vasopressors and may have other potential physiologic benefits
i. Relative vasopressin deficiency
ii. VASST trial→ norepinephrine alone vs norepinephrine plus vasopressin, showed no difference in outcome in intent-to-treat population

50
Q

Which vasopressor is not recommended in order to protect renal system?

A

Low-dose dopamine

51
Q

True or false: It is recommended that all patients on vasopressors have an arterial catheter

A

False
Only suggest that all patients requiring vasopressors have an arterial catheter placed
a. In shock states, estimation of blood pressure using a cuff may be inaccurate
b. Relatively safe, but complications
i. Higher risk of infections when femoral arterial catheters were used compared to radial artery catheters
c. Should be removed as soon as continuous hemodynamic monitoring is not required to minimize risk of complications

52
Q

What are some alternative inotropic agents were introduced/suggested?

A

a. Phosphodiesterase inhibitors increase intracellular cAMP and thus have inotropic effects independent of β-adrenergic receptors
i. Milrinone→ increase cardiac output in one small randomized trial of 12 pediatric patients
ii. Levosimendan→ increases cardiac myocyte calcium responsiveness and also opens ATP-dependent potassium channels→ inotropic and vasodilatory properties
iii. Trials comparing levosimendan with dobutamine are limited but show no clear advantage for levosimendan
iv. Significantly higher risk of supraventricular tachyarrhythmia than placebo

53
Q

What does the SS Campaign say about IV hydrocortisone?

A

Suggest against using IV hydrocortisone if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, we suggest IV hydrocortisone at a dose of 200 mg per day

  • CORTICUS→ enrolled patients with systolic blood pressure of < 90 mmHg despite adequate fluid replacement or need for vasopressors had a lower risk of death than above trial and failed to show a mortality benefit with steroid therapy
    1. Etomidate will suppress the hypothalamic pituitary-adrenal axis
    2. Subanalysis revealed use of etomidate before application of low-dose steroids was associated with an increased 28-day mortality rate
54
Q

Recommend that RBC transfusion occur only when hemoglobin concentration decreases below what Hb level in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, or acute hemorrhage?

A

<7 g/dL
PROCESS/TRISS trial addressed a transfusion threshold of 7 g/dL vs 9 g/dL
i. Results showed similar 90-day mortality, ischemic events, and use of life support in treatment groups with fewer transfusions in lower-threshold group

55
Q

What is not recommended for treatment of anemia associated with sepsis?

A

Erythropoietin

-May be associated with an increased incidence of thrombotic events in the critically ill

56
Q

What is the recommendation for antithrombin for the treatment of sepsis and septic shock?

A

Recommended not to utilize antithrombin

a. Decrease of plasma activity at onset of sepsis correlates with DIC and lethal outcome
b. Phase III clinical trial of high-dose antithrombin for adults with sepsis and septic shock did not demonstrate any beneficial effect on overall mortality
c. Antithrombin was associated with an increased risk of bleeding

57
Q

What is the recommendation regarding the use of thrombomodulin or heparin for the treatment of sepsis or septic shock?

A

No recommendations

a. Most RCTs of recombinant soluble thrombomodulin have been targeted for sepsis associated with DIC, and a systematic review suggested a beneficial effect on survival without an increase of bleeding risk
b. Recombinant activated protein C→ not shown to be effective for adult patients with septic shock by the PROWESS SHOCK trial (off market)

58
Q

True or false: It is suggested against the use of sodium bicarbonate therapy to improve hemodynamics or to reduce vasopressor requirements in patients with hypoperfusion-induced lactic acidemia with pH ≥ 7.15

A

True

No evidence supports use in tx of hypoperfusion-induced lactic acidemia associated with sepsis

Surviving Sepsis Campaign (1 decks)

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