T7 - Sépsis e MODS (1)

Question 1

Sepsis - Epidemiologia?

Answer 1

➢ Síndrome frequente
➢ Aumento de incidência: aumentou a populaçao imunodeprimida e fragilizada, esperança media de vida aumentou, mais indivíduos suscetíveis a infeção e a agressividade dos procedimentos de saúde realizados
➢ The case fatality rate of reported sepsis/septic shock range from 22% to 55%

Question 2

Sepsis?

Answer 2

➢ Infection + Organ dysfunction (at least 1)
➢ Like many syndromes, there is no ‘gold standard diagnostic test for sepsis
➢ Around 2/3 of sepsis cases come from the community and present to ED

➢ qSOFA
- FR >22 /min
- altered mentation
- PAS <100 mmHg

Question 3

Septic shock?

Answer 3

➢ Is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality (>40%)

Question 4

Shock?

Answer 4

➢ ‘… a life-threatening, generalized form of acute circulatory failure associated with inadequate oxygen by the cells. It is a state in which the circulation is unable to deliver sufficient oxygen to meet the demands od the tissues, resulting in cellular dysfunction.’
➢ Inadequate delivery
- inadequate oxygenation
- inadequate perfusion
➢ Inadequate extraction

Question 5

O2 delivery?

Answer 5

➢ Main determinants:
- Caridac Output (CO = VE x FC)
- Arterial oxygen content (CaO2)
. Oxygen supplementation
. Early endotracheal intubation / Mechanical ventilation
. Blood transfusion

Question 6

What is Cardiac Output?

Answer 6

➢ Cardiac Output (CO) = SV x HR
➢ Stroke Volume (SV)
– the amount of blood the heart pumps in one cardiac cycle
➢ It is influenced by:
– Preload: degree of myocardial distension prior to shortening. An increase in the distension of the ventricle will therefore result in an increase in the force of contraction, which will increase cardiac output (LVEDV ou LVEDP)
– Afterload: force against which the ventricules must act in order to eject blood, and is largely dependent on the arterial BP and vascular tone (SVR)
– Contractility (ionotropism)

Question 7

Lactate?

Answer 7

➢ Hyperlactatemia:
– may be due to an increase in production, a decrease in clearance or a combination of both
– associated with worse outcome in any type of shock
➢ The prognostic value of lactate levels exceeds that of blood pressure / oxygen-derived variables
➢ Association between initial serum lactate level and mortality independent of clinical signs of organ dysfunction
➢ Lactate as a tool to monitor treatment response: early decrease may indicate the resolution of global tissue hypoxia and has been associated with a decreased mortality rate

Question 8

ScvO2?

Answer 8

➢ Level of oxygen saturation measured from the superior vena cava
➢ Its value is the balance between DO2 and VO2, indicating how much oxygen remains after delivery to the cells
➢ Used to indicate an adequate level of oxygenation at the cellular level
➢ The physiological value is 70% to 90%
➢ If the level of ScvO2 is below 70%, attempts to increase oxygen content will be performed
➢ ScvO2 >70% after resuscitation may not reflect adequate tissue oxygenation since the cells may not be able to utilize oxygen
- due to impairment of the microcirculation or mitochondrial dysfunction

Question 9

CO2 Gap?

Answer 9

➢ Under normal physiological conditions <6 mmHg
➢ An increase can be caused by an increase in venous CO2 from stagnant blood flow from the capillary bed with continuous CO2 production. Therefore variação de PCO2 has a correlation with tissue perfusion, which depends on changes in blood flow, but not changes in oxygen content, making its increase to be in an ischemic state, not in a hypoxic state
➢ Significant correlation with microcirculatory dysfunction
➢ Increase in PCO2 variation may be due to lactic acid buffering by bicarbonates (anaerobic respiration) during a late hypoxic state/impairment of oxygen extraction

Question 10

Septic Shock Therapy?

Answer 10

➢ Antibiotic Therapy
➢ Organ support
➢ Source control

Question 11

Tx ATB?

Answer 11

➢ Hit hard with appropriate antibiotics (s) administred adequately - early, IV, high dose ,PK/PD
➢ De-escalate when possible

Question 12

Dose, Dose Interval, and Penetration?

Answer 12

➢ Os ATBs que mais utilizamos são o Beta Lactamicos e este são tempo dependents: a sua atividade bacteriona depend eod tempo me que a concentraçoa esta acima da MIC da bactéria
➢ Pathogen
➢ Patient
- weight
- albumin level
- organ function
- measured creatinine cleareance
- extracorporeal Support
- biofilm
- fluids ressuscitation
- septic inflamatory state

Question 13

Surgery consultation?

Answer 13

➢ Early surgery consultation must be obtained for suspected acute abdomen and necrotizing infections
➢ Drainage, debridement plus device removal, decompression, and restoration of anatomy and function
➢ When clinical examination does not reveal the source, CT imaging would detect the majority of infection sources
➢ If rapidly progressive diseases (necrotizing skin and soft tissue infections or gastrointestinal tract perforation) are present, surgery is needed within 1 to 2 hours after diagnosis

Question 14

Initial Management of Shiock?

Answer 14

➢ V - Ventilate (oxygen admioistration)
➢ I - Infuse (fluid ressuscitation)
➢ P - Pump (vasoative drug)

Question 15

Ventilatory support?

Answer 15

➢ Started immediately to increase oxygen delivery and prevent pulmonary hypertension
➢ Pulse oximetry: often unreliable as a result of peripheral vasoconstriction - Blood Gas Analysis
➢ Non-invasive mechanical ventilation (NIMV) has a limited role
➢ Invasive MV in nearly all patients with severe dyspnea, hypoxemia, or persistent or worsening acidemia (ph <7.3)
➢ Invasive mechanical ventilation has the additional benefits of reducing the oxygen demand of respiratory muscles and decreasing left ventricular afterload by increasing intrathoracic pressure

Question 16

Initial Resuscitation Bundle?

Answer 16

➢ Measure lactate level. Remeasure if initial lactate is >2 mmol/L
➢ Obtain blood cultures prior to administration of antibiotics
➢ Administer broad-spectrum antibiotics
➢ Begin rapid administration of 30 ml/kg of crystalloid for hypotension or lactate >4 mmol/L
➢ Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP >65 mmHg

Question 17

Fluid Therapy of Severe Sepsis?

Answer 17

➢ Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock
➢ Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock
- VISEP
- CRYSTMAS
- CHEST
➢ We recommend that in the resuscitation from sepsis-induced hypoperfusion, at least 30 ml/kg of intravenous crystalloid ve given within the first 3 hours
➢ We recommend that following initial fluid resuscitation, additional fluids be guided by frequent reassessment of hemodynamic status
➢ We recommend using albumin in addition to crystalloids when patients require substantial amounts of crystalloids

Question 18

Fluid Challenge?

Answer 18

➢ Rate of Infusion: 500 ml - 1000 ml of crystalloids or 300-500 ml colloids over 30 mins
➢ Goal: reversal of the marker of perfusion failure that prompted the fluid challenge
➢ Safety limits: CVP of 15 mmHg measured every 10 mins

Question 19

Fluid Responsiveness?

Answer 19

➢ Spontaneous breathing
– PLR: increase in stroke volume variation or cardiac output >12%
– Inferior Vena Cava (IVC), collapsibility index >40%
➢ Mechanical Ventilation
– End-Expiratory occlusion test: increase in cardiac output or arterial pulse pressure >5%
– Inferior Vena Cava distensibility index >18%

Question 20

Vasopressors?

Answer 20

➢ Vasopressor therapy initially to target a mean arterial pressure of 65 mmHg
➢ Norepinephrine as the first choice vasopressor

➢ Epinephrine - when an additional agent is needed to maintain adequate blood pressure
➢ Vasopressin - can be added to norepinephrine with the intent of either raising MAP or decreasing NE dosage (only in patients with high value of cardiac output)