Treatment Flashcards
True or false: IV angiotensin II has been shown to increase blood pressure and allow catecholamine dose reductions in patients with vasodilator shock receiving high dose norepinephrine
True
(And improved SOFA score but no difference in mortality)
What is the mortality rate for dogs with sepsis / septic shock
- 25% mortality for dogs with dysfunction of less than 2 organs
- 70% for dogs with multi-organ dysfunction
- 80% for dogs with septic shock
What are the recommendations regarding initial cardiovascular resuscitation of septic patients in the 2021 Surviving sepsis guidelines
- Begin resuscitation immediately
- Give at least 30 mL/kg of IV crystalloid fluids within the first 3h of resuscitation (weak recommendation)
- Use dynamic measures to guide fluid resuscitation - include stroke volume variation, pulse pressure variation, echocardiography, fluid challenges (very weak recommendation)
- Use serum lactate to guide resuscitation - while considering other possible causes of elevated lactate (weak recommendation)
- Use CRT to guide resuscitation as an adjunct to other measures (weak recommendation)
What is the target MAP for resuscitation of patients with sepsis? What patients could benefit from a higher target?
65 mmHg
Patients with chronic hypertension could benefit from higher target (reduction in need for RRT when targeting 80 mmHg)
What is an acceptable delay to obtain culture samples before starting antibiotics in a patient with suspect sepsis
< 45 min
What is the recommended timing to antibiotic initiation in patients with sepsis / septic shock
- In patients with possible septic and shock or definite / probable sepsis, antibiotics should be administered within 1h of recognition of sepsis
- In patients with possible sepsis without shock, more investigations should be performed to find the infection. If infection is still suspected, antibiotics should be administered within 3h of first suspicion of sepsis
- In patients with low suspicion of sepsis and no shock, antibiotics should not be administered and patient should be monitored
(- Procalcitonin should not be used to decide when to start antibiotics)
What mode of delivery is recommended in septic humans for beta-lactams? What should be used in veterinary medicine?
In humans recommend CRI following an initial bolus
No recommendation in veterinary medicine - CRI not proven to have any benefit, can be more difficult to manage (for administration of other drugs, procedures, walks, etc), can be underdosed if often interrupted or in case of increased clearance -> not recommended. Can use prolonged intermittent boluses (over 3 hours)
What is the recommended use of procalcitonin for patients with sepsis in the 2021 Surviving sepsis guidelines
Use procalcitonin + clinical assessment to decide when to stop antimicrobials
(Do not use to decide if / when to start antimicrobials)
What is the recommended approach in a patient with sepsis that could be secondary to an IV catheter infection
- If septic shock is present, establish alternative IV access and remove the possibly infected IV
- If the patient is not in shock, ideally the catheter should still be removed but prolonged antimicrobial therapy could be considered as an alternative if catheter cannot be removed (long-term tunnelled catheter)
For common infections, what is generally considered a short course of antibiotics vs. a long course? What duration is recommended for patients with sepsis?
Short = 5-7 days
Long = 10-15 days
Short course recommended if source control is good and in pneumonia, bacteremia, UTI, intra-abdominal infection (no real recommendation when there is no direct source control)
What are the recommendations regarding vasopressor use in the 2021 Surviving sepsis guidelines
- Norepinephrine as first-line agent over other vasopressors, and specifically over dopamine (strong recommendation)
- For patients with septic shock on norepinephrine with inadequate MAP, suggest adding vasopressin instead of escalating norepinephrine > 0.5 mcg/kg/min
- For patients with inadequate MAP despite norepi and vasopressin, suggest adding epinephrine
- For patients with septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate volume status and MAP, suggest adding dobutamine to norepi or using epi alone
(- Recommended to consider invasive BP monitoring if possible
- Recommended to start vasopressors peripherally if no central access available)
In the 2021 Surviving sepsis guidelines, what types of fluids are recommended
- Crystalloids recommended as first line (strong recommendation)
- Balanced crystalloids suggested over saline (weak recommendation)
- Suggested use of albumin in patients receiving large volumes of crystalloids (weak recommendation)
- Recommend against starches (strong recommendation)
- Suggest against gelatin products (weak recommendation)
What is the 2021 Surviving sepsis guidelines recommendation regarding use of corticosteroids in sepsis
Use of corticosteroids suggested in patients with septic shock with ongoing need for vasopressors (moderate recommendation)
- should be considered in patients at 0.25 mcg/kg/min norepi or more for at least 4h
What are the recommendations regarding ventilation in patients with ARDS secondary to sepsis
- Use of lung protective ventilation
- Use low Vt (6 mL/kg rather than > 10 mL/kg) (strong recommendation)
- Use Pplat < 30 cmH2O (strong recommendation)
- Use higher PEEP over lower PEEP (weak recommendation) - Recruitment maneuvers
- For patients with moderate-severe ARDS, suggest using traditional recruitment maneuvers = maintaining pressure of 30-40 cmH2O for 30-40 sec (weak recommendation)
- Recommend not using incremental PEEP titration - Prone positioning
- For patients with moderate-severe ARDS, recommend using prone positioning for at least 12h per day
Describe a proposed decisional approach for the use of hydrocortisone in suspected CIRCI in dogs and cats
See picture
What is EGDT (early goal directed therapy) in sepsis? What are the current recommendations towards this approach?
EGDT = 6-hour resuscitation protocol for administration of IV fluids, vasopressors, inotropes, and red cell transfusion to achieve prespecified targets of blood pressure (MAP >65 mmHg), , CVP (CVP > 8 mmHg), central venous oxygen saturation (ScvO2 > 70%)
One initial study showed marked improvement in survival when following this for resuscitation but no benefit proven in subsequent trials and meta-analysis (included in patient with more severe shock and in hospitals with different “standard” non-EGDT protocols)
