Van Bockern - Sepsis Flashcards
very basic pathology of sepsis
dysregulated inflammatory response to an infxn
what type of bacteria are mc responsible for sepsis
gram positive
4 steps of sepsis
- SIRS
- sepsis
- severe sepsis
- septic shock
SIRS criteria
speed (HR): >90
infxn (temp): >100.4 (38) OR <96.8 (36)
rr: >20
s(c)ells: >12,000 OR <4,000
PCO2 < 32
sepsis criteria
2 SIRS criteria
PLUS
confirmed OR suspected infxn
severe sepsis criteria
sepsis
PLUS
hypotn: SBP < 90
AND
lactate > 4
septic shock criteria
severe sepsis w. persistent sbp < 90 and lactate > 4 despite adequate fluid resuscitation
new sepsis guidelines
6 sepsis rf
advanced age
immunosuppression/steroid use/malnutrition
DM/CA/HIV/liver dz
recent abx/drug resistance
recent procedures or travel
etoh/drug use
ddx for fever
sepsis
drug rxn
VTE
malignancy
rheumatological
lab findings in sepsis
arterial hypoxemia
adrenal insufficiency or euthyroid sick syndrome INR
platelets: 4
INR: >1.5 OR aPTT > 60s
lactate: >2
procalcitonin: >2 sd above nl
WBC: >12,000 OR 140 mg/dL w. DM
CRP: >2 sd above nl
-Pt is a 48 year old female with PMH of HIV who presented to the hospital with diarrhea for the last 5 days. She’s unable to tolerate anything PO.
-Vitals: temp 39.0, RR 15, HR 104, BP 90/70.
-On exam she had dry MM, tachy with a regular rhythm, tender abd, but no distention.
-Her labs are significant for an abnormal CBC with WBC at 19k. Abnormal BMP with cr of 2.1, Na 131, and K 3.0. ECG nml. UA nml.
what do you do next
this pt meets sepsis criteria and is hemodynamically unstable ->
-start IVF
-broad spectrum abx
-identify source
-blood cultures
what broad spectrum abx are used pre cultures for sepsis
vanco
cefepime
metronidazole
Pt is a 48 year old female with PMH of HIV who presented to the hospital with diarrhea for the last 5 days. She’s unable to tolerate anything PO.
-Vitals: temp 39.0, RR 15, HR 104, BP 90/70.
-On exam she had dry MM, tachy with a regular rhythm, tender abd, but no distention.
-Her labs are significant for an abnormal CBC with WBC at 19k. Abnormal BMP with cr of 2.1, Na 131, and K 3.0. ECG nml. UA nml.
what should be included in her sepsis work up
blood cultures BEFORE abx are started
CXR
UA
stool PCR
CD4/viral load
CT-abd
Pt is a 48 year old female with PMH of HIV who presented to the hospital with diarrhea for the last 5 days. She’s unable to tolerate anything PO.
-Vitals: temp 39.0, RR 15, HR 104, BP 90/70.
-On exam she had dry MM, tachy with a regular rhythm, tender abd, but no distention.
-Her labs are significant for an abnormal CBC with WBC at 19k. Abnormal BMP with cr of 2.1, Na 131, and K 3.0. ECG nml. UA nml.
culture shows salmonella
CT abd shows pancolitis and terminal ileitis
CD4 count is trending down
what is your assessment
sepsis (put worst dx first) 2/2 to:
salmonella enteritis w.
salmonella bacteremia
pt meets sepsis criteria w. temp, tachy, rr, and elevated WBC
stool PCR (+) salmonella, 1/2 blood cultures w. enterobacteriaceae suspected salmonella. CT w. new pancolitis and terminal ileitis
Pt is a 48 year old female with PMH of HIV who presented to the hospital with diarrhea for the last 5 days. She’s unable to tolerate anything PO.
-Vitals: temp 39.0, RR 15, HR 104, BP 90/70.
-On exam she had dry MM, tachy with a regular rhythm, tender abd, but no distention.
-Her labs are significant for an abnormal CBC with WBC at 19k. Abnormal BMP with cr of 2.1, Na 131, and K 3.0. ECG nml. UA nml.
culture shows salmonella
CT abd shows pancolitis and terminal ileitis
CD4 count is trending down
what is your plan
continue levofloxacin qd
repeat cultures
antiemetics, IVF, APAP
consult ID regarding CD4 count
don’t forget to do what when you order abx
include stop date
-81 y.o.femalewith h/o of CVA who was admitted by home health agency due to decreased PO intake and altered mental status found to have a UTI
-Vitals: 115/57, RR 17, HR 66, Pulse ox %100 on 3L
-Gen: Appears ill, Dry MM, No evidence of volume overload
-Labs: WBC 12.6, Macrocytic Anemia, Elevated Cr, Hyponatremia, elevated troponin
-ECG: No evidence of ischemia UA: Positive
does pt meet sepsis criteria
no
vitals are normal
she only meets WBC for sirs criteria
-81 y.o.femalewith h/o of CVA who was admitted by home health agency due to decreased PO intake and altered mental status found to have a UTI
-Vitals: 115/57, RR 17, HR 66, Pulse ox %100 on 3L
-Gen: Appears ill, Dry MM, No evidence of volume overload
-Labs: WBC 12.6, Macrocytic Anemia, Elevated Cr, Hyponatremia, elevated troponin
-ECG: No evidence of ischemia UA: Positive
what is your assessment
acute UTI w.
leukocytosis: urine culture w. enterococcus
-81 y.o.femalewith h/o of CVA who was admitted by home health agency due to decreased PO intake and altered mental status found to have a UTI
-Vitals: 115/57, RR 17, HR 66, Pulse ox %100 on 3L
-Gen: Appears ill, Dry MM, No evidence of volume overload
-Labs: WBC 12.6, Macrocytic Anemia, Elevated Cr, Hyponatremia, elevated troponin
-ECG: No evidence of ischemia UA: Positive
what is your plan
-switch from fosfomycin to vanco x 3 days given susceptibilities, allergies, qtc prolongation risk, and age
-IVF
bacteria to consider when choosing abx for sepsis
gram positives
gram negatives
anaerobes
pseudomonas
MRSA
atypical PNA
special situations
empiric abx coverage for sepsis covers (4)
pseudomonas
MRSA
anaerobes
special situations
62 year old female admitted for a UTI being treated with CTX (ceftriaxone) develops hypotension overnight. You are called to bedside by the rapid response team.
What should you do?
IVF
switch CTX to pip-taz AND vanco
call ICU
what abx cover pseudo
aztreonam
aminoglycosides
fluoroquinolones
carbapenems (never ertapenem)
cefepime
pip-taz
2 abx janice usually uses a DH for pseudo coverage
pip-taz
cefepime
what abx cover MRSA
tetracyclines
sulfonamides (bactrim)
lincosamide (clinda)
glycoprotein (vanco)
ceftaroline
why avoid clinda for MRSA
c.diff
why avoid bactrim for MRSA
hyperkalemia
what abx is commonly used for IV to PO transition for MRSA
doxy
what abx cover anaerobes
ampicillin-sulbactram (unasyn)
pip-taz
carbapenems
metronidazole
clinda
benefit of pip-taz for anaerobes
covers anaerobes and pseudo
what are the atypical bacteria (3)
chlamydophila pneumoniae
legionella pneumophila
mycoplasma pneumoniae
soc for atypical coverage
azithromycin
-71 y/o M hx alcohol abuse, T2DM, CAD, p/w cough and fever (mental status normal)
-T: 39.0 deg C HR: 124 BP: 82/40 RR: 24 SpO2: 84% RA; 92% 2L NC
what is the standard initial work up
-CBC
-BMP +/- LFTs
-Blood cultures
-Lactate
-UA
-CXR
-71 y/o M hx alcohol abuse, T2DM, CAD, p/w cough and fever (mental status normal)
-T: 39.0 deg C HR: 124 BP: 82/40 RR: 24 SpO2: 84% RA; 92% 2L NC
work up shows (see pic)
how do you decide if he should be inpatient or outpatient
CURB65
this pt: BUN > 19, SBP < 90 or DBP ≤ 60, Age > 65
3 rf = high risk for decompensation –> admit
4 respiratory viruses associated w. sepsis
influenza
RSV
rhinovirus
COVID
t/f: you can determine viral vs bacterial etiology of sepsis based on pt presentation
f!
when is typical flu season
nov-march (late fall to early spring)
tx for flu that decreases mortality, and length of stay
neuroaminidase inhibitor (osteltamivir)
osteltamivir is most effective for M&M reduction if given in the first __ of sx onset
48 hr
t/f: identifying if cause of pna is non-influenza virus is beneficial
f!
does not impact abx use
co-infxn w. bacteria is common
pcr testing is espensive
-71 y/o M hx alcohol abuse, T2DM, CAD, p/w cough and fever coming to ER in December
-T: 39.0 deg C HR: 124 BP: 82/40 RR: 24 SpO2: 84% RA; 92% 2L NC
-Standard initial workup: CBC, BMP +/- LFTs, Blood cultures, Lactate, UA, CXR
what additional diagnostics do you order
fluvid (covid, flu, rsv)
choose the option with covid, none of the others will affect treatment
when would you order blood cultures for pna patient
if the meet sepsis criteria
when might you order respiratory culture for pna patient (2)
-pt has had prior isolation of MRSA and/or pseudo in the past year
-pt has been hospitalized AND received IV abx in the past 90 days
denver health protocol for ICU CAP abx if prior isolation of MRSA and/or pseudomonas from respiratory tract in the past year
ceftriaxone
AND
azithromycin
+/-osteltamivir
denver health protocol for ICU CAP abx if no isolation of MRSA or pseudo from resp tract in the past year
cefepime
AND
azithromycin
+/- oseltamivir
what are the two types of lactic acidosis
A: mc dt infxn –>
-tissue hypoperfusion from sepsis hypovolemia
-shock
B causes: chronic disease and drugs
-metformin
-DKA
-etoh
-liver dz
-HIV meds
-71 y/o M hx alcohol abuse, T2DM, CAD, p/w cough and fever coming to ER in December
-T: 39.0 deg C HR: 124 BP: 82/40 RR: 24 SpO2: 84% RA; 92% 2L NC
-Standard initial workup: CBC, BMP +/- LFTs, Blood cultures, Lactate, UA, CXR
You give ceftriaxone, azithromycin, and a 30 cc/kg fluid bolus.
After initial treatment, the serum lactate is 2.4, and BP is 102/80.
what type of lactic acidosis does this pt have
type A
what type of bacteria do not significantly elevate pct
atypical
3 things outside of sepsis that can cause pct elevation
major stressors
trauma
surgery
pancreatitis
CKD
what might cause false negatives with pct elevation
drawn too early in infxn
when is pct useful in sepsis
to decide when to stop abx
NOT useful in deciding when to start
are steroids SOC with CAP tx
nope!
yes with covid
how many days of abx for initial management of CAP
5 days
do we need to cover for anaerobes if we are concerned for aspiration pna
nope, not anymore!
who gets extended spectrum abx for CAP
only pt’s w. rf
-71 y/o M hx alcohol abuse, T2DM, CAD, p/w cough and fever coming to ER in December
-T: 39.0 deg C HR: 124 BP: 82/40 RR: 24 SpO2: 84% RA; 92% 2L NC
-Standard initial workup: CBC, BMP +/- LFTs, Blood cultures, Lactate, UA, CXR
You give ceftriaxone, azithromycin, and a 30 cc/kg fluid bolus.
After initial treatment, the serum lactate is 2.4, and BP is 102/80 –> type A lactic acidosis
next…
Your patient then starts to develop EtOH withdrawal
He develops delirium tremens and is admitted to ICU and placed on a dexmedetomidine (Precedex) drip and scheduled lorazepam.
On hospital day 4, he develops a temperature of 39 deg C, HR of 120, RR of 32, and BP of 98/50. WBCs trend up to 16k. Lactate is 3.4. CXR shows bibasilar infiltrates. COVID: negative.
what do you suspect?
what do you do?
suspect HAP
-blood cultures x 2 prior to abx
-respiratory culture prior to abx
-influenza pcr if flu season
-MICU (ICU) setting: urine strep pneumo and pct
-empiric abx
limitation of non-invasive respiratory cultures (sputum or aspirate)
possible contamination or colonization
definition of HAP
pna developed 48 hours or more after hospital admit or while on ventilator
HAP abx selection
-empiric: cefepime 2g IV q 8 hr
-VAP OR hx MRSA OR IV abx in past 90 days: cefepime + vanco
-severely ill w. septic shock 2/2 pna: cefepime + vanco + amikacin
abx for aspiration pna
ceftriaxone
PLUS
azithromycin
same as standard CAP tx
don’t need to cover for anaerobes anymore
when should you cover for anaerobes w. aspiration pna
if lung abscess or empyema
6 usual suspects of sepsis
pna
bloodstream infxns
intravascular catheter
intra-abdominal infxn
urosepsis
surgical wounds
IVF resuscitation goals
-central venous pressure: 8-12 mmHg
-mean arterial pressure: 65 mm Hg
-urine output: 0.5 mL/kg1/hr1
-central venous (superior vena cava) or mixed venous SpO2: 70%
did the study Janice referenced show any difference in mortality in patients given balanced fluids vs NS vs slow vs fast infusion
nope!
janice typically boluses for faster results
what might you consider if septic pt is not responding to fluids and/or pressors
septic heart -> order TTE
remember that pressors can mask underlying HF
consideration for d.c of IVF for septic pt
d.c IVF long before pt d.c to make sure they are stable on their own
key points for IVF in sepsis
-reassess frequently
-de-escelate and diurese early
-balanced crystalloids for now
when should abx be started for sepsis
-w.in first hour of recognition of severe sepsis
-after cultures
what is PICS
post intensive care syndrome: critical illness survivors suffer from worsening impairments in physical, cognitive, or behavioral domains
rf for PICS
-ICU length of stay > 24 hr
-prolonged immobilization
-severity of illness
-advanced age
-female
-prior psych illness
-prior cognitive impairment
-lower socioeconomic status
-exposure to steroids
-hyperglycemia
what do you think when you see gram (-) and gram (+) bacteria on blood cultures in pt w. GI sx
fistula
what should you always order if your pt presents with a fever or spikes a fever during admit
blood cultures
what should always be on your GI ddx for sick pt
toothpick dx
inpt tx for COVID
-remdesivir IV
-dexamethasone
what medication improves survival for hospitalized covid pt’s
dexamethasone
