1 Sepsis

Question 1

The cornerstones of the initial treatment and stabilization of severe sepsis

Answer 1

1. Early recognition
2. Early reversal (or prevention) of hemodynamic compromise
3. Early infection control

Question 2

predominant pathogens of sepsis

Answer 2

gram-positive bacteria

Question 3

QSOFA

Answer 3

Quick Sequential Organ Failure Assessment tool
-used to identify patients at higher risk of death

AMS
RR ≥22
SBP ≤100

Question 4

Remarks on undifferentiated hypotension

Answer 4

in ED, 40% will ultimately have an infectious cause of symptoms

Question 5

septic cardiomyopathy

Answer 5

a reversible process with impaired systolic function and diastolic relaxation

the combination of intravascular volume depletion and septic cardiomyopathy may manifest as “cold shock”, impaired peripheral perfusion and cool extremities

Question 6

the most common GI manifestation of sepsis

Answer 6

Ileus, which may persist for days after shock resolves

Question 7

hematologic changes in sepsis

Answer 7

neutropenia and thrombocytopenia carries increased risk of mortality

Question 8

the most common sepsis trigger

Answer 8

acute bacterial pneumonia

Question 9

most common skin and soft tissue infection triggering a sepsis syndrome

Answer 9

cellulitis due to S aureus or S pyogenes

Question 10

Those without an obvious source of septic shock may have

Answer 10

primary bacteremia or endocarditis

the most prevalent causes of primary baccteremia in outpatients are S aureus, S pneumoniae, and N meningitidis

Question 11

community-acquired meningitis with shock is usually caused by

Answer 11

S pneumoniae or N meningitidis

Question 12

In sepsis, there is no set amount of fluid, although most patients will require a total (bolus plus infusion) of

Answer 12

2-5 liters of crystalloid in the first 6 hours to achieve optimal outocmes

similarly do not delay vasopressors when blood pressure does not respond to volume or if volume overload seems likely

Question 13

Once the patient is stabilized, other interventions that may improve patient outcomes

Answer 13

management of oxygenation and ventilation
fever control to reduce metabolic demand
control of hyperglycemia

Question 14

remarks on refractory shock

Answer 14

consider corticosteroids
hydrocortisone 50mg IV

*“Hydrocortisone shortens time to shock reversal in refractory hemodynamic shock (i.e., requiring more than on evasopressor after adequate volume restoration)

Question 15

Describe early goal-directed therapy

Answer 15

Titration of
* Fluids to CVP
* Vasopressors to MAP
* Blood transfusion and inotropes to central venous oxygen saturation (Scvo2)

This protocol decreased mortality when compared with standard care, although all patients had central venous catheters placed early

Follow-up uncontrolled observaton studies confirmed that even partial use of this approach lowered mortality

Question 16

remarks on lactate clearance

Answer 16

If initial lactate is elevated (>2 mmol/L), repeat lactate required prior to 6 hours

Lactate clearance of ≥10% was noninferior to continuous Scvo2 monitoring in the setting of ED-based resuscitation of septic shock

measure lactate using the same method 1-2 hours apart

Question 17

The important elements that improve outcomes in sepsis

Answer 17

1. Early recognition of sepsis
2. Administration of antimicrobials
3. Adequate volume resuscitation
4. Assessment of adequacy of circulation

not any specific path of resuscitation

mandatory central venous catheterization and monitoring of CVP or Scvo2 are not necessary for all patients with sepsis

Question 18

the most important variable process in volume replacement in sepsis

Answer 18

determining wheter a patient is volume responsive

Question 19

remarks on vasopressors

Answer 19

Peripheral vasopressor use to start care is safe

High-dose and prolonged infusions are better deployed using a central venous line to limit extravasation and resultant tissue necrosis

When using **peripheral catheters, make sure they are large, secured, and not distal

Question 20

remarks on vasopressin

Answer 20

give at constant infusion at a rate of 0.03 or 0.04 U/min.

Do NOT titrate the dose, because higher rates are associated with vasospasm and high morbidity

Question 21

if tachydysrhythmias are a problem, one option is:

Answer 21

phenylephrine, which as a pure a-adrenergic agonist

Question 22

what does Scvo2 <70% mean?

Answer 22

It implies a relative oxygen supply and demand mismatch

Central venous Oxygen saturation

Question 23

remarks on antibiotics

Answer 23

give ASAP in severe sepsis

combination antibiotic therapy as opposed to monotherapy leads to improved outcomes, potentially due to higher rates of bactericidal activity

Question 24

remarks on vancomycin

Answer 24

15 mg/kg loading dose

Vancomycin is often underdosed in clinical practice, and guidelines suggest an initial dose of 25-30 mg/kg in critically ill patients

Use also in patients with indwelling vascular devices

Question 25

glucose goals in sepsis

Answer 25

<180 mg/dL hyperglycemia is associated with **worsened outcomes** in the setting of sepsis

Question 26

remarks on gentamicin

Answer 26

Consider use in * adults with suspected urinary source dose: 1.0 - 1.5 mg/kg every 8 hours

Question 27

antibiotics for sepsis with neutropenia

Answer 27

Ceftazidime/Cefepime 2g IV q8 or Pip-Taz + Levofloxacin 750 mg IV q24 or moxifloxacin 400 mg IV q24 + Vancomycin 15 mg/kg LD *and consider* Fluconazole 400 mg IV q24 or micafungin 100 mg Q24

Question 28

what to give if patient is allergic to vancomycin>

Answer 28

linezolid 600 mg IV

Question 29

antibiotics to be added to regimen if patients have potential for legionella infection

Answer 29

Azithromycin 500 mg IV, then 250 mg IV q 24 or Erythromycin 800 mg IV q6

Question 30

antibiotics to be added to regimen if patients with asplenia

Answer 30

Ceftriaxone 1 g IV q24 up to 2g IV q12 if meningitis