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CDM I > Sepsis pt 2 > Flashcards

Sepsis pt 2 Flashcards

1
Q

Procalcitonin: What is procalcitonin and how does it relate to assessing sepsis?

A
  • Protein biomarker for bacterial infection
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2
Q

Procalcitonin: How does the utilization of procalcitonin impact antibiotics?

A
  • Can be utilized to deescalate antibiotics.
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3
Q

Procalcitonin: A value above or equal to ___ ng/mL is highly suggestive of sepsis.

A

2

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4
Q

National impact of severe sepsis: (T/F) Severe sepsis patients are likely to have high mortality rates.

A
  • TRUE
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5
Q

National impact of severe sepsis: Broadly describe the impact of severe sepsis patients with the hospital lengths of stay.

A
  • Long lengths of stay
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6
Q

National impact of severe sepsis: How do severe sepsis patients impact ventilator usage?

A
  • High ventilator usage
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7
Q

National impact of severe sepsis: (T/F) It’s super cheap and affordable to get sepsis. Don’t worry about it.

A
  • False * High costs, * Lower payment-to-cost ratios
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8
Q

Severe sepsis is common: How many cases of severe sepsis are there in the US annually?

A
  • 750,000 to 1.5 million cases annually
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9
Q

Severe sepsis is common: About what proportion of severe sepsis patients involve an ICU stay?

A
  • > 50% of these cases
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10
Q

Severe sepsis is common: How many deaths from severe sepsis occur annually in the US?

A

~210,000

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11
Q

Severe sepsis is common: ___% of hospitalizations are due to sepsis in the US but account for >50% of deaths while hospitalized.

A

-10%

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12
Q

Severe sepsis is common: Per ICU admission source data, where in the hospital do severe sepsis patients originate?

A
  • ED: 37% - Floor: 32% - Post-op: 16% - Other hospital: 13% - Other: 2%
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13
Q

Risk factors: Patients at higher risk for developing sepsis?

A
  • All critically ill - Severe CAP - Intra-abdominal surgery - Meningitis - Chronic dz (DM, HF, CRF, COPD) - Immunocompromised - Cellulitis - UTI
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14
Q

Risk factors: (T/F) A patient of __[a]__ (younger/older) age with an underlying comorbidity and at a __[b]__ (lower/higher) body weight is at greater risk of developing sepsis than most patients.

A
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15
Q

Sepsis symptoms: SEPSIS is an acronym that can help you remember S/Sx. What does the first “S” stand for?

A
  • S - Shivering, fever, or very cold
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16
Q

Sepsis symptoms: SEPSIS is an acronym that can help you remember S/Sx. What does the “E” stand for?

A
  • E - Extreme pain or general discomfort (“worst ever”)
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17
Q

Sepsis symptoms: SEPSIS is an acronym that can help you remember S/Sx. What does the “P” stand for?

A
  • P - Pale or discolored skin.
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18
Q

Sepsis symptoms: SEPSIS is an acronym that can help you remember S/Sx. What does the second “S” stand for?

A
  • S - Sleepy, difficult to wake up, confused
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19
Q

Sepsis symptoms: SEPSIS is an acronym that can help you remember S/Sx. What does the “I” stand for?

A
  • I - “I feel like I might die”
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20
Q

Sepsis symptoms: SEPSIS is an acronym that can help you remember S/Sx. What does the third “S” stand for?

A
  • S - Short of breath
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21
Q

Recognizing Sepsis: What does SIRS stand for?

A
  • Systemic inflammatory response syndrome (SIRS)
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22
Q

Recognizing Sepsis: Describe SIRS.

A
  • SIRS is a serious condition related to Systemic inflammation, organ dysfunction, and organ failure.
  • It is a subset of cytokine storm, in which there is abnormal regulation of various cytokines.
  • SIRS is also closely related to sepsis, in which patients satisfy criteria for SIRS and have a suspected or proven infection
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23
Q

SIRS criteria: SIRS criteria involves four components. What are the four components?

A
  • Temperature - Heart rate - Respiratory rate or PaCO2 - WBC
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24
Q

SIRS criteria: SIRS criteria involves four components. How many of the components need to be positive for the patient to truly meet SIRS criteria?

A
  • Greater than or equal to 2 positive components.
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25
Q

SIRS criteria: Temperature has to be above and below what levels to be considered a positive for SIRS criteria?

A
  • Temp. > 38C (100.4F) - Temp. < 36C (96.8F)
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26
Q

SIRS criteria: RR has to be above what rate per minute to be considered a positive for SIRS criteria?

A

RR > 20

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27
Q

SIRS criteria: Heart rate has to be above what BPM to be considered a positive for SIRS criteria?

A
  • HR > 90 BPM
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28
Q

SIRS criteria: PaCO2 has to be of what value to be a positive component for the SIRS criteria.

A
  • PaCO2 < 32 mmHg
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29
Q

SIRS criteria: (T/F) For the respiratory to be positive, the PT needs to have an RR >20 in addition to their PaCO2 being < 32 mmHg.

A
  • False - Either one indicates a positive. They don’t need to coexist.
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30
Q

SIRS criteria: WBC needs to have what properties to be a positive component for the SIRS criteria?

A
  • WBC > 12,000/mm^3 [or] - WBC < 4,000/mm^3 [or] - >10% bands *** First one is on the PPT, the other two are on MDcalc. Pick your poison.
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31
Q

SIRS: What GI conditions can mimic a systemic inflammatory response?

A
  • Pancreatitis - GI bleed
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32
Q

SIRS: What endocrine conditions can mimic a systemic inflammatory response?

A
  • DKA - Adrenal insufficiency
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33
Q

SIRS: What hypersensitivity reaction can mimic a systemic inflammatory response?

A
  • Anaphylaxis
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34
Q

SIRS: What CV condition(s) can mimic a systemic inflammatory response?

A
  • PE/DVT
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35
Q

SIRS: What autoimmune condition(s) can mimic a systemic inflammatory response?

A
  • LSE flare
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36
Q

Sepsis with acute organ dysfunction: Dermatology appearance?

A
  • Areas of mottled skin
37
Q

Sepsis with acute organ dysfunction: Cap refill time?

A
  • >
    • 3 seconds
38
Q

Sepsis with acute organ dysfunction: Urine output?

A
  • <0.5 mL/kg 1 hr or RRT
39
Q

Sepsis with acute organ dysfunction: Lactate levels greater than what level?

A

> 2 mmol/L

40
Q

Sepsis with acute organ dysfunction: Mental status?

A
  • Abrupt change in mental status
41
Q

Sepsis with acute organ dysfunction: Platelet levels?

A

< 100,000 [or] - DIC

42
Q

Sepsis with acute organ dysfunction: Respiratory impact?

A
  • Acute lung injury - ARDS
43
Q

Sepsis with acute organ dysfunction: CV impact?

A
  • Cardiac dysfunction
44
Q

Severe sepsis: What is the MCC of severe sepsis?

A
  • Pneumonia (~50% of cases)
45
Q

Severe sepsis: Blood cultures are positive in ___ of PTs experiencing severe sepsis.

A

1/3

46
Q

Severe sepsis: When blood cultures come back positive, the presence of a gram negative bacterial organism occurs in ___% of cases.

A

62%

47
Q

Severe sepsis: When blood cultures come back positive, the presence of a gram positive bacterial organism occurs in ___% of cases.

A

47%

48
Q

Severe sepsis: When blood cultures come back positive, the presence of a fungal organism occurs in ___% of cases.

A

19%

49
Q

Severe sepsis: Per the traditional definition of sepsis, the trio of (i) infection, (ii) SIRS, and (iii) ___ combine to form a positive screen suggestive of severe sepsis.

A
  • organ dysfunction
50
Q

Sepsis - Tx: What are the three phases to sepsis treatment?

A
  • Resuscitation phase - Initial management phase - Maintenance phase
51
Q

Sepsis - Tx: What is the time frame that composes the resuscitation phase?

A
  • 1st six hours
52
Q

Sepsis - Tx: While the resuscitation phase is the first six hours, what should the actual goal be to initiate treatment?

A
  • Strive for within first 3 hours
53
Q

Sepsis - Tx: The initial management phase consists of what timeline?

A
  • First 24 hours
54
Q

Sepsis - Tx: The maintenance phase consists of what timeline?

A

> 24 hours

55
Q

Sepsis - Tx: The resuscitation phase consists of many components. What are they?

A
  • Airway (access and maintain) - Pan-culture - Initiate appropriate Abx therapy - IV fluids - Tight glycemic control - Vasopressors - Sedation - (+/-) Steroids
56
Q

Sepsis - Tx: Discuss what “pan-culture” refers to in the resuscitation phase.

A

(?) - Cultures that test for both bacterial and fungal causes.

57
Q

Sepsis - Tx: The initial volume of IV fluids should be 30 mL/kg under what conditions?

A
  • MAP < 65 - Lactate > 4 mmol/L
58
Q

Sepsis - Tx: “tight glycemic control” involves not only routinely assessing BGL but also treating the patient with what via IV?

A
  • Continuous insulin drip
59
Q

Sepsis - Tx: What are the vasopressors utilized in the resuscitation phase?

A
  • Dobutamine - norepinephrine (1st line) - dopamine (use is discouraged) - phenylephrine - epinephrine - vasopressin
60
Q

Sepsis - Tx: Why may steroids be a part of the treatment plan during the resuscitation phase?

A
  • Adrenal insufficiency
61
Q

Sepsis - Tx: The “Hour 1 Bundle” is the first hour within the resuscitation phase that a lot needs to happen. What are the five procedures/labs of this period?

A

1) Measure lactate level
2) Obtain blood cultures before administering Abx
3) Administer broad-spectrum antibiotics
4) Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate >- 4 mmol/L
5) Vasopressors

62
Q

Sepsis - Tx: The vasopressors administered during the “Hour 1 Bundle” must be administered to maintain MAP greater than or equal to what value?

A

MAP >- 65 mmHg

63
Q

Sepsis - Tx: You’ve measured a lactate level during the resuscitation phase. When would you consider measuring the lactate level again?

A
  • Remeasure lactate if initial lactate is elevated (> 2mmol/L)
64
Q

Sepsis - Tx: CVP goal during the resuscitation phase?

A
  • CVP 8-12 mmHg
65
Q

Sepsis - Tx: MAP goal during the resuscitation phase?

A
  • MAP 65 mmHg
66
Q

Sepsis - Tx: Formula for (approximate) MAP?

A

~ DBP + 1/3*(SBP - DBP)

67
Q

Sepsis - Tx: When considering a patient’s MAP, what is an alternative to calculating an approximate value?

A
  • Direct invasive monitoring
68
Q

Sepsis - Tx: Urine output goal during sepsis resuscitation?

A

0.5 mL/kg/hr

69
Q

Sepsis - Tx: Central venous or mixed venous oxygen saturation goals?

A
  • 70%, 65% respectively
70
Q

Sepsis - Tx: What is the point of having goals for the CVP, MAP, urine output, and venous oxygen saturation?

A
  • Maintaining a patient within these markers has been shown to reduce the 28-day mortality rate.
71
Q

Vasopressors: What is the preferred first-line vasopressor?

A
  • Norepinephrine
72
Q

Vasopressors: How does the consideration of using dopamine compare to the other vasopressors?

A
  • Dopamine is typically discouraged.
73
Q

Vasopressors: When is phenylephrine considered as part of the vasopressor therapy?

A
  • Commonly used as an add-on, but data is limited.
74
Q

Vasopressors: While norepinephrine is the preferred first line vasopressors, what are two other common medications utilized for this purpose?

A
  • Vasopressin - Epinephrine
75
Q

Sepsis - Tx: What are the three main components of the initial management phase?

A
  • Continue Resuscitation phase - Monitor cultures for targeting Abx therapy - Constant monitoring of Vasopressors & MAP
76
Q

Sepsis - Respiratory: Respiratory support must be considered in the prevention of ARDS. What can we do for the patient to minimize their risk of ARDS?

A
  • Elevate the head of the bed

- Use mechanical ventilation weaning protocols

77
Q

Sepsis - Respiratory: CXR appearance of ARDS?

A
  • Bilateral diffuse fluffy infiltrates - Normal cardiac size - (+/-) Tracheostomy tube - (+/-) EKG wires
78
Q

Sepsis - CNS Support: What are considerations and protocols in place for PT’s CNS support?

A
  • Sedation protocols

- Avoid neuromuscular blockers if possible

79
Q

Sepsis - CNS Support: When is it most difficult to avoid neuromuscular blockers?

A
  • in PTs with ARDS
80
Q

Sepsis - CNS Support: How do you compromise between appropriate neuromuscular Tx for ARDS support?

A
  • Short course of neuromuscular blocker for patient with early, Severe ARDS.
81
Q

Sepsis - Maintenance phase: If the patient of severe sepsis survives > 24 hours, special attention must be given to prevent ___ infections.

A
  • nosocomial
82
Q

Sepsis - Maintenance phase: Why might your antibiotic therapy of choice change in the maintenance phase compared to the resuscitation phase?

A
  • Tailor Abx therapy as culture information becomes available.
83
Q

Sepsis - Maintenance phase: When considering BGLs, your main goal is to keep blood glucose in what range?

A

< 180 mg/dL

84
Q

Sepsis - Maintenance phase: What is an appropriate procedure for a patient who has experienced renal failure or fluid overload?

A
  • Dialysis
85
Q

Sepsis - Maintenance phase: What CV dz do you have to be especially aware of in a patient being treated for severe sepsis?

A
  • DVT

- Consider DVT prophylaxis

86
Q

Sepsis - Maintenance phase: What GI complication may you consider prophylaxis for?

A
  • Stress-ulcer
87
Q

Sepsis - Maintenance phase: (T/F) Parenteral feeding is preferred over enteral feeding.

A
  • FALSE - Enteral feeding if possible.
88
Q

Sepsis - Causes: When considering causes of sepsis, what tissues or organs are you considering as the most likely initially impacted structures (the cause of the sepsis)?

A
  • Lungs - Urinary tract - GI - skin and soft tissue
89
Q

Sepsis - Causes: What bacteria are the MCCs of sepsis?

A

(?) - Staph - Strep - H. flu

CDM I (9 decks)

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