Sepsis

Question 1

Septic Shock Criteria

Answer 1

Sepsis

Plus signs of end organ damage

Plus Hypotension (SBP<90)

Lactate >4

Not responding to IVF

CBC would show bands - immature neurtrophils

Question 2

What are the most common sources of sepsis

Answer 2

Lungs and urinary tract by far (PNA, pyelonephritis)

This is followed by the abdomen (perf, abscess, c. diff)

Last are skin and skin structure infections (wounds, pressure ulcers)

Question 3

Lactate and Procalcitonin in Sepsis

Answer 3

The higher the PCT, the higher the risk they are septic - more sensitive for sepsis
–Above 0.5 is concerning
–Will be elevated if bacterial origin but not viral
–used to determine when you can stop antibxs

CBC:
Leukocytosis is common but leukopenia could be worse given that the body may have used up all the neutrophils

Bandemia is common because there are a lot of immature neutrophils

Question 4

What is the relationship between lactate and PEtCO2

Answer 4

As the lactate rises, the PEtCO2 drops

If you see a rising lactate and a dropping PEtCO2, that is bad because it means the tissue is not giving off CO2 and therefore you are not able to breathe it off

Question 5

What are the major components of the management of the septic patient

Answer 5

Volume resuscitation - 30mL/kg for the first 3 hours - prefer LR
Vasopressors
Antibiotics
Adjuncts (steroids, glycemic control, nutrition, renal replacement)

Question 6

Phenylephrine vs Epinephrine: Which to give in sepsis

Answer 6

Phenylephrine will help raise the blood pressure but will not affect the HR because it is a pure alpha

Epinephrine can cause more tachycardia given that it is alpha and beta

Question 7

Broad spectrum antibiotics in sepsis

Answer 7

Per hospital protocols

Should be started within 1 hour

Vancomycin - broad spectrum gram pos
Cefepime - broad spectrum gram neg

Question 8

Glycemic control in sepsis

Answer 8

Should obtain blood glucose levels from more central source than POCT given poor capillary circulation in sepsis

Goal should upper blood glucose <180 rather than <110 given concern for hypoglycemia

Question 9

What are types of distributive shock?

Answer 9

Distributive shock - Massive Vasodilation

Septic
Anaphylactic
Neurogenic

Question 10

Hypovolemic shock: What causes it and what are the lab values?

Answer 10

Results from a loss of >20% of circulating blood volume:
-Internal/external bleeding
-Burns
-DKA/HHS
-Severe dehydration

-Decreased Cardiac Output/Cardiac Index
-Decreased Central Venous Pressure
-Decreased Wedge Pressure
-Increased Systemic Vascular Resistance (compensating for the low CO/CI
-Decreased Mixed Venous O2 Sat

Question 11

Management of Hypovolemic Shock

Answer 11

-Fluid resuscitation is the mainstay of treatment (isotonic)
-Vasopressor support (norepinephrine, dopamine, dobutamine)
-pRBC when indicated (if low H/H)

Question 12

Obstructive Shock: What is it and what are the common causes

Answer 12

Inadequate cardiac output as a result of impaired ventricular filling

Causes:
-Massive PE
-Tension PTX
-Acute cardiac tamponade
-Obstructive valvular disease
-Disease of pulmonary vasculature

Question 13

What are the laboratory studies associated with Obstructive Shock?

Answer 13

-Decreased CO/CI
-High SVR
-Normal/decreased Wedge Pressure
-Increased Central Venous Pressure

Question 14

How do manage Obstructive Shock

Answer 14

Maintain blood pressure while initiating treatment of the underlying cause
Fluid administration
Vasopressors
Mechanical ventilation as indicated
Anticoagulation, as indicated

Question 15

In Anaphylactic and Neurogenic shock, what are the hemodynamics?

Answer 15

All of them are low
There is massive vasodilation which causes everything to be low

Question 16

What is neurogenic shock and how is it treated?

Answer 16

Loss of peripheral vasomotor tone as a result of spinal cord injury, regional anesthesia etc.

Treatment:
Maintain airway
Fluids for volume expansion
Vasopressors

Question 17

What is anaphylactic shock and how is it treated?

Answer 17

IgE mediated reaction that occurs shortly after exposure to an allergen

Treatment:
-Maintain airway
-Fluids for volume expansion
-Benadryl 25-75mg IV/IM (Hives - histamine)
-Epinephrine 0.3-0.5mg SQ or IM for respiratory distress, stridor or wheezing only
-IV glucocorticoids as needed
-Consider H2 antagonist
-Inhaled beta agonist for bronchospasm

Question 18

Hypovolemic shock: What causes it and what are the hemodynamics

Answer 18

Results from a loss of >20% of circulating blood volume:
-Internal/external bleeding
-Burns
-DKA/HHS
-Severe dehydration

Everything is low but SVR is high
-Decreased Cardiac Output/Cardiac Index
-Decreased Central Venous Pressure
-Decreased Wedge Pressure
-Increased Systemic Vascular Resistance (compensating for the low CO/CI)
-Decreased Mixed Venous O2 Sat

Question 19

Septic Shock - What are the hemodynamics

Answer 19

Everything is low with the exception of high cardiac output/cardiac index

It is the only shock state with a high cardiac output

Question 20

qSOFA - what does it measure and what are the criterion?

Answer 20

Used to identify patients with suspected infection who are at greater risk for poor outcome due to sepsis

-Low blood pressure (SBP<100)
-High respiratory rate (RR>22)
-AMS (GCS<15)

Presence of 2 or more is associated with greater risk of death or prolonged ICU stay