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CDM2 - Final > Van Bockern - Sepsis > Flashcards

Van Bockern - Sepsis Flashcards

1
Q

very basic pathology of sepsis

A

dysregulated inflammatory response to an infxn

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2
Q

what type of bacteria are mc responsible for sepsis

A

gram positive

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3
Q

4 steps of sepsis

A
  1. SIRS
  2. sepsis
  3. severe sepsis
  4. septic shock
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4
Q

SIRS criteria

A

speed (HR): >90
infxn (temp): >100.4 (38) OR <96.8 (36)
rr: >20
s(c)ells: >12,000 OR <4,000
PCO2 < 32

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5
Q

sepsis criteria

A

2 SIRS criteria
PLUS
confirmed OR suspected infxn

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6
Q

severe sepsis criteria

A

sepsis
PLUS
hypotn: SBP < 90
AND
lactate > 4

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7
Q

septic shock criteria

A

severe sepsis w. persistent sbp < 90 and lactate > 4 despite adequate fluid resuscitation

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8
Q

new sepsis guidelines

A
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9
Q

6 sepsis rf

A

advanced age
immunosuppression/steroid use/malnutrition
DM/CA/HIV/liver dz
recent abx/drug resistance
recent procedures or travel
etoh/drug use

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10
Q

ddx for fever

A

sepsis
drug rxn
VTE
malignancy
rheumatological

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11
Q

lab findings in sepsis

A

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

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12
Q

-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

A

this pt meets sepsis criteria and is hemodynamically unstable ->
-start IVF
-broad spectrum abx
-identify source
-blood cultures

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13
Q

what broad spectrum abx are used pre cultures for sepsis

A

vanco
cefepime
metronidazole

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14
Q

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

A

blood cultures BEFORE abx are started
CXR
UA
stool PCR
CD4/viral load
CT-abd

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15
Q

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

A

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

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16
Q

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

A

continue levofloxacin qd
repeat cultures
antiemetics, IVF, APAP
consult ID regarding CD4 count

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17
Q

don’t forget to do what when you order abx

A

include stop date

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18
Q

-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

A

no
vitals are normal
she only meets WBC for sirs criteria

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19
Q

-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

A

acute UTI w.
leukocytosis: urine culture w. enterococcus

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20
Q

-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

A

-switch from fosfomycin to vanco x 3 days given susceptibilities, allergies, qtc prolongation risk, and age
-IVF

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21
Q

bacteria to consider when choosing abx for sepsis

A

gram positives
gram negatives
anaerobes
pseudomonas
MRSA
atypical PNA
special situations

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22
Q

empiric abx coverage for sepsis covers (4)

A

pseudomonas
MRSA
anaerobes
special situations

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23
Q

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?

A

IVF
switch CTX to pip-taz AND vanco
call ICU

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24
Q

what abx cover pseudo

A

aztreonam
aminoglycosides
fluoroquinolones
carbapenems (never ertapenem)
cefepime
pip-taz

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25
Q

2 abx janice usually uses a DH for pseudo coverage

A

pip-taz
cefepime

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26
Q

what abx cover MRSA

A

tetracyclines
sulfonamides (bactrim)
lincosamide (clinda)
glycoprotein (vanco)
ceftaroline

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27
Q

why avoid clinda for MRSA

A

c.diff

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28
Q

why avoid bactrim for MRSA

A

hyperkalemia

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29
Q

what abx is commonly used for IV to PO transition for MRSA

A

doxy

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30
Q

what abx cover anaerobes

A

ampicillin-sulbactram (unasyn)
pip-taz
carbapenems
metronidazole
clinda

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31
Q

benefit of pip-taz for anaerobes

A

covers anaerobes and pseudo

32
Q

what are the atypical bacteria (3)

A

chlamydophila pneumoniae
legionella pneumophila
mycoplasma pneumoniae

33
Q

soc for atypical coverage

A

azithromycin

34
Q

-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

A

-CBC
-BMP +/- LFTs
-Blood cultures
-Lactate
-UA
-CXR

35
Q

-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

A

CURB65

this pt: BUN > 19, SBP < 90 or DBP ≤ 60, Age > 65
3 rf = high risk for decompensation –> admit

36
Q

4 respiratory viruses associated w. sepsis

A

influenza
RSV
rhinovirus
COVID

37
Q

t/f: you can determine viral vs bacterial etiology of sepsis based on pt presentation

A

f!

38
Q

when is typical flu season

A

nov-march (late fall to early spring)

39
Q

tx for flu that decreases mortality, and length of stay

A

neuroaminidase inhibitor (osteltamivir)

40
Q

osteltamivir is most effective for M&M reduction if given in the first __ of sx onset

A

48 hr

41
Q

t/f: identifying if cause of pna is non-influenza virus is beneficial

A

f!
does not impact abx use
co-infxn w. bacteria is common
pcr testing is espensive

42
Q

-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

A

fluvid (covid, flu, rsv)

choose the option with covid, none of the others will affect treatment

43
Q

when would you order blood cultures for pna patient

A

if the meet sepsis criteria

44
Q

when might you order respiratory culture for pna patient (2)

A

-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

45
Q

denver health protocol for ICU CAP abx if prior isolation of MRSA and/or pseudomonas from respiratory tract in the past year

A

ceftriaxone
AND
azithromycin
+/-osteltamivir

46
Q

denver health protocol for ICU CAP abx if no isolation of MRSA or pseudo from resp tract in the past year

A

cefepime
AND
azithromycin
+/- oseltamivir

47
Q

what are the two types of lactic acidosis

A

A: mc dt infxn –>
-tissue hypoperfusion from sepsis hypovolemia
-shock

B causes: chronic disease and drugs
-metformin
-DKA
-etoh
-liver dz
-HIV meds

48
Q

-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

A

type A

49
Q

what type of bacteria do not significantly elevate pct

A

atypical

50
Q

3 things outside of sepsis that can cause pct elevation

A

major stressors
trauma
surgery
pancreatitis
CKD

51
Q

what might cause false negatives with pct elevation

A

drawn too early in infxn

52
Q

when is pct useful in sepsis

A

to decide when to stop abx
NOT useful in deciding when to start

53
Q

are steroids SOC with CAP tx

A

nope!

yes with covid

54
Q

how many days of abx for initial management of CAP

A

5 days

55
Q

do we need to cover for anaerobes if we are concerned for aspiration pna

A

nope, not anymore!

56
Q

who gets extended spectrum abx for CAP

A

only pt’s w. rf

57
Q

-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?

A

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

58
Q

limitation of non-invasive respiratory cultures (sputum or aspirate)

A

possible contamination or colonization

59
Q

definition of HAP

A

pna developed 48 hours or more after hospital admit or while on ventilator

60
Q

HAP abx selection

A

-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

61
Q

abx for aspiration pna

A

ceftriaxone
PLUS
azithromycin

same as standard CAP tx
don’t need to cover for anaerobes anymore

62
Q

when should you cover for anaerobes w. aspiration pna

A

if lung abscess or empyema

63
Q

6 usual suspects of sepsis

A

pna
bloodstream infxns
intravascular catheter
intra-abdominal infxn
urosepsis
surgical wounds

64
Q

IVF resuscitation goals

A

-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%

65
Q

did the study Janice referenced show any difference in mortality in patients given balanced fluids vs NS vs slow vs fast infusion

A

nope!

janice typically boluses for faster results

66
Q

what might you consider if septic pt is not responding to fluids and/or pressors

A

septic heart -> order TTE

remember that pressors can mask underlying HF

67
Q

consideration for d.c of IVF for septic pt

A

d.c IVF long before pt d.c to make sure they are stable on their own

68
Q

key points for IVF in sepsis

A

-reassess frequently
-de-escelate and diurese early
-balanced crystalloids for now

69
Q

when should abx be started for sepsis

A

-w.in first hour of recognition of severe sepsis
-after cultures

70
Q

what is PICS

A

post intensive care syndrome: critical illness survivors suffer from worsening impairments in physical, cognitive, or behavioral domains

71
Q

rf for PICS

A

-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

72
Q

what do you think when you see gram (-) and gram (+) bacteria on blood cultures in pt w. GI sx

A

fistula

73
Q

what should you always order if your pt presents with a fever or spikes a fever during admit

A

blood cultures

74
Q

what should always be on your GI ddx for sick pt

A

toothpick dx

75
Q

inpt tx for COVID

A

-remdesivir IV
-dexamethasone

76
Q

what medication improves survival for hospitalized covid pt’s

A

dexamethasone

CDM2 - Final (9 decks)

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