5. SIRS, sepsis and septic shock Flashcards
(26 cards)
Definition of sepsis pathophysiological aspect
Sepsis is a complex syndrome caused by the bacteria or their metabolic products, invading the bloodstream and resulting in a generalized response of the host, based on an interplay between the immune, inflammatory and procoagulant responses
Definition of sepsis easy
Infection + systemic response (SIRS)
How many % of bacterial cultures will be negative, even in case of clinically evident infection?
60 %
What tests can you do in addition of culture - if it´s not reliable?
- WBC
- CRP, plt
- Other inflammatory mediators (IL-1b, IL6, IL8, TNFa, TGFb)
SIRS criteria
Non-specific, not so recommended anymore
1) Temperature (<36 or >38)
2) HR > 90
3) RR > 20 or PaCO2 <32 mmHg
4) WBC (<4000 or >12000 or > 10% bands)
PIRO
Sepsis
- Predisposition
- Infection
- Response
- Organ dysfunction
New sepsis definition
Life-treathening organ dysfunction caused by a dysregulated host response to infection
qSOFA
Quick Sepsis related Organ Failure Assessment
- BP (SBP < 100 mmHg)
- RR (> 22 /min)
- Altered mental state (GCS < 15)
SOFA
- Respiration (PaO2)
- Coagulation (Plt)
- Liver (Bilirubin)
- Cardiovascular (MAP or require medications)
- CNS (GCS)
- Renal (Creatinine, urine output)
LODS
Scoring system for sepsis (Logistic Organ Dysfunction Score)
CARS
Compensatory anti-inflammatory response syndrome (related to sepsis)
- Tissue damage
- Apoptosis
- Structural dysfunction - hard to recover (weeks)
MARS
Mixed antagonistic response syndrome (related to sepsis)
Severe sepsis
Sepsis + sepsis-induced organ dysfunction / tissue hypoperfusion (lactate / oliguria)
Septic shock
Sepsis-induced hypotension persisting despite adequate fluid resuscitation
SIRS
- Hypoperfusion
- Hyperinflammation
- Functional type of dysfunction - easy to recover (1-4 days)
CARS lung
- Alveolar hyaline
- Destruction of lung tissue
- Alveolar dead-space and alveolar collapse
ARDS signs and symptoms
- Bilateral pulmonary infiltration
- Decreased O2 diffusion
- Cardiac origin excluded
- Tachypnoe (> 25 /min)
- PaCO2 < 32 mmHg
- Increased dead-space ventillation
CARS cardiovascular system
- Myocardial depression
- Vasoplegia
- Coronary hypoperfusion
- Decreased contractility
- Venous pressures = / increased
- CO decreased
- Lactate increased
CARS gastrointestinal system
Mucosal: translocation
General:
- Necrosis
- Endocrine response (CCK, GLP, PYY)
- Increased immune activation
CARS renal
- Renal (SIRS: prerenal)
- Acute tubular necrosis
Steps of sepsis therapy
1) Source control
2) Resuscitation of circulation (fluids)
3) Resuscitation of circulation (vasopressors)
4) Maintaining O2 supply (“ventilatory support”)
5) Maintaining homeostasis (“renal support”)
6) Treat individual organ dysfunction
Source control in sepsis
1) Remove implants
2) Drain abscesses
3) Wound opening, nectrectomy, amputation
4) Peritoneal lavage, drainage or enterostomy
+
1) Blood cultures
2) Broad-spectrum, high dose AB
3) Pseudomonas coverage (piperacillin, ceftazidime, cefepime, imipenem, meropenem)
Fluid resuscitation sepsis
Initial: 1000 ml crystalloid over 30 min - repeat as needed
- MAP > 65 mmHg
- Urine output > 0,5 ml/kg/h
Vasopressors sepsis
Indicated in severe hypotension (<90 mmHg SBP)
- Norepinephrine (0,01-3 microgr/kg/min)
- Epinephrine (same as above)
- Dopamine - only in special cases
