8: Resuscitation in sepsis Flashcards Preview

CLASP: Sepsis 2017/18 > 8: Resuscitation in sepsis > Flashcards

Flashcards in 8: Resuscitation in sepsis Deck (28)
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1
Q

What is the definition of hypotension?

A

BP too low to perfuse tissues

< 90 / 60 mmHg or 40 below normal

2
Q

How does hypotension come about in sepsis?

A

Bacteria produce toxins

Toxins cause cytokine production

Cytokines cause VASODILATION and leaky capillaries > REDUCED BLOOD VOLUME

BP = CO x TPR

3
Q

What is a cytokine which causes hypotension in sepsis?

A

TNF alpha

4
Q

What does hypotension cause in sepsis?

A

Hypoperfusion of organs

=> ORGAN DAMAGE due to ISCHAEMIA and LACTIC ACIDOSIS

5
Q

How does lactic acidosis exacerbate sepsis?

A

Further vasodilation

Reduces cardiac output by reducing contractility of heart muscle

Cells can’t function outwith their optimum pH

6
Q

What is a renal problem caused by hypoperfusion in sepsis?

A

Acute kidney injury (AKI)

7
Q

What are clinical signs of hypovolaemia?

i.e dehydration

A

Cold peripheries, skin turgor, clammy

Tachycardia

Hypotension (including postural)

Decreased JVP

Dry mucuous membranes

Poor urine output

8
Q

Why does heart rate increase in sepsis?

A

Attempt to compensate for reduced BP

9
Q

Why does respiratory rate increase in sepsis?

A

Increased oxygen requirement of cells

Attempt to compensate for metabolic acidosis

10
Q

What is the normal level of lactate in the blood?

A

< 1.8 mmol/l

11
Q

What does an elevated lactate indicate?

A

Widespread anaerobic respiration

i.e widespread hypoperfusion –> hypoxia

12
Q

A lactate level of > ___ mmol/l is abnormal.

A

> 4 mmol/l

13
Q

How is urine output measured?

A

Directly (less accurate)

Catheter bag (more accurate)

14
Q

What is the minimum healthy urine output for a patient?

A

0.5 ml/kg/hr

which translates to about 30ml/hr in an adult

15
Q

In sepsis, ____ suggests renal hypoperfusion.

A

oliguria

< 0.5 ml/kg/hr

16
Q

What fluids are given to patients with sepsis?

A

0.9% NaCl, Hartmann’s solution

Crystalloids (gelofusin, blood transfusions) - don’t redistribute into soft tissue, “maintain oncotic pressure”

17
Q

What is a small risk of using colloid fluids e.g gelofusin?

A

Anaphylaxis

18
Q

What are some risks of blood transfusions?

A

Infection - e.g Hepatitis C

Transfusion reactions - Type II hypersensitivity, antibody-mediated reaction against RBCs

19
Q

What is a fluid challenge?

A

Initial resuscitation to replace water and salt

Repeat 500ml boluses of 0.9% NaCl or Hartmann’s, reassess vitals until resuscitated

20
Q

How much fluid is usually required to resuscitate someone?

A

2L

21
Q

It’s always better to give too ___ than too ___ fluid.

A

too much

too little

22
Q

What are the risks of

a) fluid overload
b) hypovolaemia?

A

a) Pulmonary oedema, treat with diuretics

b) Organ hypoperfusion, failure and death

23
Q

What changes in monitoring should be seen after fluid resuscitation?

A

Increased BP

Increased urine output

Reduced HR

Reduced lactate

24
Q

If a patient is still hypotensive after fluid resuscitation, what are they in?

What is the cause of the persistent hypotension?

A

Septic shock

Low TPR due to vasodilation

Rx: vasopressors (adrenaline, noradrenaline) which cause vasoconstriction and increased myocardial contractility

25
Q

What receptors do

a) adrenaline
b) noradrenaline act on?

A

Adrenaline is a mixed alpha/beta agonist

Noradrenaline acts on alpha receptors only

26
Q

What is the target MAP in septic shock?

A

> 65 mmHg

27
Q

How are inotropes given to someone in septic shock?

A

Central venous catheter

28
Q

What is the target urine output for someone in septic shock?

A

> 30 ml/hr

i.e > 0.5ml/kg/hr in a 60kg person