8: Resuscitation in sepsis Flashcards Preview

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

Flashcards in 8: Resuscitation in sepsis Deck (28)
Loading flashcards...
1

What is the definition of hypotension?

BP too low to perfuse tissues

< 90 / 60 mmHg or 40 below normal

2

How does hypotension come about in sepsis?

Bacteria produce toxins

Toxins cause cytokine production

Cytokines cause VASODILATION and leaky capillaries > REDUCED BLOOD VOLUME

BP = CO x TPR

3

What is a cytokine which causes hypotension in sepsis?

TNF alpha

4

What does hypotension cause in sepsis?

Hypoperfusion of organs

=> ORGAN DAMAGE due to ISCHAEMIA and LACTIC ACIDOSIS

5

How does lactic acidosis exacerbate sepsis?

Further vasodilation

Reduces cardiac output by reducing contractility of heart muscle

Cells can't function outwith their optimum pH

6

What is a renal problem caused by hypoperfusion in sepsis?

Acute kidney injury (AKI)

7

What are clinical signs of hypovolaemia?

i.e dehydration

Cold peripheries, skin turgor, clammy

Tachycardia

Hypotension (including postural)

Decreased JVP

Dry mucuous membranes

Poor urine output

8

Why does heart rate increase in sepsis?

Attempt to compensate for reduced BP

9

Why does respiratory rate increase in sepsis?

Increased oxygen requirement of cells

Attempt to compensate for metabolic acidosis

10

What is the normal level of lactate in the blood?

< 1.8 mmol/l

11

What does an elevated lactate indicate?

Widespread anaerobic respiration

i.e widespread hypoperfusion --> hypoxia

12

lactate level of > ___ mmol/l is abnormal.

> 4 mmol/l

13

How is urine output measured?

Directly (less accurate)

Catheter bag (more accurate)

14

What is the minimum healthy urine output for a patient?

0.5 ml/kg/hr

which translates to about 30ml/hr in an adult

15

In sepsis, ____ suggests renal hypoperfusion.

oliguria

< 0.5 ml/kg/hr

16

What fluids are given to patients with sepsis?

0.9% NaCl, Hartmann's solution

Crystalloids (gelofusin, blood transfusions) - don't redistribute into soft tissue, "maintain oncotic pressure"

17

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

Anaphylaxis

18

What are some risks of blood transfusions?

Infection - e.g Hepatitis C

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

19

What is a fluid challenge?

Initial resuscitation to replace water and salt

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

20

How much fluid is usually required to resuscitate someone?

2L

21

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

too much

too little

22

What are the risks of

a) fluid overload

b) hypovolaemia?

a) Pulmonary oedema, treat with diuretics

b) Organ hypoperfusion, failure and death

23

What changes in monitoring should be seen after fluid resuscitation?

Increased BP

Increased urine output

Reduced HR

Reduced lactate

24

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

What is the cause of the persistent hypotension?

Septic shock

Low TPR due to vasodilation

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

25

What receptors do

a) adrenaline

b) noradrenaline act on?

Adrenaline is a mixed alpha/beta agonist

Noradrenaline acts on alpha receptors only

26

What is the target MAP in septic shock?

> 65 mmHg

27

How are inotropes given to someone in septic shock?

Central venous catheter

28

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

> 30 ml/hr

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