Bacteremia/Sepsis

Question 1

what are endotoxins a part of? when the body responds to the bacteria, what happens?

Answer 1

cell wall of gram-negative bacteria; it causes a cascade of events that leads to illness

Question 2

what are exotoxins?

Answer 2

proteins released into the surrounding area by the bacteria during cell growth

Question 3

what do exotoxins do to your body? what do they lead to?

Answer 3

enzymatically inactivate or modify key cellular parts, leading to cell death or dysfunction

Question 4

what does botulism exotoxin do?

Answer 4

decreases the release of NT from cholinergic neurons causing flaccid paralysis

Question 5

what does tetanus exotoxin do?

Answer 5

decreases the release of NT from inhibitory transmitters causing spastic paralysis

Question 6

what does cholera exotoxin do?

Answer 6

induces fluid secretions into the intestinal lumen causing diarrhea

Question 7

what is one specific category of exotoxins?`

Answer 7

superantigens

Question 8

what happens when bacteria is engulfed by APCs? (normal process)

Answer 8

after ingested, epitopes are put on the cell surface, CD4 cells recognize the epitope, expansion of the specific CD4 cell and immunity to newly introduced antigen

Question 9

what happens with exotoxins and APCs? what does this cause excessive activation of?

Answer 9

they do not get ingested by APCs, it binds directly to it and cross links with CD4 cells (activates up to 20% of lymphocytes); excessive activation of lymphocytes and macrophages (uncontrolled synthesis and release of inflammatory cytokines)

Question 10

definition of infection

Answer 10

presence of bacteria with LOCAL inflammatory response

Question 11

definition of bacteremia

Answer 11

presence of viable bacteria in the blood

Question 12

definition of sepsis…what is it clinically characterized by

Answer 12

evidence of infection plus life threatening organ dysfunction, clinically characterized by an acute change in 2 pts or greater in SOFA score

Question 13

definition of septic shock

Answer 13

sepsis with fluid, unresponsive hypotension, serum lactate level greater than 2mmol/L and needing vasopressors to maintain mean arterial pressure of 65mm Hg or greater

Question 14

three things that can cause cardiogenic shock

Answer 14

MI, valve damage, surgery

Question 15

three things that can cause hypovolemic shock

Answer 15

loss of whole blood, loss of plasma, loss of extracellular fluid

Question 16

two things that can cause obstructive shock

Answer 16

inability to fill heart (tamponade) and embolus

Question 17

three things that can cause distributive shock?

Answer 17

neurogenic shock, presence of vasodilating substances in the blood (anaphylactic shock), presence of inflammatory mediators (septic shock)

Question 18

mortality is higher for pts who progress to ________ ________

Answer 18

septic shock

Question 19

which two age groups are more likely to get sepsis? are men or women more likely to get it?

Answer 19

neonatal period (birth to one month) and >65 yrs; men

Question 20

predisposing host factors of sepsis (6)

Answer 20

extremes of age, immunosuppressive therapy, recent surgery, granulocytopenia, hyposplenism, diabetes

Question 21

what is the SOFA used for?

Answer 21

sequential organ failure assessment- used to monitor for potential sepsis in ICU pt (constant, routine monitoring)

Question 22

what are the seven variables for SOFA?

Answer 22

1). PaO2/FIO2 ratio
2). glascow coma scale score
3). mean arterial pressure
4). administration of vasopressors with type/dose/rate of infusion
5). serum creatinine or urine output
6). bilirubin
7). platelet count
score 0-24

Question 23

what is qSOFA (quick SOFA) used for?

Answer 23

used in ED pts with known infection and to see if they are septic

Question 24

what are the three assessment measures for qSOFA?

Answer 24

low BP (SBP <100), high RR (>22), and altered mentation (GCS <14)

Question 25

what does bacteria do to procoagulation?

Answer 25

it increases procoagulation, so it alters the procoagulation/anticoagulation balance

Question 26

cell damage leads to ________ _________ which leads to fluid leaking from the ______ to the ________ __________

Answer 26

vascular damage; vessels; interstitial space

Question 27

what are the mechanism steps of sepsis starting from hypovolemia (5 steps)

Answer 27

hypovolemia, hypotension, hypoperfusion of organs (leads to signs and symptoms), organ failure, death

Question 28

what are the initial signs and symptoms (sepsis)- 4

Answer 28

fever, vasodilation, warm flushed skin, +/- visible source of infection

Question 29

what are the 3 main signs of organ involvement (septic shock)

Answer 29

neurologic, renal, cardiac

Question 30

what are circulation, pulm, neuro, renal, GI, cardiac, and hematologic signs/symptoms of hypoperfusion

Answer 30

``` Circulation- hypotension Pulmonary- pulmonary edema- ARDS Neuro- altered mental status Renal- oliguria--- acute renal failure GI- infarcted bowel---GI bleeding Cardiac- angina (Hypoperfusion of muscle!) Hematologic- DIC ```

Question 31

a patient presents with ______ and _________ suspect sepsis

Answer 31

fever and hypotension

Question 32

look for what kind of source for sepsis?

Answer 32

bacterial

Question 33

tx for sepsis

Answer 33

1) . IV fluid and vasoconstrictive agents- circulation support 2) . ongoing assessment of labs for progression of sepsis 3) . ABX- broad spectrum until culture results are back

Question 34

what cells are impaired in hyperglycemia?

Answer 34

phagocytes

Question 35

what does insulin prevent during sepsis? what level should blood sugar be kept between?

Answer 35

apoptotic cell death that is caused from hyperglycemia; 80-100

Question 36

when are corticosteroids used in sepsis tx? what are guidelines for dosage?

Answer 36

those with vasopressor dependent septic shock; no greater than 300 mg/day for at least 5 days then tapered

Question 37

what staph bacteria is a part of the normal flora? what does this cause?

Answer 37

S Aureus; skin infections

Question 38

what does staphylococcal bacteremia invade? by invading this, what three things can it lead to?

Answer 38

bloodstream; endocarditis, osteomyelitis (60% of cases are caused by S aureus), other metastatic deep infections

Question 39

tx of uncomplicated bacteremia

Answer 39

vancomycin 1 g q 12 hrs PLUS either impenem, meropenem, or piperacillin-tazobactam

Question 40

90% of toxic shock syndrome cases occur in what population?

Answer 40

women of childbearing age

Question 41

what two bacteria produces toxins for toxic shock syndrome?

Answer 41

staph aureus and strep pyogenes

Question 42

what is the most common toxin of toxic shock syndrome?

Answer 42

toxin 1 (TSST-1), which is a superantigen produced by S aureus

Question 43

how does a toxin cause toxic shock syndrome?

Answer 43

toxin is produced in a certain area (not a spread of bacteria like sepsis) and then the toxin is sent to the bloodstream, causing massive inflammatory rxn

Question 44

presentation of TSS (7)

Answer 44

fever, macular rash (desquamation 1-2 weeks after onset), systemic hypotension, vomiting, diarrhea, myalgias, conjunctivitis

Question 45

what are some non-menstrual conditions that can cause TSS (11)

Answer 45

diaphragm or contraceptive sponge use, IV drug use, osteomyelitis, pilonidal abscess, septic arthritis, cellulitis, burns, empyema, lung abscess, postpartum infection, postop wound infection

Question 46

tx of TSS

Answer 46

supportive measures, ABX (staph- nafcillin or oxacillin, strep- PenG + clinda), cardiac/renal/pulm monitoring, surgery

Question 47

what are the four types of shock?

Answer 47

cardiogenic, hypovolemic, obstructive, distributive