Lecture 5 - Sepsis

Question 1

Systemic Inflammatory Response Syndrome (SIRS) definition

Answer 1

2 of the following

Temp > 38 or < 36
HR > 90BPM
RR > 20 or PaCo < 32
WBC > 12,000, < 4,000 or > 10% bands

Question 2

Sepsis definition

Answer 2

SIRS with a presumed or confirmed infection process

Question 3

Severe Sepsis defintion

Answer 3

Sepsis associated with organ dysfunction and hypo perfusion

Question 4

Septic shock definition

Answer 4

Sepsis with hypotension and perfusion abnormalities despite adequate fluid restriction

Question 5

Low need organs

Answer 5

Periphery
stomach
kidney
liver

Question 6

High need organs

Answer 6

Heart
Brain

Question 7

Distributive Shock (sepsis)

Answer 7

Low - tissue perfusion
Low - Preload
Low - Afterload
Cardiac output - normal or harder

Question 8

Sepsis bundle to be completed within 1hr

Answer 8

1. Measure serum lactate lvl
2. obtain blood cultures prior to admin of ABX
3. Admin broad-spec aBX

Question 9

Sepsis bundle to be completed within 3hrs

Answer 9

4. Admin 30ml/kg of crystalloid for Hypotension if (< 90 mm HG)
5. Apply vasopressors (for hypotension that doesn’t respond to initial fluid resuscitation) to keep SBP > 90mm HG

Question 10

Signs of hypovolemia

Answer 10

Urine output = < 0.5ml/kg/hr, oliguria
Central venous pressure (CVP) < 7
Pulmonary edema = no
BUN: Cr ratio = > 20:1

Question 11

Treatment of Hypovolemia

Answer 11

need aggressive fluid now

1 or more signs then treat

Question 12

Signs of Hypervolemia

Answer 12

Urine output > 0.5ml/kg/hr
CVP > 13**
Pulmonary edema = yes**
BUN: Cr ration > 20:1….nah

Question 13

Treatment for Hypervolemia

Answer 13

continue maintenance fluid and consider IV furosemide

Question 14

Types of Resuscitation Fluids

Answer 14

Crystalloids
Colloids

Question 15

Crystalloid fluids

Answer 15

Normal Saline
Dextrose
Lactated ringeres

Question 16

Colloid fluids

Answer 16

Natural = albumin
Semi-synth = Hydroxyethyl Starch (HES)

Question 17

Hypovovolemia recommendations

Answer 17

Crystalloids, strong recommendation

min 30ml/kg of crystalloid 1st 3 hours…only if they need fluid**

1st dose usually over 30-60min, subsequent doses over 30-60min but lower amounts 500-1000ml

Question 18

common barriers to rapid ABX admin

Answer 18

1. excessive workload
2. no notification from MD of new abx order in EPIC
3. inadequate IV access bc of multiple non-abx mds
4. no IV access
5. lack of availability of abx on unit
6. pt off unit for urgent procedure/test

Question 19

1st line vasopressor of choice for septic shock?

Answer 19

Norepinephrine

inc MAP + dose dependent incr in systemic vascular resistance

** Dont use Dopamine except in rare instances **

Question 20

When to use Vasopressin for septic shock?

Answer 20

1. dont go over 0.04u/min due to necrosis, 2nd line
2. used in those who dont respond to catecholamine vasopressors

Question 21

Using Vasopressin info

Answer 21

> 15mcg/min NE or > 200mcg/min phenylephrine = didn’t respond

No bolus should be given
dont use as single agent for refractory hypotenstion
1/10 bleeding varices dose
0.04 u/min

Question 22

When is phenylephrine good

Answer 22

patients w/ severe tachycardia ( > 150) or moderate tachycardia ( > 100 + active MI or A.fib)

Question 23

vasopressors SSC recomednations

Answer 23

1. target SBP of 90 mmHG = strong rec
2. NE is 1st choice vasopressor = strong rec
3. Can add 0.04 u/min vasopressin to NE when SBP < 90 and NE infusion rate > 15mcg/min = ungraded rec

Question 24

When is IV hydrocortisone used?

Answer 24

if adequate fluid restrictions and NE infusion at > 15mcg/min failed to maintain systolic BP > 90

& vaso 0.04 for purpose of this course

Dose: 50mg IV q6hrs