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Clinical Decision Making Exam 1 > Schoenwald - Sepsis > Flashcards

Schoenwald - Sepsis Flashcards

1
Q

bacteria in the bloodstream

A

bacteremia

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2
Q

t/f: not all bacteremia is sepsis

A

T

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3
Q

2 indications of bacteremia

A

positive blood cultures

fever/chills

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4
Q

systemic response to infxn → organ failure - can be fatal

A

sepsis

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5
Q

what do you think when you see SIRS

A

sepsis

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6
Q

SIRS in the setting of infxn, when associated w. acute organ dysfxn

A

severe sepsis

infxn + SIRS + organ dysfxn = sepsis

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7
Q

life-threatening organ dysfxn caused by dysregulated host response to infxn

A

sepsis

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8
Q

subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound and increase mortality

A

septic shock

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9
Q

how is organ dysfxn identified in sepsis

A

SOFA score →

sequential organ failure assessent

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10
Q

SOFA score doesn’t take into account

A

lactic acid

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11
Q

using SOFA score, the higher the score,

A

the worse the prognosis

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12
Q

components of the SOFA score (6)

A

respiration

coagulation

liver

CVD

CNS

renal

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13
Q

problem w. SOFA score

A

can’t be done fast/bedside

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14
Q

2 or higher on SOFA score reflects

A

overall mortality risk of 10% in hospitalized pt

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14
Q

2 or higher on SOFA score reflects

A

overall mortality risk of 10% in hospitalized pt

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15
Q

what sepsis score can be done bedside

A

qSOFA

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16
Q

problem w. qSOFA

A

not very sensitive

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17
Q

components of qSOFA

A

2 of 3:

RR 22 or higher

GCS < 13

SBP 100 or less

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18
Q

for sepsis dx, 2021 guidelines use (2)

A

SIRS criteria

qSOFA

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19
Q

pathway of sepsis (4)

A

inflammation → coagulation → fibrinolysis → coagulopathy

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20
Q

driving force of acute organ dysfxn in sepsis

A

coagulopathy

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21
Q

major class of bacteria associated w. sepsis

A

gram negative → lipopolysaccharide wall

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22
Q

3 proinflammatory mediators activated in sepsis

A

TNF

interleukins

platelet activating factors

clotting factors driven to areas of inflammation

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23
Q

4 classic signs of inflammation

A

rubor → redness

calor → heat

tumor → swelling

dolor → pain

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24
Q

interleukins that down regulate initial proinlammatory response

A

IL4

IL10

  • repair existing damage*
  • limit new damage*
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25
Q

why does such a massive systemic rxn occur in sepsis

A

regulation of initial response of Il4 and IL10 is lost

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26
Q

what mediators are responsible for cytokine storm in sepsis

A

TNF

IL1

IL6

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27
Q

what indicates activation of clotting

A

d-dimer

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28
Q

is d-dimer used as a sepsis screening tool

A

no

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29
Q

normal process to remove clots that is suppressed in sepsis

A

fibrinolysis

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30
Q

key inhibitor of fibrinolysis

A

plasminogen activated inhibitor-1 (PAI-1)

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31
Q

PAI-1 is produced by

A

endothelial cells

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32
Q

what increases activity of PAI-1

A

endotoxins released by gram negative rods

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33
Q

system responsible for vast majority of O2 delivery to tissues

A

microcirculation

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34
Q

injury to microvascular system leads to

A

leaky capillaries → edema

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35
Q

leaky capillaries lead to (6)

A

neutrophil migration/adhesion

increased coagulation

decreased fibrinolysis

increased inflammation

endothelial injury/loss of barrier integrity

altered microcirculatory perfusion

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36
Q

results of sepsis (4)

A

decreased O2 delivery dt capillary damage

decreased cardiac output

increased anaerobic metabolism

DIC

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37
Q

what metabolite indicates increased anaerobic metabolism

A

lactic acid

38
Q

widespread imbalance btw inflammation, coagulation, and fibrinolysis

A

DIC (disseminated intravascular coagulation)

clotting and bleeding at the same time

39
Q

4 labs elevated in DIC

A

PT

PTT

fibrin monomers

d-dimer

40
Q

3 labs decreased in DIC

A

protein C

fibrinogen

platelet count

41
Q

4 labs elevated in sepsis

A

Cr

ALT/AST/bili

lactate

procalcitonin

42
Q

3 things decreased in sepsis

A

urine output

mental status

bp

43
Q

when do we start to worry about lactate

A

>2 mmol/L

44
Q

when do we start to worry about procalcitonin

A

>2.0 ng/ml

45
Q

what is procalcitonin

A

protein biomarker for bacterial infxn

usually doesn’t go >2 in viral infxn

46
Q

clinical usefulness of procalcitonin

A

can be used to deescalate (d/c) abx

47
Q

risk of abx in sepsis

A

collateral damage → c.diff, SJS, resistant bacterial infxn

48
Q

procalcitonin > __ is highly suggestive of sepsis

A

2

49
Q

majority of sepsis pt’s originate in

A

hospital

mainly ER

50
Q

rf for sepsis (7)

A

critically ill

severe CAP

intra abd surgery

meningitis

chronic dz

decreased immune fxn

cellulitis

UTI

51
Q

3 greatest risk for sepsis

A

65 yo+

underlying comorbidity

higher body wt

52
Q

sx of sepsis

A

SEPSIS:

shivering/fever

extreme pain/worst ever discomfort

pale skin

sleepy - difficult to wake/confused

I feel like I might die

SOB

53
Q

SIRS criteria (4)

A

temp >100.4 OR <96.8

HR > 90 bpm

RR > 20 OR PaCO2 < 32

>12,000 WBC

think sepsis

54
Q

mimics of sepsis (7)

A

pancreatitis

GI bleed

SLE flare

DKA

anaphylaxis

adrenal insufficiency

PE/DVT

55
Q

2 values highly suggestive of severe sepsis

A

cap refill 3 seconds or more

lactate > 2 mmol/L

56
Q

mc cause of severe sepsis

A

PNA

~50%

57
Q

blood cultures are positive in __ of severe sepsis

A

⅓

58
Q

severe sepsis is caused by what 3 types of pathogens

A

gram negative bacteria: 62%

gram positive bacteria: 62%

fungi: 1.9%

59
Q

screening for severe sepsis takes into account (3)

A

infxn

SIRS

acute organ dysfxn

60
Q

tx for sepsis is divided into (3)

A

resuscitation

initial

maintenance

61
Q

resuscitation phase:

initial phase:

maintenance phase:

A

resuscitation: 1st 6 hr
initial: 24 hr
maintenance: >24 hr

62
Q

goal to start tx for sepsis

A

w. in 3 hr
* sooner the better*

63
Q

tx for resuscitation phase of sepsis (8)

A

airway

pan-culture

initiate abx

IV fluids

tight glycemic control

vasopressors

sedation

steroids

64
Q

abx options for sepsis (4)

A

vanco

quinolone

carbapenem (not ertapenem)

zosyn

65
Q

2 abx commonly used for resuscitation phase

A

vanco

zosyn

66
Q

indications for fluids in resuscitation phase (2)

A

MAP < 65

lactate > 4

67
Q

initial rate for fluids

A

30 mL/kg continuous

68
Q

glycemic control in resuscitation phase

A

continuous insulin drip

69
Q

first line vasopressor in resuscitation phase

A

norepinephrine

also consider dobutamine, phenylephrine, vasopressin

70
Q

pressor NOT recommended in sepsis

A

dopamine

71
Q

in resuscitation phase, what should be done before starting abx

A

blood cultures

72
Q

hour-1 sepsis bundle

A
  1. measure lactate
  2. obtain cultures
  3. abx
  4. rapid admin of crystalloid
  5. vasopressor
73
Q

indications for vasopressor

A

hypotensive during or after fluid resuscitation

74
Q

goal for bp in resuscitation phase

A

maintain MAP above 65

75
Q

4 goals in resuscitation phase that reduce 28 day mortality rate

A

CVP 8-12 mmHg

MAP 65 mm Hg

urine output 0.5 ml/kg/hr

central venous O2 sat 70% OR mixed venous O2 sat 65%

76
Q

what 3 scenarios indicate initiation of abx w.in 1 hr of sepsis recognition

A

sepsis definite or probable with OR without shock

sepsis is possible WITH shock

77
Q

when should abx be administered w.in 3 hours of sepsis recognition

A

w.in 3 hr if infxn persists

78
Q

tx for initial management phase of sepsis (3)

A

continue resuscitation phase

target abx to cultures

constant vasopressor monitoring

79
Q

indications to cut back on fluids (2)

A

lactic acid

capillary refill

80
Q

common respiratory condition associated w. sepsis

A

ARDS

81
Q

management of ARDS (3)

A

special attention to pressures/volumes

elevate head of bead

weaning protocols

82
Q

what is this showing

A

normal CXR

83
Q

what is this showing

A

bilateral diffuse fluffy infiltrates

normal cardiac size

EKG wires

→ ARDS

84
Q

CNS support for sepsis w.o ARDS

A

sedation

avoid neuromuscular blockers

85
Q

CNS support for sepsis pt w. early, severe ARDS

A

sedation

short course of neuromuscular blocker

86
Q

tx for maintenance phase of sepsis (if pt survives > 24 hr)

A

prevent nocosomial infxn

restore premorbid condition

tailor abx to cultures

87
Q

general supportive care for sepsis (5)

A

bg < 180 mg/dl

dialysis for renal/hypervolemia

DVT prophylaxis

stress-ulcer prophylaxis

enteral feeding

88
Q

what causes sepsis (4)

A

bacteria in:

lungs

urinary tract

GI

skin/soft tissue

89
Q

tx for ICU pt w. severe or critical COVID19 (4)

A

corticosteroids (dexamethasone)

venous thromboprophylaxis

remdisivir if not ventilated

prone ventilation

90
Q

tx NOT recommended for covid

A

hydroxychloroquine

91
Q

t/f: severe sepsis is uncommon

A

F!

it’s common :(

92
Q

critical aspect of sepsis management

A

early recognition

Clinical Decision Making Exam 1 (22 decks)

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