Sepsis

Question 1

What do you need to diagnose sepsis?

Answer 1

Temperature >38 or <36
HR >90 bpm
RR >20 breaths/min or PaCO2 <32
WBC >12000, <4000 or >10% immature bands

Question 1

What causes SIRS?

Answer 1

Activation of immune system due to infection trauma burns noninfectious inflammatory process

Question 2

Sepsis

Answer 2

SIRS plus culture proven infection or presumed presence of infection

Question 3

Severe sepsis

Answer 3

Sepsis plus one or more organ dysfunction

Question 4

Septic shock

Answer 4

Sepsis + refractory hypotension with mean systemic BP <65 mmHg unresponsive to crystalloid fluid challenge of 20-40 cc/kg

Question 5

How is sepsis graded?

Answer 5

organ dysfunction and hemodynamic compromise

Question 6

what leads to improved sepsis outcomes?

Answer 6

early id with abx and IVF

Question 7

which patients need a lower threshold?

Answer 7

elderly (can decompensate quickly)

Question 8

severe sepsis is sepsis + organ dysfunction and what

Answer 8

not due to pre-existing condition
must persist despite adequate fluid resuscitation

Question 9

mortality rate of severe sepsis

Answer 9

20-40%

Question 10

signs of severe sepsis

Answer 10

hypotension
elevated lactate
decreased urinary output
acute lung injury/ARDS
creatinine >2 mg/dL
bilirubin >2 mg/dl
thrombocytopenia
coagulopathy
ams

Question 11

septic shock quickly leads to

Answer 11

circulatory collapse

Question 12

what is multiple organ dysfunction syndrome

Answer 12

severe acquired dysfunction of at least 2 organ systems lasting 24-48 hours in setting of sepsis, trauma, burns, or severe inflammatory condition

Question 13

what is related to mortality in MODS

Answer 13

number of dysfunctional organs and duration of dysfunction

Question 14

cause of MODS

Answer 14

uncontrolled hyperinflammatory response

Question 15

pathophysiology of MODS

Answer 15

dysregulated immune response –> multiorgan involvement
interaction of complement cascade, coagulation cascade, platelets, and leukocytes at vascular endothelium level

Question 16

what does immune response in MODS result in @ tissue level?

Answer 16

microvascular injury
thrombosis
loss of endothelial integrity

–> Tissue ischemia

Question 17

what causes global tissue hypoxia in MODS?

Answer 17

decreased preload
vasoregulatory dysfunction
myocardial depression
impaired tissue extraction d/t microcirculatory dysfunction or mitochondrial dysfunction

Question 18

what can mimic sepsis?

Answer 18

thyrotoxicosis
aortic regurgitation
arterosclerosis
cirrhosis

high cardiac output state and wide pulse pressure without shock

Question 19

what causes variance in sepsis presentation

Answer 19

infection source
patient age
underlying comorbidities
timing of presentation

Question 20

early manifestations of sepsis

Answer 20

tachycardia
oliguria
hyperglycemia

poor cardiac function = no high CO as expected

Question 21

what is the relationship between sepsis and blood cultures

Answer 21

<50% ahve + blood cultures
many have no microbial cuase identified

Question 22

established sepsis s/s

Answer 22

altered mental status
metabolic acidosis and respiratory alkalosis\
hypotension with decreased SVR and elevated CO
coagulopathy

Question 23

late manifestations of sepsis

Answer 23

acute lung injury
ARDS
ARF
hepatic dysfunction
refractory shock

Question 24

diagnosis of sepsis

Answer 24

H&P
look for hidden or missed sources (if unknown)? including skin and soft tissue, CNS, GI tract, indwelling devices
obtain cultures (prior to abx if possible): blood, urine, fluids

Question 25

most common sites of infection

Answer 25

urinary tract
respiratory tract

Question 26

what should be done to stabilize septic patient?

Answer 26

oxygen - monitor with pulse ox and intubate if needed d/t increased work of breathing/airway compromise
IV access, may need central line for pressors
CBC, CMP, coag, ABG
serum lactate (to assess severity and monitor)

Question 27

What are additional diagnostic studies that may be ordered based on presentation?

Answer 27

radiography
cultures of blood, urine, sputum, CSF, paracentesis (ascites), thoracentesis (pleural effusion)
advanced imaging
US or ERCP for biliary
Echo for cardiac fxn/vegetations

Question 28

you need to admit your septic patient. What do you need to make sure the unit has?

Answer 28

Vital sign monitoring with capability to measure central venous pressure and central venous oxygen saturations
telemetry
continuous pulse ox

Question 29

treatment principles for sepsis

Answer 29

early aggressive resuscitation
early antibiotics
early source id

Question 30

treatment approach for sepsis

Answer 30

empiric abx while culture pending
fluid resuscitation
pressors and/or inotropes
additional as needed: drainage of abscesses, removal of lines, moderate control of hyperglycemia, steroids if indicated

Question 31

how soon should antibiotics be given?

Answer 31

within 1 hour

Question 32

factors that go into antibiotic choice

Answer 32

penetration into suspected site
resistance patterns
efficacy against most likely organisms
prior exposure to specific antibiotics
risk of side effects

Question 33

when should antifungals be considered

Answer 33

recent abd surgery
TPN
chronic steroids

Question 34

most common organisms causing sepsis

Answer 34

E. Coli
staph aureus
klebsiella
strep pneumoniae

consider MRSA and pseudomonas (even though not most common)

Question 35

if pseudomonas is unlikely what antibiotics should be used?

Answer 35

vancomycin (if MRSA concern) + 3rd gen or 4th gen or zosyn/ticarcillin-clavulanate or carbapenem

Question 36

if pseudomonas is likely what abx should be used?

Answer 36

vancomycin plus two of the following: