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Flashcards in Sepsis/ARDS Deck (19)
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1

Define septic shock

Sepsis + Hypotension despite fluid resucitation + Perfusion abnormalities (e.g. lactic acidosis, oliguria, mental status change)

2

What are the top three organ systems, ranked by prevalence, affected by sepsis?

1) Respiratory
2) Cardiac
3) Renal

3

Are septic patients more likely to be hypercoaguable or hypocoaguable?

Hypercoaguable

4

Arrange the following terms into a mechanism order:

D-dimer
Plasmin
Fibrin
Plasminogen
Fibrinogen

Thrombosis leads to clot formation. Thrombin activates fibrinogen to fibrin which can form the basic scaffolding of a clot. Fibrin polymers link at a D-attachment site with other polymers. When the clot is to be broken down, plasminogen is activated to plasmin (e.g. by tPA). Plasmin then breaks down the fibrin polymers into fibrin degradation products (FDPs) which are smaller than fibrin. However, the D-dimer attachment remains and these small FDP dimers can be detected in the blood. Elevated D-dimer indicates activation of clot system (thrombosis) or DIC.

5

In sepsis, is the endothelium more or less responsive to endothelium-derived vasodilators?

More responsive

6

During what time frame should adequate antibiotics be started after sepsis is recognized in a patient?

Within one hour (although ASAP is best)

7

In sepsis early-goal directed therapy, what are the accepted ranges for the following values and in what order are they achieved?

MAP
SvO2
CVP
Hct

CVP 8-12mmHg (if not then crystalloid or colloid)
MAP 65-90mmHg (if not then vasoactive agents)
Hct >30% (if not then transfuse)
SvO2 >70% (if not then give inotropic agents)

8

A large study evaluated the benefit of dopamine vs norepinephrine for the treatment of hypotension in septic shock. Which is preferred and for what reason?

Norepinephrine preferred because of fewer adverse events (i.e. tachycardia, arrhythmias, and less need for additional vasopressors)

9

What are the criteria for ARDS?
(Hint: 4)

(i) Acute onset
(ii) Bilateral opacities on CXR
(iii) Relative hypoxemia
(iv)

10

What are 4 of the most common causes of ARDS?

Aspiration
Pneumonia
Sepsis
Trauma

11

Physiologically, what causes the hypoxia seen in ARDS?

What happens to pulmonary artery pressure and heart function?

V/Q mismatch

Pulmonary artery hypertension leading to right-heart failure

12

You're managing a patient with ARDS. Based on the primary literature, do you prefer to be liberal or conservative when resuscitating with fluids?

Conservative

Trial demonstrated that conservative fluid management scheme led to better oxygenation and shorter length of ventilation and ICU stay, but no difference in mortality

13

What is the theory behind limiting the stretch of the lungs in ARDS?

By limiting lung stretch one is reducing the release of pro-inflammatory cytokines (e.g. IL-6) which could promote inflammation and worsen the physiologic response.

14

What is a preferred strategy in ARDS management, permissive hyperoxia or permissive hypercapnia?

What are some reasons why?

Permissive hypercapnia (reduce chances of oxygen toxicity from free radicals which can promote hyalinization, inflammation, and edema of the lung parenchyma)

Permissive hypercapnia is thought to reduce ventilator associated lung injury and limits tidal volumes

15

What was the ARDS NIH Network study and what did it add to the management algorithm of ARDS?

Explored the use of lower TV (6 mL/kg for ideal weight based on height) compared to standard ventilation techniques.

The trial was ended prematurely because of the survival benefit of lower TV

16

What inhaled drug and what positional change are thought to be beneficial in ARDS? What is the physiologic affect?

Inhaled NO (vasodilator which improves V/Q mismatching)
Prone positioning improves oxygenation of dorsal lung units thus improving potential V/Q mismatch of ARDS

17

Is methylprednisolone generally recommended in ARDS?

No, based on trials

18

What is the standard treatment of ARDS?

Supportive care

(Often placement on ventilator with low TV ~6 mL/kg per ideal body weight based on height and plateau pressure of 30 mmHg

19

What are the SIRS criteria?

2 of the following:
(i) T38C
(ii) HR >90bpm
(iii) RR > 20 or PCO212K or 10% bands