Sepsis Exam 4 Flashcards
(68 cards)
1
Q
Epidemiology of sepsis and septic shock
A
- Affects millions of patients per year
- Potentially 5.3 million deaths annually
- Mortality varies depending on definitions
2
Q
risk factors for sepsis and septic shock
A
- Age: <2yr or >55yr
- Chronic / serious illness
- Impaired immunity
- Breach of natural barriers
- Chronic infections
- Protein calorie malnutrition
3
Q
risk factors for sepsis and septic shock: Chronic / serious illness
A
- Cancer
- diabetes
- COPD
- cirrhosis or biliary obstruction
- cystic fibrosis
- CKD
- CHF
- collagen vascular disease
- obesity
4
Q
risk factors for sepsis and septic shock: Impaired immunity
A
- Transplantation
- chemotherapy
- radiation therapy
- drug-mediated immunosuppression
- blood transfusions
5
Q
risk factors for sepsis and septic shock: Breach of natural barriers
A
- Trauma
- surgery
- catheterization
- intubation
- burns
6
Q
risk factors for sepsis and septic shock: Chronic infections
A
- HIV
- decubitus ulcers or non-healing wounds
7
Q
Epidemiology of sepsis and septic shock: organisms
A
- gram + becoming the major cause in recent years
- gram - not far behind
- fungi does cause it but not to the same extent
8
Q
What is the APACHE II?
A
- use APACHE II to make sure that we’re comparing pts on the same level
- the higher the score, the higher risk of mortality
- sees how sick a person is
9
Q
What are the SIRS criteria?
A
Have to have >= 2 of the following:
- T > 38.3⁰C (100.9⁰F) or <36⁰C (96.8⁰F)
- HR > 90bpm or >2SD above ULN for age
- RR > 20bpm or PaCO2 < 32mmHg
- WBC >12,000/mm3 or < 4,000/mm3
10
Q
Define Sepsis-2 for a person that has sepsis
A
SIRS PLUS suspected or documented infection
11
Q
Define Sepsis-2 for a person that has severe sepsis
A
Sepsis PLUS organ dysfunction
12
Q
Define Sepsis-2 for a person that has septic shock
A
- Acute circulatory failure characterized by persistent arterial hypotension unexplained by other causes
- Hypotension: SBP <90mmHg, MAP <60, or↓ SBP >40mmHg from baseline
13
Q
Sepsis-2 Clinical Criteria: general variables
A
- T > 38.3⁰C (100.9⁰F) or <36⁰C (96.8)
- HR > 90bpm or >2SD above ULN for age)
- RR > 20bpm or PaCO2 < 32mmHg
- altered mental status
- Significant edema or +fluid balance (>20ml/kg over 24hr)
- hyperglycemia (>120mg/dL) in absence of diabetes
14
Q
Sepsis-2 Clinical Criteria: inflammatory variables
A
- WBC >12,000/mm3 or < 4,000/mm3
- > 10% bands w/normal WBC
- C-reactive protein (CRP) >2SD above normal
- Procalcitonin (PCT) >2SD above normal
15
Q
Sepsis-2 Clinical Criteria: hemodynamic variable
A
- SBP <90mmHg, MAP < 60, ↓ SBP >40mmHg from baseline
- SvO2 > 70%
- CI > 3.5l/min/m^2
16
Q
Sepsis-2 Clinical Criteria: organ dysfunction variables
A
- Pao2/FIO2 ratio <300
- UOP <0.5ml/kg/hr x ≥2hr
- SCr ↑0.5mg/dL
- INR >1.5 or aPTT > 60sec
- Ileus
- platelets <100,000/mcL
- Tbili > 4mg/dL
17
Q
Sepsis-2 Clinical Criteria: perfusion variables
A
- Hyperlactatemia >1mmol/L
- decreased capillary refill or skin mottling
18
Q
Who is qSOFA used for?
A
used on pts who are not in the ICU
19
Q
What are the components of qSOFA?
A
- Altered mental status
- respiratory rate ≥22
- SBP ≤100mmHg
20
Q
How does sepsis 3 define sepsis?
A
life-threatening organ dysfunction caused by a dysregulated host response to infection
21
Q
Higher SOFA means higher…
A
mortality
22
Q
According to sepsis 3, how do you define organ dysfunction?
A
- Acute change in SOFA score ≥2 consequent to the infection
- Baseline SOFA assumed to be 0 if no known preexisting organ dysfunction
- SOFA ≥2 reflects an overall mortality risk of ~10% in a general hospital population w/suspected infection
23
Q
According to sepsis 3, how do you define septic shock?
A
- Subset of septic patients in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality
- hypotension (MAP < 65mmHg) AND lactate > 2mmol/L
24
Q
What does SOFA stand for?
A
- sequential organ failure assessment score
- use THIS one for ICU pts
25
According to sepsis 3, how do you define sepsis?
Suspected or documented infection PLUS acute ↑ ≥2 SOFA points
26
What is the goal of fluid therapy in sepsis?
- restore intravascular volume
- ↑cardiac output (CO)
- augment O2 delivery
- improve tissue oxygenation
27
What is given for initial resuscitation fluid thearpy?
* Crystalloids: cheap salts / sugars; as solutions of ions capable of crossing semipermeable membranes
* Colloids: more expensive; suspensions of large plasma-derived or semi-synthetic molecules that cannot cross semipermeable membranes
28
Normal values of electrolytes in plasma
- Na: 140mEq/L
- Cl: 100mEq/L
- K: 4mEq/L
- Ca: 9.6mg/dL
- Mg: 2.4mg/dL
- HCO3-: 24mEq/L
29
Normal osmolality of plasma
291 (275 - 295)
30
Normal pH of plasma
7.35 - 7.45
31
What does the Surviving Sepsis Campaign (SSC) recommend for sepsis induced hypoperfusion?
≥30ml/kg of IV crystalloid fluid within the first three hours
32
What does the Surviving Sepsis Campaign (SSC) recommend for initial resuscitation and subsequent intravascular volume replacement in patients w/sepsis and septic shock?
- crystalloids
- weak: can give crystalloids or saline for fluid resuscitation
- if pt needing large amount of crystalloids, can supplement with colloids
33
What happens after initial resuscitation?
- additional fluids should be guided by frequent reassessment of hemodynamic status
- fluid challenge technique be applied where fluid administration is continued as long as hemodynamic factors continue to improve
34
What are the ways in which you can check for fluid responsiveness?
- Central Venous press. (CVP)
- Stroke Vol. Variation (SVV)*
- Pulse Press. Variation (PVV)*
- Vena cava dimensions / collapsability
- Passive leg raise (PLR)*
- End-expiratory Occ. Test
- Fluid challenge*
35
Fluid Responsiveness: Central Venous press. (CVP)
- debunked for the most part
| - it's never been shown that if the CVP is low, that the pt is responding to fluids; not used anymore
36
Fluid Responsiveness: Stroke Vol. Variation (SVV)*
- heart lung interaction when pt is on ventilator; apply pressure to keep the alveoli open; can also affect blood flow; keeps blood from venous return to right atrium; pts on mechanical ventilator (MV), if it shows that you have >12% increase in cardiac output, it shows that pt will response to fluid
- Can’t be used if spontaneously breathing, arrhythmias, low tidal volumes (Tv)/lung compliance
37
Fluid Responsiveness: Pulse Press. Variation (PVV)*
- when pt is on mechanical ventilation, usually do what's called positive pressure; when a critically ill pt breathes out, may not breathe that well and alveoli is probably collapsing -> have to push pressure to keep that alveoli open which could in turn affect blood flow in thoracic cavity; positive pressure applied at the end of expiratory breath (instead of inhalation like normal); this keeps blood from venous return to the right atrium; pts who are on MV (mechanical ventilator) who have a set RR (not taking any spontaneous breaths), you'll see variations in pulse pressure and stroke volume, systolic and diastrolic throughout resp cycle; if you're volumed up, shouldn't see variation; if you're seeing variation (>12% increase in cardiac output) between inspiration and expiration in the venous return (SV or PP), then that suggests that you'll respond to fluid
- Can’t be used if spontaneously breathing, arrhythmias, low tidal volumes (Tv)/lung compliance
38
Fluid Responsiveness: Vena cava dimensions / collapsability
- not recommended
- Can’t be use if spontaneously breathing, low Tv/lung compliance
- not useful because SVC requires TEE; look at ultrasound to see hwo much the vena cava collapsed
39
Fluid Responsiveness: Passive leg raise (PLR)*
- in your lower extremities, you actually have 300 mL of blood in your venous side esp if you're lying flat; kick legs up and monitor CO; kind of like a fluid challenge
- increase CO >10% shows response to fluid
40
Fluid Responsiveness: End-expiratory Occ. Test
- ecclude ventilator for 15 seconds and then see how CO changes
- pts can't tolerate this; not commonly done
- increase in >5% CO shows response to fluid
41
Fluid Responsiveness: Fluid challenge*
- administer 100mL of fluid; if CO increases by >6% then shows response to fluid
- administer 500mL of fluid; if CO increases by >15% then shows response to fluid
42
Albumin ADE / comments
- Theoretically risk of disease transmission
| - Expensive vs. crystalloids AVOID in TBI
43
NS ADE / comments
- Hyperchloremic metabolic acidosis
- Cl- content may lead to AKI
- PREFERRED in TBI
44
LR ADE / comments
- Lower risk of hyperchloremic metabolic acidosis
| - May have lower AKI risk vs. NS
45
Plasmalyte ADE / comments
- Lower risk of hyperchloremic metabolic acidosis
| - May have lower AKI risk vs. NS
46
In general, what are ADE's of fluids?
- increase in pulmonary edema
- increased prolonged ventilation
- increased tissue edema
- poor wound healing
- impaired contractility
- abd compartment syndrome: bowel edema + inflammation already going on increases intra-abd pressure, decreases abd perfusion, lead to organ failure
- hepatic congestion
- over-stretched myocardium that falls off starling curve
47
What can cause a pt to have increased Vd?
- Sepsis
- Trauma
- Severe hypoalbuminemia
- Fluid therapy
- Parenteral nutrition
- Reduced CO
- Pleural effusion
- Ascites
- Mediastinitis
- these conditions give an apparent increase in Vd (Post-surgical drainage, early phase burns)
48
What can cause a pt to have increased clearance?
- late phase burns
- Acute Leukemia
- Hyperdynamic sepsis phase
- Increased CO
- Poly-trauma
49
What can cause a pt to have decreased clearance?
- Renal failure
| - >75yr
50
When to administer antibiotic therapy?
- if cultures do not delay administration, obtain a culture
- initiate ASAP (within 1 hour of sepsis or septic shock)
- for every hour that passes with lack of antibiotics after pt is hypotensive, you get a 8% decrease in survival
- recommend empiric broad-spectrum to cover all likely pathogens
51
How long should antibiotics be administered for?
- 7-10 days (weak recommendation)
- longer in these pts: Slow clinical response, undrainable foci of infection, bacteremia w/S. aureus, some fungal and viral infections, or immunological deficiencies
- shorter in these pts: those w/rapid clinical resolution following effective source control of intra-abdominal or urinary sepsis and those w/anatomically normal pyelonephritis
52
What are factors / considerations that will help guide empiric therapy?
* Site of infection
* Prevalence of pathogens within the community, hospital, and even specific unit/ward
* Resistance patterns of the prevalent pathogens
* Presence of immunodeficiencies, i.e. neutropenia, HIV, splenectomy, etc.
* Age/patient comorbidities, organ function, presence of invasive devices
* Pharmacokinetic / pharmacodynamic changes
53
If your suspected source is pulmonary, which antibiotic would you use to treat?
- VAP: Zosyn or cefepime ± vanc ± Cipro or aminoglycoside
| - HAP: Zosyn, cefepime ± vanc ± cipro or aminoglycoside
54
If your suspected source is intra-abdominal, which antibiotic would you use to treat?
Zosyn or cefepime / MTDZ, ± fluconazole or micafungin
55
If your suspected source is genitourinary / kidneys, which antibiotic would you use to treat?
- Community acquired: ceftriaxone
| - CAUTI / Hosp. acquired: zosyn, cefepime
56
If your suspected source are central lines, which antibiotic would you use to treat?
- Zosyn ± vanc
| - cefepime ± vanc
57
If your suspected source is SSTI, which antibiotic would you use to treat?
- Purulent: vancomycin
- Non-purulent: zosyn ± vanc
- Necrotizing: vanc + zosyn or cefepime/mtdz
- Plus clindamycin if toxic shock suspected
58
How do you calculate MAP?
* CO * SVR
* where CO = HR * stroke volume
* OR (2DBP + SBP)/3
59
Which vasopressor does the SSC recommend?
- norepinephrine (NE) as first line
- weak recommendation for adding vasopressin or epinephrine (EPI)
- weak recommendation for starting dobutamine in pts w/ evidence of persistent hypoperfusion despite adequate volume loading + use of vasopressors
60
Which vasopressor shouls you never use for septic shock?
dopamine
61
What are vasopressors used for?
to help pt reach their perfusion goal
62
SSC perfusion endpoints
- initial target mean arterial pressure (MAP) of ≥65mmHg in patients with septic shock requiring vasopressors
- Suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion
63
What are the ways in which you can measure perfusion endpoints?
- Physiologic
- Hemodynamic
- Metabolic
64
Physiologic ways to measure perfusion endpoints
- Heart rate goal < 90 – 100bpm
| - Urine output(?) goal of >0.5ml/kg/hr
65
Hemodynamic ways to measure perfusion endpoints
- MAP goal of >65mmHg
- Mixed venous oxygenation SvO2
- Central venous oxygenation ScvO2
66
Metabolic ways to measure perfusion endpoints
- Lactate goal of < 2mmol/L or 10% decrease within initial 6hr
- Base deficit
67
Use of steroids in septic shock
- Do not use if adequate fluid resuscitation and pressors are able to able to restore hemodynamic stability; if not then administer IV hydrocortisone 200mg/d
- Use if not responsive to fluid and moderate-high dose vasopressors -> IV HC <400mg/day x ≥3 days
- Pressor doses: >0.1 mcg/kg/min NE or equivalent pressor dose, EPI 0.1mcg/kg/min, PE 1mcg/kg/min, Vaso 0.04 units/min
68
Metabolic resuscitation
- pts have love levels of thiamine and Vitamin C if they are in septic shock
- administer supplements
- in his notes: IV thiamine 200mg IV q12 + Vit C 1500mg IV q6hr + HC 50mg IV q6hr
