Sepsis guidelines 2021 Flashcards
(31 cards)
Definition of sepsis
Dysregulated host response to infection
Against using qSOFA
qSofa: GCS <15, RR >=22, SBP <=100
Positive qSofa 2
over SIRS, NEWS and MEWS
At least 30 ml/kg of IV crystalloid should be given within the first 3 hours of resuscitation
WEAK
Dynamic measures: better diagnostic accuracy in predicting fluid responsiveness
example
1. Passive leg raising combined with cardiac output measurement
2. Fluid challenges against stroke volume
3. Systolic pressure or pulse pressure
4. Increases of SV in response to changes in thoracic pressure
**>15% increase in pulse pressure could indicate that the patient is fluid responsive using a passive leg-raise test for 60-90 seconds
Lactate
can be used to screen for the presence of sepsis among undifferentiated adult patients with clinically suspected sepsis
Lactate cut off 1.6-2.5 mmol/L
Lactate is a biomarker for tissue hypoxia and dysfunction
Guiding resuscitation to decrease serum lactate
Capillary refill time to guide resuscitation as an adjunct
Initial target MAP
65 mmHg
Admit patient to ICU
within 6 hours
Adults with possible septic shock or HIGH likelihood for sepsis
Administer antimicrobials within 1 hour of recognition
Adults with possible sepsis WITHOUT shock
Administration of antimicrobials within 3 hours from the time sepsis was first recognized
Patients at high risk for MRSA
Patients at risk for MRSA
1. Prior history of MRSA infection or colonization
2. Recent IV antibiotics
3. History of recurrent skin infections or chronic wounds
4. Presence of invasive devices
5. Hemodialysis
6. Recent hospital admission and severity of illness
Recommend using emperic antimicrobials with MRSA coverage
For adults with sepsis or septic shock and high risk for MDR
Risk factors for MDR infection
1. Proven infection or colonization with an antibiotic-resistant organism within preceeding year
2 Local prevalence of antibiotic- resistant organism
3 Hospital-acquired/health care associated
4 Broad-spectrum antibiotic use within the preceeding 90 days
5 Concurrent use of selective digestive decontamination
6 Travel to highly endemic country preceding the 90 days
7 Hospitalization abroad preceding the 90 days
2 antimicrobials with gram negative coverage
**Local information about the resistance patterns of the most common causative agents of sepsis: essential to choose the most appropriate empirical antibiotic therapy
Emperic double coverage of gram negeative bacilli is most important in patients
At high risk for resistant organisms with severe illness (septic shock)
For adults with sepsis or septic shock at high risk for fungal infections
Using empiric antifungal therapy
Risk factors for fungal infection:
Febrile neutropenia patients who fail to defervesce after 4-7 days of broad-spectrum antibacterial therapy
Optimizing dosing strategies based on
kinetic/pharmacodynamic (PK/PD) principles
Scenarios that affect the concentration of some antibiotics
1. Augmented renal clearance
2. AKI
3. Hypoalbuminemia
4. RRT
5. Extracorporeal membrane oxygenation
Daily assessment for de-esclatation of antimicrobials
Over fixed duration of therapy
Patients with sepsis or septic shock and ADEQUATE source control where optimal duration of therapy is unclear
Use procalcitonin and clinical evaluation to decide when to discontinue antimicrobials
First line fluid for resuscitation
balanced crystalloids (LR) over normal saline
Adverse effects of NSS
1. Hyperchloremic metabolic acidosis
2. Renal vasoconstriction
3. Increased cytokine secretion
4. AKI
Use albumin in patients
Who received large volume of crystalloids
Effects of albumin :
1. Higher blood pressure at early and later time points
2. Higher static filling pressures
3. Lower net fluid balance
Vasoactive management
1st line: norepinephrine (a-1 and b-1 adrenergic receptor agonist) vasoconstriction–> inc MAP with minimal effect on HR
2nd line: vasopressin
3rd line: epinephrine (b-1 and moderate b-2 and a-1 adrenergic receptor activity)
Low dose: b1: increased CO, decreased SVR, and variable effect on MAP
Higher dose: increase SVR and CO
SE: arrhythmia and impaired splanchnic circulation, increase aerobic lactate production via stimulation of skeletal b-2 adrenergic receptors
*Vasopressin is started when the dose of norepinephrine is 0.25-0.5 ug/kg/min
Fixed dose: 0.03 units/min
Ceiling 0.06 units/min
Produced in hypothalamus
Stored and released by the posterior pituitary gland
Binds to the V1 receptors on vascular smooth muscle thus increased arterial blood pressure
S/e: cardiac, digital and splanchnic ischemia
Dopamine: dose-dependent fasion on dopamine 1, a-1 and b-1 adrenergic receptors
Lower dose dopamine: vasodilation via dopamine 1 in renal, splanchnic, cerebral, and coronary beds
Higher dose: vasoconstriction and increased systemic vascular resistance via a1-receptor and b1-receptor activity can lead to dose-limiting arrhythmia
Inotropes
Patients with septic shock and cardiac dysfunction (low CO and elevated cardiac filling pressures) with persistent hypoperfusion
Noepinephrine+dobutamine
ORRRR
Epinephrine alone
Dobutamine
MOA: Increases CO and oxygen transport increases splanchnic perfusion and tissue oxygenation improves intramural acidosis and hyperlactatemia
S/e of dobutamine infusionL severe vasolatation–> result in lower MAP
>inotropic response may be blunted in sepsis with a preserved chronotropic effect causing tachycardia without an increase in stroke volume
Suggest invasive monitoring of arterial blood pressure
Start vasopressors peripherally
For sepsis-induced hypoxemic respiratory failure
Use high-flow nasal oxygen over NIV
HFNC:
warms and humidifiers secretions
High flow rates better match patient demand
Washout of nasopharyngeal dead space
Modest positive airway pressure effect
**allows airflow as high as 60L per minute to achieve Fio2 95-100%
NIV
Main risk: delaying need for intubation and increasing the risk of an interval aspiration events
Other S/E
Increased risk for gastric insufflation and aspiration, facial skin breakdown, excessively high tidal volumes, discomfort related to the inability to eat or effectively phonate
Protective ventilation in ARDS
BERLIN definition of ARDS
Mild PaO2/Fio2 <=300 mmHg
Moderate PaO2/Fio2 <=200 mmHg
Severe PaO2/Fio2 <=100 mmHg
**Plateau pressure remain >30 cmH20 after reduction of TV to 6 ml/kg PBW, TV maybe reduced to as low as 4 mg/Kg
RR should be increased to a max of 35 breaths/min during TV reduction to maintain minute ventilation
*No single mode of ventilation is shown to be advantageous
Low TV ventilation 6 mL/kg
Upper limit goal for plateau pressure 30 cm H20
Higher PEEP (may open lung units to participate in gas exchange and may increase PaO2)
*PEEP >5 cm H20 is required to avoid lung collapse
Low TV (without ARDS)
Using traditional recruitment maneuvers
Using prone ventilation for greater than 12 hours daily
Using intermittent NMBA boluses
Veno-venous (VV) ECMO when conventional mechanical ventilation fails (severe ARDS)
On going requirement for vasopressor therapy
IV corticosteroids
Restrictive transfusion therapy over
Liberal
