Sepsis/Septic Shock

Question 1

What is bacteremia?

Answer 1

Bacteria in the bloodstream

Question 2

What is sepsis?

Answer 2

A systemic response to an infection leading to organ failure and death.

Question 3

What is septic shock?

Answer 3

Subset of sepsis with circulatory and cellular/metabolic abnormalities

Question 4

How can you monitor for organ dysfunction?

Answer 4

SOFA (sequential organ failure assessment) score

Question 5

What is needed to calculate a SOFA score?

Answer 5

PaO2
Platelets
Bilirubin
MAP
GCS score
Cr and Urine output

Question 6

A SOFA score greater than ___ reflects a mortality risk of 10% in a hospitalized patient.

Answer 6

2

Question 7

SOFA scores cannot be done quickly at bedside. What assessment can be used quickly at bedside to assess for sepsis?

Answer 7

qSOFA

Question 8

What are the components of the qSOFA?

Answer 8

Respiratory rate >/= 22
Altered mental status (GCS <13)
Systolic BP = 100mmhg

Question 9

How many components of the qSOFA must be met to indicate a poor outcome?

Answer 9

2

Question 10

What is the driving force of acute organ dysfunction in sepsis?

Answer 10

Coagulopathy

Question 11

List 4 classic signs of inflammation.

Answer 11

Redness
Heat
Swelling
Pain

Question 12

What is responsible for down regulation of the initial proinflammatory response?

Answer 12

Interleukin system (IL4 and IL10)

Question 13

Severe sepsis disrupts homeostasis by activating ____ and _____, and suppressing ______.

Answer 13

Inflammation and coagulation

Finbrinolysis

Question 14

What is the key inhibitor of fibrinolysis in sepsis?

Answer 14

Plasminogen activator inhibitor 1 (PAI-1)

Question 15

PAI-1 is produced by?

Answer 15

Endothelial cells

Question 16

______ released by gram negative rods increase activity of PAI-1

Answer 16

Endotoxins

Question 17

What are the lab findings of DIC?

Answer 17

Elevated: PT, PTT, Fibrin monomers, D-dimer
Decreased: Protein C, Fibrinogen, Platelet count

Question 18

What are the lab findings of sepsis?

Answer 18

Elevated: Cr, ALT AST T bili, Lactate, Procalcitonin.

Question 19

What is procalcitonin?

Answer 19

Protein biomarker for bacterial infection

Question 20

What is the normal level for procalcitonin?

What value suggests sepsis?

Answer 20

Normal is = 0.15 Values > 2.0 is suggestive of sepsis

Question 21

Where do the majority of sepsis patients originate?

Answer 21

Emergency department (37%) and Floor (32%)

Question 22

What are the effects of sepsis on the body?

Answer 22

1. Decreased 02 delivery because of damaged to capillaries
2. Decreased cardiac output (increase heart rate)
3. increased anaerobic metabolism
4. DIC

Question 23

What is the most common cause of severe sepsis?

Answer 23

community acquired pneumonia

Question 24

A lactate level greater than what indicates severe sepsis?

Answer 24

greater than 2mmol/L

Question 25

What are the three phases of sepsis treatment?

Answer 25

- Resuscitation Phase ( 1st 6hours/sooner the better - initial management phase (24 hours) - Maintenance phase (>24 hours)

Question 26

Do you assess and maintain airway during the resuscitation phase?

Answer 26

Yes

Question 27

What elements are included in the resuscitation phase?

Answer 27

1. Access and maintain airway 2. Pan-culture 3. Initiate appropriate antibiotic therapy What is this? 4. IV fluids (If MAP <65 or lactate >4) initial volume 30ml/kg 5. Tight glycemic control (continuous insulin drip) 6. Vasopressors-dobutamine, norepinephrine, dopamine, phenylephrine, epinephrine, vasopressin 7. Sedation 8. Steroids possibly

Question 28

What are the goals of sepsis resuscitation? (other than survival of course)

Answer 28

1. CVP 8-12mm hg 2. MAP 65mm Hg 3. Urine output 0.5ml/kg/hr 4. General venous or mixed venous O2 sat 70% or 65% (respectively) Reduces 28-day mortality rate

Question 29

What do you do during the hour 1 bundle: initial resuscitation

Answer 29

1. Measure lactate level 2. Obtain blood cultures before admin of antibiotics 3. Administer broad spectrum antibiotics (vanco, pip/tazo/ carbapenems) 4. begin rapid admin of 30ml/kg crystalloid for hypotension or lactate > 4 5. Maintain MAP >/= 65mmhg (vasopressors)

Question 30

Why would you administer vasopressor?

Answer 30

Vasopressors are used to stimulate vasoconstriction and increase blood pressure for pts in shock

Question 31

What are some vasopressor medications?

Answer 31

1. Norepinephrine- this is the preferred first line 2. Vasopressin 3. Epinephrine 4. Phenylephrine- commonly used as add on

Question 32

What vasopressor analog is discouraged from being used?

Answer 32

dopamine

Question 33

What elements are apart of the "initial management phase"

Answer 33

1. Continue the resuscitation phase 2. Monitor cultures for targeting antibiotic therapy 3. Constant monitoring of vasopressors (maintenance of MAP >65mmhg

Question 34

What is a common respiratory problem and needs special attention to pressure and volumes?

Answer 34

ARDS

Question 35

What will ARDS look like on X-ray?

Answer 35

Bilateral diffuse fluffy infiltrate, normal cardiac size

Question 36

What type of medications should you avoid when giving central nervous system support?

Answer 36

Avoid neuromuscular blockers if possible (in pts without ARDS)

Question 37

What type of protocol do you implement with central nervous system support?

Answer 37

Sedation protocol

Question 38

What is involved with the maintenance phase?

Answer 38

1. if survive >24 hours, attention to preventing nosocomial infections 2. Restore premorbid condition 3. Tailor antibiotic therapy as culture info available

Question 39

What is involved with general supportive care for sepsis pts?

Answer 39

1. Blood glucose management <180 mg/dl 2. Dialysis for renal failure or fluid overload 3. DVT prophylaxis- Low molecular weight heparin 4. Stress-ulcer prophylaxis- commonly a PPI or H2 blocker 5. Enteral feeding if possible

Question 40

What causes sepsis?

Answer 40

1. Lungs 2. Urinary tract 3. GI 4. Skin and Soft tissue

Question 41

What are most common bacteria for sepsis?

Answer 41

strep pneumo, staph and ecoli