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Flashcards in Surviving Sepsis Deck (58)
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1

Sepsis

life-threatening organ dysfunction caused by a dysregulated host response to infection

2

Septic shock

subset of sepsis with circulatory and cellular/metabolic dysfunction associated
with a higher risk of mortality

3

Initial resuscitation

Recommend that treatment and resuscitation begin immediately
Early effective fluid resuscitation for stabilization of sepsis induced tissue hypoperfusion or spetic shock

4

What is the recommended human dose of crystalloids for sepsis induced tissue hypoperfusion?

At least 30 mL/kg of IV crystalloid fluid be given within the first 3 hours
a. Fixed volume of fluid enables initiation of resuscitation while obtaining more specific information and while awaiting more precise measurements of hemodynamic status (PROCESS and ARISE, 2 L in PROMISE Trial)
b. little literature includes controlled data to support this volume of fluid

5

What is the recommendation following initial fluid resuscitation?

Additional fluids be given and guided by frequent reassessment of hemodynamic status
a. Reassessment should include a thorough clinical examination and evaluation of available physiologic variables (heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output, and others, as available) as well as other noninvasive or invasive monitoring

6

What is the recommendation if the type of shock is not elucidated from reassessment?

Further hemodynamic assessment (such as assessing cardiac function) to determine the type of shock
Ex- echocardiography

7

Are dynamic variables recommended over static to predict fluid responsiveness?

NO, It is only suggested that dynamic over static variables be used to predict fluid responsiveness, when available
a. CVP no longer justified (static)
b. Dynamic measures demonstrated better diagnostic accuracy at predicting those patients who are likely to respond to a fluid challenge by increasing SV
i. Fluid challenges against stroke volume measurements or the variations in systolic pressure, pulse pressure in mechanically ventilated patients

8

What is the recommended initial target MAP in patients with septic shock requiring vasopressors?

65 mm Hg
-Human studies comparing MAP of 65 mmHg to 85 mmHg revealed improved cardiac index, but did no change in renal function, arterial lactate levels or oxygen consumption, 1 study had mortality as primary outcome and there was no significant difference in mortality at 28 or 90 days; higher risk of arrhythmias at maintaining MAP at 85 mmHg; Subgroup of older patients (>75 years) had reduced mortality at MAP of 65 mmHg

9

True or false: It is recommended to guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion

False--> Suggested
a. NOT A DIRECT MEASURE OF TISSUE PERFUSION→ surrogate
b. A significant reduction in mortality was seen in lactate-guided resuscitation compared to resuscitation without lactate monitoring, but no evidence for difference in ICU length of stay

10

What is normal MAP for dogs and cats?

60-100 mmHg

11

What is normal SAP for dogs and cats?

90-140 mmHg (D)
80-140 mmHg (C)

12

What is normal DAP for dogs and cats?

50-80 mmHg (D)
55-75 mmHg (C)

13

What is the recommendation for screening for sepsis and performance improvement?

Recommend that hospitals and hospital systems have a performance improvement program for sepsis, including sepsis screening for acutely ill, high-risk patients

14

True or false: Sepsis screening has been associated with decreased mortality

True
Due to IMPLEMENTATION of “BUNDLE” (core set of recommendations- separate development)
-Vary widely, but use of performance improvement programs with sepsis bundling and practice guidelines such as SSC were associated with significant increase in compliance and reduction in mortality

15

Overall hospital mortality rate has decreased by how much for every 3 months a hospital participated in the SSC?

Mortality decreased 0.7% for every 3 months a hospital participated in the SSC

Associated with a 4% decreased LOS for every 10% improvement in compliance with bundles
i. Study of 1800 patients with sepsis or septic shock demonstrated a 36%–40% reduction of the odds of dying in the hospital with compliance with either the 3 or 6 hour SSC bundles

16

True or false: Recommend that appropriate routine microbiologic cultures be obtained before starting antimicrobial therapy in patients with suspected sepsis or septic shock

True
If doing so results in no substantial delay in the start of antimicrobials
Sterilization of cultures can occur within minutes to hours after the first dose of an appropriate antimicrobial

17

True or false: Appropriate routine microbiologic cultures always include at least two sets of blood cultures (aerobic and anaerobic)

True

18

True or false: Pan culture of all sites that could potentially be cultured should be discouraged because this practice can lead to inappropriate antimicrobial use

True

19

How long of a time frame can be considered to be no substantial delay in the initiation of antimicrobial therapy while cultures are being obtained?

45 minutes

20

What is the mainstay of antibiotic stewardship programs and is associated with less resistant microorganisms, fewer side effects, and lower costs?

Antibiotic de-escalation

21

In potentially septic patients in whom a site of infection is not clinically apparent, what should be evaluated and where should at least one blood culture set should be obtained from?

Evaluate IVC (in place > 48 hours) should be removed in whom a site of infection is not clinically apparent or a suspicion of IVC-associated infection exists
At least one blood culture set should be obtained from the IVC

22

True or false: Without suspicion of catheter-associated infection and in whom another clinical infection site is suspected, at least one blood culture should be obtained peripherally

True
No recommendation can be made as to where additional blood cultures should be drawn.
Options include:
a) all cultures drawn peripherally via venipuncture
b) cultures drawn through each separate IV device but not through multiple lumens of the same IVC or
c) cultures drawn through multiple lumens in an intravascular device

23

Administration of IV antimicrobials should be initiated as soon as possible after recognition and within how long for both sepsis and septic shock?

1 hour
Mortality increases by 7.6% for every hour without antimicrobials

24

What are causes of delays to antimicrobials?

High frequency of failure to recognize potential existence of sepsis or septic shock and of inappropriate empiric antimicrobial initiation

25

What are possible solutions to delays in antimicrobial initiation?

Use of “stat” orders or including a minimal time element in antimicrobial orders, communication, addressing delays in obtaining blood and site cultures pending antimicrobial administration, and sequencing antimicrobial delivery optimally or using simultaneous delivery of key antimicrobials
i. Expedited IV access→ IO catheters, IM drugs

26

It is recommended that empiric broad-spectrum therapy with one or more antimicrobials for patients presenting with sepsis or septic shock be initiated. What drives choice of antimicrobials?

Choice of empiric antimicrobial therapy depends on complex issues related to the patient’s history, clinical status, and local epidemiologic factors

27

Because of the high mortality associated with inappropriate initial therapy, empiric regimens should err on the side of over-inclusiveness; What factors must be assessed and used in determining the appropriate antimicrobial regimen at each medical center and for each patient?

ia) Anatomic site of infection with respect to typical pathogen profile and to the properties of individual antimicrobials to penetrate that site
b) Prevalent pathogens within the community, hospital, and even hospital ward
c) Resistance patterns of those prevalent pathogens
d) Presence of specific immune defects (neutropenia, splenectomy and acquired or congenital defects of immunoglobulin, complement or leukocyte function or production
e) Age and patient comorbidities including chronic illness (e.g., diabetes) and chronic organ dysfunction (e.g., liver or renal failure), presence of invasive devices that compromise the defense to infection

28

What risk factors should be assessed for infection with MDR pathogens?

Prolonged hospital/chronic facility stay, recent antimicrobial use, prior hospitalization, and prior colonization or infection with MDR organisms

29

What can improve outcome in some circumstances regarding acquired pathogens?

Early involvement of infectious diseases specialists

30

What is recommended once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted?

Recommend that empiric antimicrobial therapy be narrowed
Important strategy to reduce both the development of pathogen resistance and cost
Spectrum of coverage should be narrowed by eliminating unneeded antimicrobials and replacing broad-spectrum agents with more specific agents (de-escalation)