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ID Exam 3 B
Berman Sepsis and Septic Shock
| Question | Answer |
|---|---|
| Sepsis is defined as | life threatening conditions caused by dysregulated host response to infection, resulting in ORGAN DYSFUNCTION |
| septic shock is | subset of sepsis with PROFOUND circulatory, cellular, and metabolic abnormalities, presenting as fluid-refractory hypotension requiring vasopressor therapy with associated tissue hypoperfusion |
| Septic shock is CLINICALLY defined as requirement of ________ to maintain MAP >/= to _________ and lactate _________ after adequate fluid resuscitation | vasopressors; 65 mmHg; >2 mmol/L |
| Simplifed version of sepsis/septic shock--> 2 things | 1. endothelial cells are releasing a lot of cytokines 2. macrophages are activating all parts of the immune system and that can even affect the clotting cascade *(overwhelming response of our pro-inflammatory cytokines that is suppose to target pathogen but we start damaging our organs (hence ORGAN DYSFUNCTION |
| How we recognize sepsis is through the ________ effect | hemodynamic |
| Hemodynamic effect: Sepsis and Septic shock are associated with _______ ________ ______, high catecholamines, and vascular _________; increased vasodilation, capillary leak due to tissue damage. | excessive sympathetic activity; hypo-reactivity (blood vessels not responding to Norepi or Epi being released) |
| What are the hallmark effects of Sepsis? | Low systemic vascular resistance, high cardiac output with tachycardia and hypotension |
| Give examples of where sepsis can cause multiple organ dysfunction | Brain: altered mental status; Heart: tachycardia, hypotension, increase in lactate (heart not able to carry O2 so start anaerobic metabolsim); kidneys: AKI (acute oluguria or anuria, Increased serum creatinine, and metabolic acidosis |
| Other examples of organ dysfunction are seen in the blood (decreased platelets and protein C, increased D-Dimer, disseminated intravascular coagulation (DIC); what about damage to the liver? | Jaundice, increased AST/ALT, decreased albumin, incerased INR >1.5, and acute liver failure |
| Organ dysfunction in the lungs? | tachpnea, Hypoxia (PaO2 <70 mmHg, SaO2 <90%, acute respiratory distress syndrome (ARDS), PaO2/FiO2 </= 300 |
| Using SOFA to define sepsis, what goes into the sepsis clinical criteria? | INFECTION + Change in SOFA (greater than or equal to 2) Sepsis-related; organ; failure; assessment (consisting of decreased PaO2/FiO2; hypotension or vasopressors; decerase in platelets; decrease in glasgow coma scale, incerase in bilirubin, or increased creatinine oliguria |
| What is the main idea of the SOFA score? | Idea is we're trying to measure how much organ failure is there. So the more organ failure you have--> the higher the score will be (so a +2 from your baseline) |
| What are the 2 most commonly used screening tools for the detection of sepsis or septic shock? | SIRS (Systemic inflammatory response syndrome) qSOFI (Quick sequential Organ Failure Assessment) |
| SIRS criteria is considered positive if a pt meets 2 or more of the following: | Temperature <36 C or 38 C (<96.8 F or > 100.4) Respiratory rate >20/min Heart rate >90 bpm WBC <4000 or >12000/mm^3 (leukopenia) or (Leukocytosis) |
| qSOFA is considered positive if a pt meets 2 or more of the following criteria: | SBP < or = to 100mmHg RR > or = to 22/min Altered mental status (Glasgow coma scale (GCS) < 15) |
| Which of the screening tools is less specific but more sensitive? | SIRS criteria (can give a lot of False (+)) |
| Which of the screening tools is more specific but less sensitive? | qSOFA (can give a lot of False (-)) |
| Guidelines recommend against using _______ compared to SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock | qSOFA (study showed that only 24% of pts with infection had a qSOFA score of 2 or 3 giving tons of false (-) due to low sensitivity |
| What is the clinical criteria for Septic shock? | Sepsis + Vasopressors to maintain MAP > or = to 65 mmHG AND Serum lactate level is greater than or equal to 2 IN THE ABSENSE OF HYPOVOLEMIA |
| Berman emphasized lactate levels in septic shock is really related to the body's inability to perfuse and get oxygenated blood to our organs so our body turns to (1)_______ _______ | anaerobic metabolism to make energy and its all related more to PERFUSION |
| Goals of management of sepsis deals with: | infectious disease management and hemodynamic management |
| Infectious disease management consists of: | prompt initiation of antibiotics; aggressive abtibiotic dosing; source control; tailor regimen based on culture data; duration of therapy depends on infection and clinical response |
| Hemodynamic management consists of: | early, aggressive resuscitation with BALANCED crystalloids; if hemodynamically unstable after fluid resuscitation--> initiate vasopressors and initiate steroids (if refractory) |
| Where can the main sources of infection come from for sepsis/septic shock? | Pulmonary (40%) looking at CAP/VAP; Intra-abdominal (35%) looking at diverticulitis; Genitourinary (15%) UTI/ Pyleonephritis |
| Other sources of infection could come from? | bacteremia, skin and soft tissue, CNS, miscellaneous |
| Who are the main causitive pathogens for sepsis infections? (*Be able to determine gram + or gram -) | Gram (-) 44-59% consisting of E.Coli, Klebsiella, Proteus, Enterobaceter/P. Aeruginosa Gram (+) 37-52% consisting of S. aureus, S. pneumo, E. faecalis Fungi 4-10% consisting of C. Albicans Anaerobes 5% consisting of Bacteroides fragilis, C. Diff |
| First step is getting culture and rapidly starting antibiotics | 1. obtain 2 sets of 🩸 cultures before antibiotic therapy (peripheral draw and from any invasive line) -obtain microbiologic culture (sputum, urine) to determine possible infection sources -obtain lactic acid w/in 1 HOUR of recognizing sepsis/septic shock and remeasure w/in 6 hours if >2mmol/L -if culture takes >45 min, DO NOT DELAY admin of abx |
| Berman: "if you are suspecting sepsis/septic shock-->obtain a lactic acid or a lactate and if elevated greater than 2, we need to reassess that every ____ hours to see how the body is perfusing; the exception is? | 6h; If it takes too long for cultures such as 45 min--> then you should not delay the administration of antibiotics **hard stick--> give them abx and we'll get the cultures when we can" |
| Antibiotic timing: If sepsis is definite or probable and shock is present then we--> | adminster abx immediately, ideally within 1 hour of recognition |
| Antibiotic timing: If sepsis is definite or probable and shock is absent then we--> | adminster abx immediately, ideally within 1 hour of recognition |
| If sepsis is POSSIBLE and shock is present then we--> | adminster abx immediately, ideally within 1 hour of recognition |
| If sepsis is possible and shock is absent--> | rapid assessment of infectious vs non-infectious causes of acute illness; administer abx w/in 3 hours if concern for infection persists |
| Berman "if someone has that hypotension requiring vasopressors--> if that is present and you think sepsis is a possible cause, then we need to get abx started w/in __ _____ no matter what, even if you think there are other causes. | 1 hour |
| If we dont have septic shock--> its a little heard to tell perhaps there are other causes of their clinical presentation, then we do a little work up and we have _____ | 3 hours |
| When choosing antibiotic therapy. consider the suspected source of infection when choosing abx; Broad spectrum IV abs should be initiated that target: | both gram + and gram - bacteria at minimum |
| If high risk for MDR (multi-drug resistant gram (-) organism, use ___ abx with gram (-) coverage | 2 |
| Risk factors for MRSA include: | prior history of MRSA infection or colonization; recent IV abx w/in 90 days; history of recurrent skin infections or chronic wounds; presence of invasive devices (i.e. infusion port; HD; recent hospital admissions |
| Risk factors for MDR Gram (-) organisms consists of: | proven infection or colonization w/ abx-resistant organism in the last year; local prevalence of abx-resistant organisms > or= 10%; Hospital acquired infection; broad spectrum abx use w/in 90 days; travel to hihgly endemic country w/in last 90 days; hospitalization abroad w/in 90 days |
| 2 agents w/ gram (-) activity--> Name 2 combinations? | 2 Beta lactams--> Cefepime or Piper/Tazo as one agent and other FQ or glycoside |
| Risk factors for candida-related sepsis | Candida colonizations at multiple sites (urine, lungs); surrogate markers (B-D-glucan assay (neutropenia, immunosppuression, high severity of illness, long ICU stay); Central venous catheters, IV drug use, TPN, GI tract perforation; Emergency GI or hepatobiliary surgery; acute renal failure or HD, severe thermal injury |
| What are the principles of managing abx? | 1. administer loading doses of abx 2. optimize PK/PD principles-> i.e prolonged infusion of B-lactam 3. Emergent source control |
| what should we consider when determining duration of antimicrobials in sepsis/septic shock? | assess at least daily for ability to de-escalate (choose abx that are more narrow than what we originally chose and base on cultures we get back); use shortest effective duration over longer durations |
| What is the role of Procaclitonin (PCT) | 1. undetectable in healthy states, but rises rapidly in pro-inflammatory states, especially bacterial infections 2. can be elevated in some non-infectious conditions including trauma, burns, certain cancers, cardiogenic shock, peritoneal dialysis and cirrhosis |
| Guidelines recommend _______ use of PCT for initiation of abx | AGAINST |
| If optimal duration of therapy is unclear, consider use of PCT AND _______ _______ to decide when to discontinue antimicrobials | clinical evaluation |
| Goal of earlu aggressive resuscitation is to: | correct hypovolemia and increase perfusion; increase BP and normalize HR, MAP goal >/= to 65 mmHg; restore perfusion and normalize lactic acid |
| STEP 2: Fluid resuscitation with ISOTONIC crystalloids given as an IV bolus--> DOSE? | at least 30 mL/kg (IBW) w/in 3 hours; Use ABW if obese (>/=30) *balanced crystalloids are preferred |
| Consider _______ if require substantial amounts of crystalloid to maintain adequate MAP | Albumin *if we give them lots of fluids and pt is still having issues with Hyperkalemia, we can consider Albumin |
| Which fluids for resuscitation will we avoid using? | Colloids such as Hetastarch and gelatin |
| What are the 2 types of IV fluids? | Crystalloids (aqueous solution of salts and other water soluble molecules) and Colloids (large molecular weight solutions (>30,000 Da) these remain in the intravascular space for hours to days but are expensive. |
| Total body water consists of: | Intracellular fluid (ICF) 2/3 Extracellular Fluid (ECF) 1/3 |
| Extracellular fluid (ECF) 1/3 is divided further into Interstitial (75%) and Intravascular (25%). Which are we targeting for septic shock? | Intravascular space *this is because we need to start perfusing the body better. so we want the fluid to be intravascular. |
| In septic shock, we are going to focus on these 2 fluids for resuscitation (so the fluids that are similar to our plasma and specifically want to use balanced fluids (ones that have BUFFERS),** which 2 are we needing to focus on for the exam? | Lactated ringers and Plasmalyte (Normosol) |
| Why are we interested mainly in LR and Plasmalyte/Normosol? | Na Content (130 and 140); they contain buffers (Lactate (28); Acetate (27) Gluconate (23); they are both isotonic and they are BALANCED |
| Why can't we use Dextrose 5%? | we can't use hyotonic fluids since they won't stay in the intravascular space. |
| For exam purposes when choosing resusitation fluids, we need to know? | Na+ content, because thats usually what controls the tonicity; Know if its isotonic or hypotonic; and if its a BALANCED fluid or not. |
| What is our most common colloid? What is the problem with it? | Albumin; can cause volume overload b/c of these proteins that pull in a lot of fluid |
| Hydroxyethyl starch has what adverse effects? | can cause renal dysfunction and increased mortality |
| Due to high cost and potential increased AE's, colloids are reserved for pts who have received _____ volumes of crystalloids and required _______ fluid resuscitation | High; additional |
| What is the distribution of IV fluid for Isotonic fluids in the 1. Intracellular; 2. Interstitial; 3. Intravascular? *Based on 1 L | 1. none 2. 750 mL 3. 250 mL |
| What is the distribution of IV fluid for Dextrose 5% in the 1. Intracellular; 2. Interstitial; 3. Intravascular? *Based on 1 L | 1. 667 mL 2. 250 mL 3. 83 mL |
| What is the distribution of IV fluid for Albumin 5% in the 1. Intracellular; 2. Interstitial; 3. Intravascular? *Based on 1 L | 1. none 2. none 3. 1000 mL (remember that albumni will get into the Intravascular space but again can cause VOLUME OVERLOAD |
| Many pts require > 30 mL/kg of fluids, continued resuscitation based on restoring ______ | perfusion |
| What do we look for on a physical exam when pt is receiving fluid resuscitation? | vital signs. CAPILLARY REFILL, pulse, skin tugor, and warmth, mental status, urine output (Goal >/= 0.5mL/kg/hr |
| What do we look for on lab findings when pt is receiving fluid resuscitation? | LACTIC ACID, serum creatinine, AST/ALT |
| STEP 3: Vasopressor Therapy: we initiate when? and what agents do we use? | initiate when Hypotension refractory to fluid resuscitation (MAP <65mmHg); Norepi (NE is first line vasopressor), Vasopressin if refractory to NE, Corticosteroids (last line if the above won't work |
| MAP formula: | BP--> CO x SVR MAP--> 2/3 DPB + 1/3 SBP |
| Drug: NE: MOA and AE? | a1 agonism, weak b agonism; AE: arrhythmias |
| Drug: Epi: MOA and AE? | potent a1, and b agonism; AE: arrhythmias, splanchnic and cardiac ischemia, LACTIC ACIDOSIS, HYPERGLYCEMIA |
| Drug: Vasopressin: MOA and AE? | stimulates V1 and V2 AE: DIGITAL AND MESENTERIC ISCHEMIA, cardiac ischemia, arrhythmias |
| Drug: Phenylephrine: MOA and AE? | selective a1 agoinst; AE: splanchnic vasoconstriction; BRADYCARDIA |
| Drug: Dopamine: MOA and AE? | D1 activity w/ low doses (1-4 mcg/kg/min); increased b1 w/ moderate doses (5-10 mcg/kg/min); Increased a1 and b1 with high doses (10-20 mcg/kg/min) AE: arrhythmias, CARDIAC ISCHEMIA, variable hemodynamic effects based on dose |
| Drug: Angiotensin II: MOA and AE? | Vasoconstriction at AT1 receptors and release of aldosterone AE: THROMBOSIS, tachycardia, peripheral ischemia, thrombocytopenia |
| Drug: Dobutamine: MOA and AE? | Primarily B agonism, minimum a1 AE: Arrhythmias, hypotension |
| All vasopressors are ________ and can cause tissue necrosis due to local vasoconstriction | Vesicants |
| What is the preferred administration for Vasopressors? | Central Venous Catheters (CVC-aka CENTRAL LINE) |
| Guidelines recommend starting _______ via ________ line when CVC not available | Vasopressors; peripheral |
| What is the first line agent over other vasopressors? | Norepinephrine |
| If inadequate MAP on NE, add this drug as an adjunct vasopressor instead of escalating NE dose; this is also the 2nd line vasopressor | Vasopressin |
| This is a newer agent; may yse as adjucntive vasopressor after NE and Vasopressin, but it comes with increased risk of THROMBOSIS | Angiotensin II |
| Consider this agent as an adjuct vasopressor after NE and Vasopressin; can use alone IF CARDIAC DYSFUNCTION SUSPECTED | Epinephrine |
| This agent may be used with evidence of cardiac dysfunction despite adequate fluid resuscitation and use of vasopressors; use this agent in combination with NE | Dobutamine |
| This agent is NOT PREFERRED--> it may be used in patients at low risk of tachyarrhythmias or with absolute or relative bradycardia | Dopamine |
| This agent has no recommendation, not routinely used; may use in pts with tachyarrhythmias | Phenylephrine |
| Step 4: Corticosteroids: Recommendation is for adults with spetic shock and an _________ requirement for vasopressor therapy and given IV | ongoing |
| Which corticosteroid and what is the dose? | IV hydrocortisone at 200 mg/day given as 50 mg IV q 6h |
| _________ infusion corticosteroids not recommended due to higher rates of hyperglycemia compared to intermittent dosing | Continuous |
| Start corticosteroids when vasopressor doses exceed ___________ mcg/kg/min NE equivalents. Early admin of corticosteroids is associated with improved outcomes | >/= 0.25 |
Created by:
Xander635
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