Septic Shock differentiation/treatment

Card Set Information

Author:
mansiu
ID:
18715
Filename:
Septic Shock differentiation/treatment
Updated:
2010-05-12 00:13:00
Tags:
Sepsis
Folders:

Description:
Differentiation and treatment of sepsis, severe sepsis and septic shock
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user mansiu on FreezingBlue Flashcards. What would you like to do?


  1. Pathophysiology of sepsis
    • - Normal host response to infection
    • - Pro/ anti inflammatory mediators released
    • - Vasodilate tissues to allow more blood
    • - Balance of mediators guides tissue repair/healing
    • - Inflammation is intended to be local and contained
  2. General Concept
    • There has to be a homeostasis between inflammation and fibrinolysis
    • When inflammation increases coagulation also increases
    • Imbalance between inflammation and fibrinolysis predisposes towards sepsis
  3. Host Response during Sepsis
    • - Disruption of pro/ anti inflammatory equilibrium
    • - Characterized by systemic inflammation and tissue injury
  4. Systemic proinflammatory reactions cause:
    • - Endothelial damage causig vasodilation (NO released)
    • - Microvascular dysfunction
    • - Increased microvascular permeability (tight junctions loosen up, causing 3rd spacing of fluids, plasma into tissues, causes low BP )
    • - Impaired tissue oxygenation (due to microvascular thrombi)
    • - Organ injury
  5. Sequence of events in Sepsis Summary
    • 1. Infection
    • 2. Disruption of pro/anti inflammatory equilibrium
    • 3. systemic inflammation and widespread tissue injury
    • 4. Endothelial dysfunction and microvascular thrombosis
    • 5. Hypoperfusion and ischemia of vital organs
    • 6. Acute Organ dysfunction (severe sepsis)
    • 7. Death :(
  6. What is an infection?
    Presence of pathogens in normally sterile body fluids (blood, urine, csf, and for the most part lower respiratory tract)
  7. SIRS: Systemic Inflammatory Response Syndrome is WHAT ??? (OLD 1991 definition)
    • Temperature: > 38 C or < 36 C (hypothermia worst prognosis)
    • Heart Rate: > 90 bpm (excluding any other causes)
    • Respiratory Rate: > 20 bpm or PaCO2 < 32mmHg
    • WBC: > 12000 cells/ml or < 4000 cells/ml OR > 10% immature forms of wbc (bands)
  8. ACCP/SCCM 1991 consensus definitions
    Sepsis: Infection + >/= 2 SIRS criteria

    Severe Sepsis: Infection + >/= 2 SIRS criteria + organ dysfunction

    Septic Shock: Infection + >/= 2 SIRS criteria +/- organ dysfunction + hypothension despite fluid resuscitation
  9. 2001 Diagnostic Criteria for Sepsis ** for Exam focus on 2001

    Infection
    Pathological process induced by a microorganism
  10. 2001 Diagnostic Criteria for Sepsis

    General Parameters
    • Fever
    • - Core temp > 38.3
    • Hypothermia: < 36

    • Heart Rate
    • > 90 bpm or 2 SD > the normal value for age
  11. General Parameters continued...
    • Tachypnea:
    • - > 30 bpm

    Altered mental status

    Significant edema or positive fluid balance: > 20 ml/kg over 24 hrs
  12. General Parameters...more...
    Hyperglycemia in the absence of diabetes: Glucose >100 mg/dl

    Leukocytosis: WBC count > 12,000

    Leukopenia: WBC < 4,000
  13. General parameters...a little more
    Normal WBC with > 10% immature forms

    Increased plasma C reactive protein: if it is > 2 SD the normal value (< 1 mg/dl) Eg: >17 mg/dl

    Increased plasma procalcitonin: > 2 SD the normal value ( < 0.01 ng/ml) Eg: >10 ng/ml
  14. Hemodynamic Parameters: Arterial hypotension
    • Arterial hypotension
    • - SBP < 90 mmHg
    • - MAP < 70
    • - SBP down more than 40 mmHg (adults)
    • - SBP > 2 SD below normal for age (pediatrics)
  15. Hemodynamin parameters: SVO2
    • Mixed venous oxygen saturation: > 70%
    • - Children usually are 75-80% thus not used as a sign or sepsis in newborn or children
  16. Hemody. parameters: Cardiac Index
    • Increased Cardiac Index (mostly late sepsis)
    • > 3.5 L/min/m*m in adults
    • - Children normally 3.5-5.5 L/min/m*m thus not to be used as sign of sepsis
  17. Tissue perfusion parameters
    • --Hyperlactatemia: > 3 mmol/L
    • Normal: 0.5-1.5 mmol/L

    -- Decreased capillary refill

    --Mottling: irregular pattern of patches or spots (poor skin perfusion in CHF pt.)
  18. Organ Derangements in sepsis

    Microcirculatory dysfunction
    • 3rd spacing of fluids causes tissue edema
    • leads to compression of capillary beds
    • deformed red blood cells plug capillary lumens
    • Causes: low no. of functional capillaries, low oxygen extraction
  19. Hypotension
    • Endothelial injury releases endogenous vasodilators
    • - Prostacyclin, nitric oxide
    • Vasopressin deficiency
    • Systolic and diastolic ventricular dysfunction
    • Hypovolemia

    • -Early sepsis: low CO and low SVR
    • -Late Sepsis: after vol. resuscitation hyperdynamin CO and SVR continues to be low
  20. Lung
    • Edothelial injury in the pulmonary vasculature
    • Pulmonary edema accompanied by ventilation-perfusion mismatch and arterial hypoxemia
    • Acute respiratory distress syndrome !
  21. Gastrointestinal Tract
    • Intubated/sedated pts develop bacteria overgrowth of upper GI tract
    • Pathogens can aspirate into lungs-- nosocomial pneumonia
    • Endothelial abnormalities lead to translocation of bacteria and endotoxin into the systemic circulation
  22. Liver
    • Liver ischemia due to hypoperfusion
    • Liver makes clotting factors: if not making any then super anticoagulated (high INR and aPTT)
    • Dysfunctional reticuloendothelial system: decreased clearance of bacteria and byproducts that have entered the venous portal system from gut.
  23. Kidney
    • Acute renal failure- common
    • Acute tubular necrosis is most common
    • Potential causes:
    • systemic hypotension
    • cytokine release (TNF)
    • direct renal vasoconstriction
    • activation of neutrophils by endotoxin
  24. Nervous system:
    • Altered sensorium
    • peripheral neuropathy
    • microvascular thrombi in brain? microabscesses??
  25. Clinical assessment of patient
    • Physical exam
    • Procedures: CXR, LP, CT
    • Labs: Chem 12, CBC with differential, coags, lactate, ABG
    • Assessment of catheters
    • cultures
  26. Microbial ecology
    • Lungs, abdomen, and bloodstream are most commonly infected.
    • 90% of sepsis caused by bacteria.
    • Fungi sometimes possible
    • Community versus nosocomial
  27. Pathogens in rank order
    • 1. Coagulase-negative staph
    • 2. Staph aureus
    • 3. enterococci
    • 4. Candida species
    • 5. E. coli
    • 6. Klebsiella
    • 7. enterobacter
    • 8. pseudomonas
    • 9. serratia
    • 10. viridans strep
  28. Management of Sepsis
    • Initial resuscitation (within 6 hrs)
    • Infection issues: diagnosis, abx therapy, source identification and control
    • Hemodynamic support
    • Adjunctive therapy
    • supportive therapy

What would you like to do?

Home > Flashcards > Print Preview