Therapeutics - Sepsis 4
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Corticosteroids should not be administered for the treatment of sepsis in the absence of______________.
When hydrocortisone is given, you should use continuous or intermittent flow?
Continuous (though intermittent still used – new thing)
What effect do low dose Corticosteroids have on 28 day mortality in sepsis?
What effect do low dose Corticosteroids have on rates of shock reversal in sepsis?
What effect do low dose Corticosteroids have on duration of time to shock reversal in sepsis?
Shorter in patients who had a response to corticotropin
What risks do low dose Corticosteroids havein sepsis?
Increased hyperglycemia, hypernatremia, superinfections (immunocomprimised), delayed wound healing, muscle weakness
_______________may spare vasopressin requirements.
What are the “Other” supportive therapies for Severe Sepsis?
- Recombinant Activated Protein C (rhAPC)
- Mechanical ventilation of sepsis- for induced acute respiratory distress syndrome (ARDS)
- Sedation, analgesia, and neuromuscular blockade
- Glucose control
- Renal replacement therapy
- Bicarbonate therapy
- DVT prophylaxis
- Stress ulcer prophylaxis
Red blood cell transfusion occur only when hemoglobin concentration decreases to ______________.
Blood products should be administered only to target a hemoglobin concentration of _________________in adults.
7.0 –9.0 g/dL
Should erythropoietin as a specifc treatment of anemia associated with severe sepsis?
Should Fresh frozen plasma not be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures?
Should antithrombin be used for the treatment of severe sepsis and septic shock?
In patients with severe sepsis, administer platelets prophylactically when counts are in the absence of apparent bleeding.
<10,000/mm3 (10 x 109/L)
We suggest prophylactic platelet transfusion when counts are if the patient has a significant risk of bleeding.
< 20,000/mm3 (20 x 109/L)
What are the safety concerns with blood products?
- Infectious complications (Viral & Bacterial)
- Transfusion Related Acute Lung Injury (TRALI)
- Transfusion Related Immunomodulation (TRIM)
- Transfusion Related Circulatory Overload (TACO)
What medications cause Thrombocytopenia/drop in platelets?
- Pipercillin/Tazobactam (common)
- Pantoprazole or PPI can do it as well (though more rare)
What is theTarget a tidal volume in patients with sepsis-induced ARDS?
6 mL/kg predicted body weight
Mechanically ventilated sepsis patients be maintained with the head of the bed elevated to __________degrees to limit _______________and to prevent the development of__________________.
- aspiration risk
- ventilator-associated pneumonia
Is routine use of the pulmonary artery catheter for patients with sepsis-induced ARDS advised?
Is a conservative or liberal ﬂuid strategy for patients with established sepsis-induced ARDS who do not have evidence of tissue hypoperfusion recommended?
In the absence of speciﬁc indications such as bronchospasm, should ß2-agonists for treatment of sepsis-induced ARDS be used?
Continuous or intermittent sedation be ___________________in mechanically ventilated sepsis patients, targeting specific titration endpoints.
Neuromuscular blocking agents (NMBAs) should be ___________if possible in the septic patient without ARDS due to the________________________________________.
- risk of prolonged neuromuscular blockade following discontinuation
A short course of NMBA of not greater than ___ hours for patients with early sepsis-induced ARDS and a _______________________is recommended.
A protocolized approach to blood glucose management in ICU patients is recommended with severe sepsis commencing insulin dosing when 2 consecutive blood glucose levels are >______.
Blood glucose values be monitored every _________ until glucose values and insulin infusion rates are stable and then every __________thereafter.
Glucose levels obtained from capillaryies should be interpreted with caution, as such measurements may not _______________________________________.
Accurately estimate arterial blood or plasma glucose values
ADA recommends a BG range of _______________in critically ill patients and SCCM targets a range of _______________in adult ICU patients
- 140-180 mg/dL
- 150-180 mg/dL
When should bicarbonate therapy not be used in sepsis?
Improving hemodynamics or reducing vasopressor requirements in patients with hypoperfusion-induced lactic acidemia with pH ≥7.15
Patients with severe sepsis should receive daily pharmacoprophylaxis against __________________________.
Venous thromboembolism (VTE)
daily DVT pharmacoprophylaxis should be accomplished with daily ___________________________________.
subcutaneous low-molecular weight heparin (LMWH)
If creatinine clearance is <30 mL/min, pharmacoprophylaxis should be accomplished with:
- Salteparin (grade 1A) or another form of LMWH that has a low degree of renal metabolism or UFH
- E.g. Lovanox 30 mg QD (Vs 40)
Patients with severe sepsis be treated with a combination of pharmacologic therapy and _____________________________whenever possible to prevent DVT.
intermittent pneumatic compression devices
Septic patients who have a contraindication for heparin use (eg, thrombocytopenia, severe coagulopathy, active bleeding, recent intracerebral hemorrhage) not receive pharmacoprophylaxis, but receive_____________________________, such as___________________________.
- mechanical prophylactic treatment
- graduated compression stockings or intermittent compression devices
Stress ulcer prophylaxis using __________ or ______________be given to patients with severe sepsis/septic shock who have_______________.
- H2 blocker or proton pump inhibitor
- bleeding risk factors
When stress ulcer prophylaxis is used, ______________ rather than _______________are preferred.
proton pump inhibitors rather than H2RA
Patients __________________should not receive DVT prophylaxis.
without risk factors
What are the 2 independent risk factors for getting stress ulcer prophylaxis?
Ventilation and coagulopathy (increased INR or PTT)
What is the only FDA approved drug for stress ulcer prophylaxis
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