ID: sepsis

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twinklemuse
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ID: sepsis
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2011-03-10 17:11:36
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ID: sepsis
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  1. 4 parameters of systemic inflamm response syndrome (SIRS)
    • temp: >38 or <36 c
    • HR: >90 bpm
    • RR: >20 br/m, or PaCO2 <32 mmHg
    • WBC: >12,000 or <4000 or band >10%
  2. what three conditions may need SIRS (systemic inflamm response syndrome) process?
    • sepsis
    • pancreatitis
    • MI
  3. 2 criteria to be sepsis
    • systemic inflamm response to a documented infxn
    • at least 2 SIRS criteria + infxn
  4. definition of severe sepsis?
    sepsis (2SIRS + infxn) AND organ dysfuct, hypoperfusion or hotn
  5. hypoperfusion and perfusion abnormality in severe sepsis may include what 3 things?
    • lactic acidosis
    • oliguria
    • acute alter in mental status
    • (slide 7)
  6. severe sepsis has what 2 responses?
    inflamm and procoagulant response (microvascular injury)
  7. clinidal lab of sepsis (SIRS) induced hypotension
    • SBP <90 mmHg
    • or >40 mmHg from baseline
  8. septic shock (SIRS shock) is subset of severe sepsis with hotn despite ___
    • adequate fluid resuscitation (after initial fluid challenge or blood lactate conc 4 mmol/L)
    • inotrope and vasopressor maintain BP but pt still in this category
    • (slide 9)
  9. definition of organ failure
    • lungs: PO2/FiO2 <250 (or 200 if the lung is the only failed organ)
    • CV SBP: <90 (or MAP <70)
    • renal: U/O <0.5 ml/kg/hr
    • hematol plt: <80,000 -100,000 or 50% dec from baseline over 3 days
  10. do you need infection to qualify as sepsis?
    yes
  11. most common sites of infxn
    • lungs (hence sepsis common in PNA)
    • intra-abd organs
    • urinary tract
  12. GN sepsis is mostly caused by which organism?
    e.coli
  13. GP sepsis is caused by which organism?
    • s.aur
    • s.pneumo
    • s. epi
    • enterococcus
  14. which fungal sepsis is common in BMT pt and neutropenic pt?
    aspergillos
  15. risk factors for sepsis?
    • elderly
    • inc use of invasive procedure and high risk surgery
    • abx resistant organism
    • inc prevalence of immunocompromised pts
  16. review of pathophys of sepsis (5 stages)
    • 1) infxn
    • 2) inflamm (endothelial damage)
    • 3) coagulation
    • 4) anti-inflamm and apoptosis
    • 5) organ fail
  17. endothelial cells release ___, a potent vasodilator and key mediator in septic shock during immune response. (slide 21)
    nitric oxide
  18. 3rd stage increases factors __ and ___ to inc coagulation thrombin.
    • Va
    • VIIIa
    • need heparin ppx
  19. what happens during stage IV, late sepsis?
    • immunosupp
    • anti-inflamm
    • shift from Th1 to Th2
    • apoptosis
  20. what happens during stage V organ failure sepsis?
    • CV: circ shock, dec vascular resistance, hypovol, dec myocardial contractility
    • resp: inc microvascular permeability leads to lung injury
    • renal: dec blood flow leads to renal fail
  21. can you improve mortality of sepsis
    • nothing in the past has improved mortality
    • needs early intervention
  22. first step to dx sepsis?
    • check if infection
    • 2 or more blood cx
    • 1 or more blooc cx should be percutaneous
    • 1 blood cx from each vascular access device in place 48h
    • imaging studies
  23. abx should be started asap. upon diagnosis, within ___ h. upon ER admission, within ___h.
    • within 1st hour
    • within 3 hrs
  24. which spectrum abx do you use for sepsis abx?
    broad spectrum optimize PK/PD
  25. when do you use combo tx for sepsis?
    • pseudo
    • neutropenic
    • immunocompromised
  26. combo tx is usually how long? what if no response, then how long?
    • usu 3-5 d then deescalate
    • duration 7-10d if slow response
  27. inc of WBC can indicate what 4 conditions? so which is a more reliable marker of infxn?
    • sepsis (duh)
    • MI
    • major surgery
    • corticosteroid therapy (esp in brain surgery)
    • use "shift to left"
    • (slide 31)
  28. 4 probs of corticosteroid during dx of infection?
    • anti-inflamm effect (mask infection)
    • mask pain (i.e. peritonitis in pt with UC and bowel perforation)
    • ablate febrile response to infxn
    • cause mental status change
  29. general parameter for sepsis
    • infxn
    • temp, HR, tachypnea, altered mental status, significant edema (>20ml/kg over 24h), hyperglycemia (>140)
  30. inflamm parameter for sepsis dx
    • WB >120000 or <4000 or >10% band
    • plasma CRP >2 SD above normal
    • plasma procalcitonin >2SD above nml
  31. hemodynamic parameter for sepsis dx?
    • hotn sbp <90
    • sbp dec > 40 mmHg
    • MAP <70
  32. organ dysfunction parameter for sepsis dx?
    • arterial hypoxemia (PaO2/FiO2 <300)
    • acute oliguria (uo <0.5ml/kg hr for at least 2h)
    • creatinine inc >0.5 (check UO first)
    • INR >1.5, aPPT >60s
    • thrombocytopenia (<100,000)
    • hyperbili (total bili >4)
  33. tissue perfusion parameter for sepsis dx?
    • hyperlactatemia >3mmol/L
    • dec capillary refill or mottling
  34. what to do immediately if pt hotn or elevated serum lactate 4 mmol/L?
    initial resuscitation
  35. goals for initial resuscitation?
    (cental venous pressure, MAP, UO, central venous or mixed venous oxygen saturation)
    • CVP 8-12 mmHg
    • MAP >65 mmHg
    • UO 0.5ml/kg/hr
    • Oxygen >70 or 65%
  36. what should you use for central venous pressure during initial resuscitation? what not to use?
    • use crystalloids (NS, LR) or colloids
    • don't use D5W
  37. what do you use to inc mean arterial pressure? what not to use
    • DOC: norepi
    • dopamine
    • alt: epi
    • do not use low dose dopamine for renal protect
  38. what to do if venous oxygen saturation target is not achieved during initial resusc?
    • transfure packed RBC if required to hematocrit of >30%
    • start dobutamine inf
  39. what inotropic agent to use if pt has myocardial dysfunction?
    dobutamine!!
  40. is high dose corticosteroids better for survival of sepsis?
    • nope
    • early short course (48h) is good
  41. if adrenal insuff during septic shock, what to give? clinical presentation of adrenal insuff?
    • corticosteroid
    • single random cortisol level <15-20 ug/dL
    • 250ug ACTH stimulation test with weak cortisol responsne (<9)
  42. AE of corticosteroids
    • neuromyopathy
    • hyperglycemia
    • dec lymphocyte
    • immunosuppression
    • loss of intestinal epithelial cells via apoptosis
  43. can you use steroids to treat sepsis if there is no shock? what are the exceptions?
    • nope!
    • use steroid if pt's endocrine or CS hx warrants it
  44. what to use if hotn responds poorly to adequate fluid resus and vasopressors
    use IV hydrocortisone
  45. hydrocortisone dose for sepsis?
    • low dose
    • <300 mg/d
    • wean off if vasopressor not required
  46. target tidal volume for mechanical vent?
    6ml/kg
  47. what position should you keep mechanically vent pt?
    semi-recumbent (45 deg)
  48. why do you set PEEP for mech ventilated pt? (positive end expiratory pressure)
    to avoid extensive lung collapse at end-expiration
  49. what kind of sedation infusion methods to use produce awakening?
    • either intermittent bolus sedation
    • or continuous infusion
    • to predetermined end points (sedation scales)
  50. for severe sepsis, goal for glucose?
    when to monitor? how often monitor once stable?
    • <150mg/dL
    • monitor q1-2h
    • monitor q4h once stable
  51. which is easier management in HD unstable pt, tho they are both equivalent? intermittent HD vs. CVVH
    • CVVH
    • (slide 53)
  52. how to dvt ppx?
    • low dose UFH or :LMWH
    • if heparin CI, compression stocking
  53. if very high risk DVT, which preferred? UFH vs. LMWH
    use LMWH
  54. what to give for stress ulcer ppx?
    • H2 block or PPI
    • (weigh benefit/risk b/c potential for VAP develop)
  55. is selective digestive tract decontamination recommended? (slide 56)
    nope!!
  56. how do TNF-a and IL-b contribute to anemia?
    they decrease the expression of erythropoietin gene and protein
  57. can you transfuse for anemia pt?
    yes
  58. can you use recombinant human EPO for anemia pt?
    nope!
  59. when do you transfuse for anemia pt? (Hg level)? what is the target Hg level?
    • transfuse if <7g/dL
    • target 7-9 g/dL
  60. what should you NOT use to treat sepsis-related anemia?
    erythropoietin
  61. what can you use if there is active bleed or it is prior to a procedure to treat anemia?
    • fresh frozen plasma
    • (usually not recommended)
  62. when do you administer platelet for anemia tx?
    when plt is <5000 (really low)
  63. how much platelet is normally required for surgery or invasive procedure?
    50,000/mm3
  64. 10 important things to consider during sepsis
    • initial resuscitation
    • corticosteroid
    • mechanical ventilation
    • sedation/analgesia
    • glucose control
    • renal replacement
    • dvt ppx
    • stress ulcer ppx
    • selective digestive tract decontamination (no recommendation)
    • tx of anemia
  65. according to sepsis trial, protein C level is __ (high/low) in sepsis pt.
    • low
    • (slide 60)
  66. is protein C active in its natural state?
    • nope, needs to be activated (the action of thrombin complexed with thrombomodulin)
    • APC (activated version)
  67. APC adn protein S ___ (activate/inhibit) the activities of Va and VIIIa
    • inhibit
    • (slide 61)
  68. What is Xigris(R)? (generic name, actions, significance, when to start tx?, risk)
    • drotrecogin alfa (activated)
    • recombinant human activated protein C (APC)
    • natural anticoagulant (inhibit factors Va and VIIIa)
    • anti-inflamm
    • first time statistically significant dec of mortality!
    • start w/i 48h of dx of severe sepsis
    • risk is bleed but can transfuse
  69. when can you use APC? when can you not?
    • use in pt at high risk of death (APACHE >25), sepsis induced organ dysfunct, at least one organg failure
    • DO NOT USE in low risk (APACHE <20)

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