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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%
what three conditions may need SIRS (systemic inflamm response syndrome) process?
2 criteria to be sepsis
- systemic inflamm response to a documented infxn
- at least 2 SIRS criteria + infxn
definition of severe sepsis?
sepsis (2SIRS + infxn) AND organ dysfuct, hypoperfusion or hotn
hypoperfusion and perfusion abnormality in severe sepsis may include what 3 things?
- lactic acidosis
- acute alter in mental status
- (slide 7)
severe sepsis has what 2 responses?
inflamm and procoagulant response (microvascular injury)
clinidal lab of sepsis (SIRS) induced hypotension
- SBP <90 mmHg
- or >40 mmHg from baseline
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)
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
do you need infection to qualify as sepsis?
most common sites of infxn
- lungs (hence sepsis common in PNA)
- intra-abd organs
- urinary tract
GN sepsis is mostly caused by which organism?
GP sepsis is caused by which organism?
- s. epi
which fungal sepsis is common in BMT pt and neutropenic pt?
risk factors for sepsis?
- inc use of invasive procedure and high risk surgery
- abx resistant organism
- inc prevalence of immunocompromised pts
review of pathophys of sepsis (5 stages)
- 1) infxn
- 2) inflamm (endothelial damage)
- 3) coagulation
- 4) anti-inflamm and apoptosis
- 5) organ fail
endothelial cells release ___, a potent vasodilator and key mediator in septic shock during immune response. (slide 21)
3rd stage increases factors __ and ___ to inc coagulation thrombin.
what happens during stage IV, late sepsis?
- shift from Th1 to Th2
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
can you improve mortality of sepsis
- nothing in the past has improved mortality
- needs early intervention
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
abx should be started asap. upon diagnosis, within ___ h. upon ER admission, within ___h.
- within 1st hour
- within 3 hrs
which spectrum abx do you use for sepsis abx?
broad spectrum optimize PK/PD
when do you use combo tx for sepsis?
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
inc of WBC can indicate what 4 conditions? so which is a more reliable marker of infxn?
- sepsis (duh)
- major surgery
- corticosteroid therapy (esp in brain surgery)
- use "shift to left"
- (slide 31)
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
general parameter for sepsis
- temp, HR, tachypnea, altered mental status, significant edema (>20ml/kg over 24h), hyperglycemia (>140)
inflamm parameter for sepsis dx
- WB >120000 or <4000 or >10% band
- plasma CRP >2 SD above normal
- plasma procalcitonin >2SD above nml
hemodynamic parameter for sepsis dx?
- hotn sbp <90
- sbp dec > 40 mmHg
- MAP <70
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)
tissue perfusion parameter for sepsis dx?
- hyperlactatemia >3mmol/L
- dec capillary refill or mottling
what to do immediately if pt hotn or elevated serum lactate 4 mmol/L?
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%
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
what do you use to inc mean arterial pressure? what not to use
- DOC: norepi
- alt: epi
- do not use low dose dopamine for renal protect
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
what inotropic agent to use if pt has myocardial dysfunction?
is high dose corticosteroids better for survival of sepsis?
- early short course (48h) is good
if adrenal insuff during septic shock, what to give? clinical presentation of adrenal insuff?
- single random cortisol level <15-20 ug/dL
- 250ug ACTH stimulation test with weak cortisol responsne (<9)
AE of corticosteroids
- dec lymphocyte
- loss of intestinal epithelial cells via apoptosis
can you use steroids to treat sepsis if there is no shock? what are the exceptions?
- use steroid if pt's endocrine or CS hx warrants it
what to use if hotn responds poorly to adequate fluid resus and vasopressors
use IV hydrocortisone
hydrocortisone dose for sepsis?
- low dose
- <300 mg/d
- wean off if vasopressor not required
target tidal volume for mechanical vent?
what position should you keep mechanically vent pt?
semi-recumbent (45 deg)
why do you set PEEP for mech ventilated pt? (positive end expiratory pressure)
to avoid extensive lung collapse at end-expiration
what kind of sedation infusion methods to use produce awakening?
- either intermittent bolus sedation
- or continuous infusion
- to predetermined end points (sedation scales)
for severe sepsis, goal for glucose?
when to monitor? how often monitor once stable?
- monitor q1-2h
- monitor q4h once stable
which is easier management in HD unstable pt, tho they are both equivalent? intermittent HD vs. CVVH
how to dvt ppx?
- low dose UFH or :LMWH
- if heparin CI, compression stocking
if very high risk DVT, which preferred? UFH vs. LMWH
what to give for stress ulcer ppx?
- H2 block or PPI
- (weigh benefit/risk b/c potential for VAP develop)
is selective digestive tract decontamination recommended? (slide 56)
how do TNF-a and IL-b contribute to anemia?
they decrease the expression of erythropoietin gene and protein
can you transfuse for anemia pt?
can you use recombinant human EPO for anemia pt?
when do you transfuse for anemia pt? (Hg level)? what is the target Hg level?
- transfuse if <7g/dL
- target 7-9 g/dL
what should you NOT use to treat sepsis-related anemia?
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)
when do you administer platelet for anemia tx?
when plt is <5000 (really low)
how much platelet is normally required for surgery or invasive procedure?
10 important things to consider during sepsis
- initial resuscitation
- mechanical ventilation
- glucose control
- renal replacement
- dvt ppx
- stress ulcer ppx
- selective digestive tract decontamination (no recommendation)
- tx of anemia
according to sepsis trial, protein C level is __ (high/low) in sepsis pt.
is protein C active in its natural state?
- nope, needs to be activated (the action of thrombin complexed with thrombomodulin)
- APC (activated version)
APC adn protein S ___ (activate/inhibit) the activities of Va and VIIIa
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)
- first time statistically significant dec of mortality!
- start w/i 48h of dx of severe sepsis
- risk is bleed but can transfuse
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)