-
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
- oliguria
- 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?
yes
-
most common sites of infxn
- lungs (hence sepsis common in PNA)
- intra-abd organs
- urinary tract
-
GN sepsis is mostly caused by which organism?
e.coli
-
GP sepsis is caused by which organism?
- s.aur
- s.pneumo
- s. epi
- enterococcus
-
which fungal sepsis is common in BMT pt and neutropenic pt?
aspergillos
-
risk factors for sepsis?
- elderly
- 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)
nitric oxide
-
3rd stage increases factors __ and ___ to inc coagulation thrombin.
-
what happens during stage IV, late sepsis?
- immunosupp
- anti-inflamm
- shift from Th1 to Th2
- apoptosis
-
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?
- pseudo
- neutropenic
- immunocompromised
-
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)
- MI
- 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
- infxn
- 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?
initial resuscitation
-
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
- dopamine
- 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?
dobutamine!!
-
is high dose corticosteroids better for survival of sepsis?
- nope
- early short course (48h) is good
-
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)
-
AE of corticosteroids
- neuromyopathy
- hyperglycemia
- dec lymphocyte
- immunosuppression
- loss of intestinal epithelial cells via apoptosis
-
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
-
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?
6ml/kg
-
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?
- <150mg/dL
- 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
use 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)
nope!!
-
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?
yes
-
can you use recombinant human EPO for anemia pt?
nope!
-
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?
erythropoietin
-
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?
50,000/mm3
-
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
-
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)
- anti-inflamm
- 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)
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