CCP 226 Immune 🐛

Question 1

target UO in sepsis

Answer 1

1. > 0.5mL/kg/hr

this is based on KDIGO definition of AKI being Urine output less than 0.5 mL/kg/h for 6 hours

Question 2

SIRS Criteria (≥ 2 meets SIRS definition)

Answer 2

1. Temp >38°C (100.4°F) or < 36°C (96.8°F)
2. Heart rate > 90
3. Respiratory rate > 20 or PaCO₂ < 32 mm Hg
4. WBC > 12,000/mm³, < 4,000/mm³, or > 10% bands

Question 3

qSOFA (Quick SOFA) Score for Sepsis

Answer 3

1. Altered mental status GCS <15
2. Respiratory rate ≥22
3. Systolic BP ≤100
4. qSOFA Scores 2-3 are associated with a 3- to 14-fold increase in in-hospital mortality

Question 4

risk factors for sepsis

Answer 4

1. Advancing age of patients
2. Immunosuppression (diabetes, cancer, steroids, etc)
3. Multi drug resistant infection

Question 5

definition of sepsis

Answer 5

1. Life threatening organ dysfunction caused by a dysregulated host response to infection

Question 6

definition of septic shock

Answer 6

1. Despite adequate fluid resuscitation, requires vasopressors to maintain a MAP >65 mmHg
   with a lactate >2mmol/L

Question 7

qSOFA

Answer 7

1. Respiratory rate > 22 per minute
2. Altered mental status (GCS <15)
3. Systolic blood pressure < 100 mmHg

Question 8

most common sources of infection in sepsis

💵💵💵💵 MONEY SLIDE 💵💵💵💵

Answer 8

Meningitis
Pneumonia
Intra-abdominal
Genitourinary
Skin and soft tissue
Endocarditis
Lines/Tubes

Question 9

% increase in mortality for each hour delay in ABX in septic shock

💵💵💵💵 MONEY SLIDE 💵💵💵💵

Answer 9

8% per hour

Question 10

results of VAAST trial (vasopressin in septic shock)

Answer 10

1. can add vasopressin to NE to achieve MAP goal

2. can add vasopressin to NE to decrease NE dose

Question 11

Type A lactic acidosis

Answer 11

Type A = Tissue Hypoxia

1. Shock: septic, hypovolemic, cardiogenic,
obstructive
2. Acute mesenteric ischemia
3. Acute limb ischemia
4. Carbon monoxide poisoning
5. Cocaine use

Question 12

Type B lactic acidosis

Answer 12

Type B = Independent of Tissue Hypoxia

Seizure
DKA
Thiamine deficiency

Drugs; metformin, isoniazid, beta 2
agonists, epinephrine, Propofol,
salicylates

Inborn errors of metabolism
Malignancy (e.g. lymphoma)

Question 13

most common type of bacteria in lung infection

Answer 13

1. Gram Positive Streptococcus pneumoniae, which is responsible for almost 50% of cases

Question 14

most common type of bacteria in abdominal infection

Answer 14

1. Gram Negative

2. Anerobes

Question 15

most common type of bacteria in renal infection

Answer 15

1. Gram Negative E coli and Klebsiella pneumoniae

Question 16

Sepsis treatment pathway

💵💵💵💵 MONEY SLIDE 💵💵💵💵

Answer 16

1. Cultures and source control (ie. drain abscess)
2. Early Antibiotics
3. Restore Perfusion (fluid loading)
4. Adjuncts (ie. vasopressors, steroids)

Question 17

sepsis MAP goal in early resuscitation

Answer 17

MAP ≥ 65 (based on original EGDT data)

Question 18

A higher MAP goal (ie. 80) may be beneficial in what septic populations?

Answer 18

1. History of CKD

2. History of chronic HTN

Question 19

As norepinephrine doses rise, what adjunct should be considered?

Answer 19

1. Vasopressin

2. dose 0.03 - 0.04 units/min

Question 20

What are two pitfalls of epinephrine infusion in sepsis?

Answer 20

1. Causes rise in skeletal lactate production, which skews lactate-clearance trending.
2. More arrhythmogenic than other pressors.

Question 21

common gram positive infections

Answer 21

1. MRSA.
2. Streptococcus .
3. Staphylococcus.

Question 22

PCADS mnemonic in sepsis

Answer 22

1. Perfusion
2. Cultures
3. Antibiotics
4. Diagnose
5. Source control

Question 23

Osteomyelitis definition

Answer 23

bone infection

Question 24

myositis definition

Answer 24

Skeletal muscle infection

Question 25

pathophysiological process of fluid extravasation in sepsis

Answer 25

1. Microbe elicits an innate immune response in host 2. Inflammatory response is produced by IL 1, 6, and TNF-a 3. Inflammation spreads the membrane-like wall of the vasculature, allowing for fluid to escape into the interstitium.

Question 26

pathophysiological process of septic cardiomyopathy

Answer 26

1. inflammatory mediators such as IL 1, 6, and TNF-a cause disruption of cardiac myocyte activity 2. leads to troponin elevation, myocardial depression, and some ECG changes

Question 27

initial recommended fluid loading in sepsis

Answer 27

30mL/kg based on The Current Surviving Sepsis Campaign "Sepsis 3.0" guidelines

Question 28

passive leg raise test

Answer 28

1. Elevate the legs to 45 degrees for 40-60 seconds 2. watch for increase in Arterial BP (MAP) or decrease in HR Indicates volume responsiveness

Question 29

oxygen delivery equation

Answer 29

DO2 = CO x CaO2 CaO2 = (1.34 x Hgb x SaO2) + (0.003 x PaO2)

Question 30

oxygen consumption equation

Answer 30

VO2 = CO x (CaO2 - CvO2)

Question 31

oxygen extraction ratio

Answer 31

O2ER = (CaO2 - CvO2) / CaO2

Question 32

Normal serum calcium levels

Answer 32

1. Serum Ionized = between 1.15 and 1.30 mmol/L (anything over 1.0 is ok) 2. Serum Total = 2.2 to 2.7 mmol/L serum ionized calcium is the only one that is really important because that is the amount of "useful" calcium you have in your serum. ionized is the Ca++ content measured on your EPOC

Question 33

Components of the 1 hour sepsis bundle

Answer 33

1) Measure lactate 2) Obtain cultures 3) Begin broad-spectrum ABx 4) Isotonic 30mL/kg bolus if MAP < 65 or Lactate > 4 5) Vasopressor if MAP <65 (following fluid admin) this is based on american "CMS Core Measures" protocol for centre for medicare and Medicaid services guidelines

Question 34

refractory septic shock treatment pathway

Answer 34

1) Optimize DO2 (Preload, afterload, contractility) 2) Source control (remove infected lines) 3) Correct profound metabolic acidosis (pH <7.0) 4) Correct hypocalcemia (serum ionized Ca++ < 1.0) 5) Adjunctive therapies (corticosteroids)

Question 35

What are some examples of non-infectious aetiologies that can cause SIRS?

Answer 35

Trauma, burns, pancreatitis, transfusion reactions

Question 36

What is the definition of septic shock as per sepsis 3?

Answer 36

1) Vasopressors required after sufficient fluid resuscitation to maintain map > 65mmHg 2) Lactate greater than 2 And a diagnosis of sepsis

Question 37

define sepsis

Answer 37

Life threatening organ dysfunction cause by a dysregulated host response to infection

Question 38

most common type of bacteria in skin infection

Answer 38

Gram positive, generally group A streptococcus (i.e., Streptococcus pyogenes), followed by methicillin-sensitive Staphylococcus aureus

Question 39

most common type of gram positive organisms

Answer 39

1. Step 2. Staph 3. MRSA

Question 40

most common type of gram negatives organisms

Answer 40

1. salmonella 2. e. coli 3. space bugs 🐛

Question 41

what is the role of measuring serum lactate in sepsis resuscitation?

Answer 41

1. serum lactate Identifies and can help quantify decreased tissue perfusion 2. Trending lactate helps inform resuscitative efforts. 3. important to recognize that the use of epinephrine or concomitant liver failure can confound lactate measurements

Question 42

how do the Organisms found in sepsis cause direct injury that can provoke hemodynamic collapse

Answer 42

excreted toxins cause direct vessel injury which opens endothelial tight junctions leading to vascular collapse

Question 43

how does host immune response result in endothelial injury and hemodynamic collapse in sepsis

Answer 43

1. pathogen-excreted toxins activate the innate immune response and results in vasodilatory cytokine release 2. the host immune system continues to release pro-inflammatory chemokines that promote ongoing inflammation and endothelial derangement

Question 44

how can pulse pressure variation on a-line be used to assess fluid responsiveness in sepsis?

Answer 44

1. PPV of >10%-15% is an accurate predictor of fluid responsiveness 2. patient must be in sinus rhythm 3. patient must be mechanically ventilated with no spontaneous breaths 4. patient must have normal lung compliance and abdominal compartment pressures 5. patient must have an arterial line PPV % = PPmax – PPmin × 100

Question 45

Early Goal Directed Therapy (EGDT) definition

Answer 45

1. The Rivers trial (2001) randomized patients with severe sepsis or septic shock to early goal-directed therapy (EGDT) vs. standard therapy 2. EGDT used aggressive management of 5 key parameters to specified targets to optimise oxygen delivery to tissues in sepsis

Question 46

Early Goal Directed Therapy (EGDT) cocktail

Answer 46

Target Parameters: 1. CVP 8-12 mmHg 2. MAP 65 – 90 mmHg 3. Urine output >0.5 ml/kg/hr 4. Mixed venous oxygen saturation >65% / ScvO2 >70% 5. Haematocrit >30% Target Interventions 1. Reduce work of breathing by early use of mechanical ventilation 2. Large-volume fluid resuscitation 3. Use of vasoactive agents: noradrenaline, dobutamine 4. Transfusion

Question 47

why is normal saline a poor resuscitative fluid

Answer 47

1. Normal saline increases systemic inflammation and multiorgan system dysfunction via hyperchloremia and worsened metabolic acidosis

Question 48

when are Adjunctive corticosteroids recommended in sepsis? 💵💵💵💵 MONEY SLIDE 💵💵💵💵

Answer 48

1. shock that are refractory to catecholamines and volume resuscitation 2. defined as IV fluids to the limit of volume responsiveness and requires two vasopressors to reach a MAP goal >65 mmHg

Question 49

sepsis initial treatment pathway 💵💵💵💵 MONEY SLIDE 💵💵💵💵

Answer 49

1. Early investigations to determine infectious source 2. Early source control with appropriate antibiotics 3. Ongoing crystalloid resuscitation (Plasmalyte or LR preferred) as long as fluid responsive 4. First line vasopressor NORepinephrine 2 to 200 mcg/min for MAP goal of 65 mmHg 5. consider EPInephrine 2 to 50mcg/min if bradycardic 6. consider vasopressin 0.03-0.04 units/min when NORepinephrine >15mcg/min 7. foley/central line/invasive arterial monitoring 8. trend lactate and fluid responsiveness 9. If lactate fails to improve on subsequent readings consider septic-induced cardiomyopathy or other source of hyperlactatemia 10. adjunctive agents such as corticosteroids if refractory shock

Question 50

common reasons why sepsis is missed as an inpatient diagnosis

Answer 50

1. Lack of knowledge of sepsis risk factors, signs, symptoms 2. Observations performed infrequently in certain patients 3. Failure of sepsis screening processes 4. Rationalize that fever is disease related 5. "it can’t be sepsis because there is no fever" 6. Staff do not give high priority to watching for sepsis due to workload and/or lack of knowledge 7. Failure to communicate sepsis risk/symptoms in clinical handover 8. Not testing lactate when appropriate 9. Anchoring on current diagnosis, sepsis not considered

Question 51

clinical exam findings for sepsis based on source of infection 💵💵💵💵 MONEY SLIDE 💵💵💵💵

Answer 51

1. Cough/sputum/chest pain/shortness of breath (lungs) 2. Abdominal pain/distension/vomiting/diarrhea (abdomen) 3. Dysuria/frequency/indwelling catheter (kidneys) 4. Skin or joint (pain/swelling/redness) (skin) 5. Central line present (line sepsis) 6. Mottled skin, cold extremities (shock) 7. Fever/headache/nuchal rigidity (meningitic)

Question 52

clinical exam findings for lungs as a primary source of infection (identify source/source control)

Answer 52

1. Cough 2. sputum 3. chest pain 4. shortness of breath

Question 53

clinical exam findings for abdomen as a primary source of infection (identify source/source control)

Answer 53

1. Abdominal pain 2. distension 3. N/V/D

Question 54

clinical exam findings for GU/kidneys as a primary source of infection (identify source/source control)

Answer 54

1. Dysuria/frequency 2. presence of indwelling catheter 3. cloudy/foul smelling urine

Question 55

clinical exam findings for skin as a primary source of infection (identify source/source control)

Answer 55

1. heat (Calor) 2. pain (dolor) 3. redness (rubor) 4. swelling (tumor)

Question 56

STAT labs in a patient with suspected sepsis

Answer 56

1. Serum Lactate (Repeat q2h if initial lactate >2 mmol/L) 2. CBC and differential (looking for WBC count >12,000 or <4000 or bands >10%) 3. INR, PTT, electrolytes, BUN, creatinine, glucose, LFT, lipase, troponin 4. Blood cultures X 2 sets BEFORE antibiotics (include culture from central line, if present) 5. Urinalysis and urine C&S 6. Sputum for C&S

Question 57

STAT investigations in a patient with suspected sepsis

Answer 57

1. Labs 2. CXR 3. ECG

Question 58

initial broad-spectrum ABX coverage for sepsis at any site

Answer 58

1. vancomycin + piperacillin-tazobactam

Question 59

initial broad-spectrum ABX coverage for CNS infection (meningitis)

Answer 59

1. vancomycin + cefTRIAXone + acyclovir

Question 60

initial broad-spectrum ABX coverage for GI/GU infection

Answer 60

1. piperacillin-tazobactam

Question 61

initial broad-spectrum ABX coverage for skin infection

Answer 61

1. vancomycin

Question 62

initial broad-spectrum ABX coverage for Community Acquired Pneumonia (CAP) infection

Answer 62

1. cefTRIAXone | 2. azithroMYCIN

Question 63

Comprehensive Head to toe assessment for infection source

Answer 63

1. Diagnostic imaging (XR/CT) 2. Urine microscopy/culture 3. Sputum culture 4. Faeces for C.difficile if diarrhoea 5. Wound swab for culture 6. Nasopharyngeal swabs 7. Lumbar puncture (if indicated)

Question 64

goal for timing of ABX in sepsis

Answer 64

1. Administer after blood cultures drawn and within 1 hour of presentation

Question 65

high risk patient cohorts for sepsis

Answer 65

1. Looks unwell (homeless/poor baseline health status) 2. Age > 65 3. Recent surgery 4. Immunocompromised (AIDS; chemotherapy; neutropenia; asplenia; transplant; chronic steroids) 5. Chronic illness (diabetes; renal failure; hepatic failure; cancer; alcoholism; IV drug use)

Question 66

common sites for culturing in working up sepsis

Answer 66

blood, urine, cerebrospinal fluid [CSF], ascites fluid

Question 67

preferred vasopressors in order of administration in sepsis

Answer 67

1. Norepinephrine 0.01-3.0 μg/kg/min 2. Vasopressin 0.03 units/min (Addition of vasopressin generally utilized once norepinephrine dose is ≥15 μg/min) 3. Epinephrine 0.01-2 μg/kg/min

Question 68

steroid dosing in refractory septic shock

Answer 68

Hydrocortisone 50 mg IV q6h for shock refractory to catecholamines and volume resuscitation

Question 69

what is the role of Methylene blue in refractory septic shock

Answer 69

Can counteract vasoplegia in distributive shock, but benefits to tissue oxygen delivery or mortality have not been demonstrated last ditch hail mary

Question 70

discuss "source control" and how to Find and control the source of infection in sepsis

Answer 70

1. Remove old indwelling catheters as soon as possible. (The risk of a line-associated bloodstream infection is dependent on the duration and type of access) 2. Physical exam requires full exposure and inspection to assess for CNS, odontogenic, sinus, respiratory, GI, GU, and soft tissue infections. 3. CXR, Bedside U/S of the heart, lungs, abdominal right upper quadrant, kidneys, and bladder, CT scans as indicated by patient presentation

Question 71

discuss the approach to ongoing Monitoring for organ dysfunction and inadequate perfusion in Sepsis/critical illness

Answer 71

1. Serial exams to evaluate Vital signs, mental status, cardiopulmonary exam, capillary refill, peripheral pulse, and skin 2. Urine output (Normal urine output is at least 0.5 mL/kg/h) 3. Chem-7/BMP (optimize acid/base status and electrolytes while monitoring renal function and maintaining relative euglycemia) 4. Lactate (Identifies and quantifies decreased tissue perfusion. Trending lactate helps inform resuscitative efforts. confounded by epinephrine or liver failure) 5. Blood gas (early detection of critical acid-base disturbances and ARDS)

Question 72

Sepsis definition (sepsis-3)

Answer 72

“life-threatening organ dysfunction due to a dysregulated host response to infection.”

Question 73

Sequential Organ Failure Assessment (SOFA) Score

Answer 73

1. SOFA Score is a mortality prediction score that is based on the degree of dysfunction of six organ systems 2. score is calculated on ICU admission and q24 hours until discharge using the worst parameters measured during the prior 24 hours

Question 74

give some examples of why a septic patient may not meet SIRS criteria (ie, why does SIRS have shitty sensitivity for sepsis)

Answer 74

1. elderly patients not mounting a febrile response 2. current beta blocker use 3. diagnostic futility of the WBC

Question 75

discuss the use of vasopressin in sepsis

Answer 75

1. Adding low-dose vasopressin (0.01-0.04 units/min) as a catecholamine-sparing agent in patients responding appropriately to norepinephrine infusion offers no survival advantage 2. Vasopressin infused at 4 units/h (0.07 units/min) may decrease dysrhythmias and increase cardiac index measurements compared with norepinephrine alone. However, it also increases total bilirubin measurements, should be used with caution in patients with mesenteric ischemia due to its strong effects on splanchnic vasculature, and is generally not recommended

Question 76

describe the role of ProCESS, ARISE, and ProMISe trials in current best practice guidelines for management of sepsis, and their impact on our understanding of EGDT

Answer 76

1. In the initial study of early goal-directed therapy for sepsis, the treatment arm of the study received the majority of its fluid resuscitation early, while the control arm received the same volume but had it administered later, in violation of the treatment protocol. 2. When repeated in the ProCESS, ARISE, and ProMISe trials, in which the treatment and control arms all received fluid resuscitation and antibiotics in the same way, the additional measures recommended in Rivers’s Early Goal-Directed Therapy protocol (central venous pressure of 8-12 mm Hg, red blood cell transfusion and dobutamine for central venous oxygen saturation <70%, vasodilators for MAP >90 mm Hg) made no difference in ultimate mortality

Question 77

Patients at highest risk of fungemia

Answer 77

the chronically ill with multiple comorbidities recent antibiotic exposure a CVC in situ known Candida colonization

Question 78

the addition of antifungal therapy should be considered in which cohorts of patients with sepsis?

Answer 78

patients on TPN, with neutropenia or other immunosuppression, or with peritonitis or another breach of bowel wall integrity