Sepsis

Question 1

What is sepsis?

Answer 1

SIRS due to infection (proven or suspected)

Question 2

What are the criteria for SIRS?

Answer 2

Two or more of:
1. temp >38 or Less then 36
Hr greater than 90
3. RR >20
4. WBC >12000 or 10%bands

Question 3

Non-infectious causes of SIRS:

Answer 3

1. tissue injury (MI, pancreatitis, trauma, etc)
2. metabolic (thyroid storm, acute adrenal insuff)
3. therapy related (cytokines e.g. GM-CSF, opiates, blood products)
4. malignancy (tumor lysis synd)
5. neurologic (subarach hemorrhage)

Question 4

What are possible factors that may contribute to afebrile infections in septic patients?

Answer 4

1. extremes of age
2. chronic kidney disease or uremia
3. corticosteroids
4. NSAIDs/acetaminophen
5. DM (due to leukocyte dysf)
6. Neuro insults (stroke or malformations may result in damage to fever resp area)

Question 5

Earliest and very sensitive test for sepsis

Answer 5

RR

Question 6

What is severe sepsis?

Answer 6

sepsis plus either:

• organ dysfunction
• evidence of hypoperfusion or hypotension

Question 7

What is septic shock?

Answer 7

• a subset of severe sepsis

- sepsis + hypotension not responding to fluid resuscitation

Question 8

Pro-inflammatory cytokines:

Answer 8

IL-1, IL-6, IL-8, TNF-alpha

Question 9

Anti-inflammatory cytokines:

Answer 9

IL-10

Question 10

What is the pathogenesis of septic shock?

Answer 10

in response to blood stream invasion, the host’s defense system is activated; this causes release of cytokines and inflammatory mediators

If inflammatory response is…
1. excessive–results in inflammatory response
2. inadequate–results in ongoing release on microbial toxins
Results in tissue injury, then shock/MOF

Question 11

Clinical manifestations of sepsis

Answer 11

• fever
• tachycardia (due to change in preload)
• tachypnea
• hypotension
• mental status change
• nausea/vomiting
• loss of appetite (or “not tolerating feeds”)

Question 12

How much time do you have to detect and treat sepsis?

Answer 12

“silver day” (**6 hours is best)

Question 13

What improves outcomes, in terms of sepsis?

Answer 13

earlier treatment

Question 14

Sepsis work-up before starting antibiotics?

Answer 14

gram stain and culture
blood cultures x2 (periph and via vasc access)
imaging (CXR, CT, etc)

Question 15

What are 4 ways to manage sepsis (broad)?

Answer 15

1. eradicate microorg
2. neutralize microbial toxin
3. modulate host response
4. supportive care (for MOF/shock)

Question 16

What antibiotic can decrease toxin production?

Answer 16

clinda

Question 17

Goals of Early Goal Directed Therapy (4)

Answer 17

1. central venous pressure: 8-12 mmHg
2. MAP >65 mmHg
3. urine output >0.5 mL/kg/hr
4. central venous O2 sat >70%

MEMORIZE8,7,6,5
(8-12=central venous pr,70=O2, 65=map, .5=pee)

Question 18

Why is adequate urine output important to monitor?

Answer 18

it is a good measurement of general organ perfusion

Question 19

What should antibiotics be given to a potentially septic patient?

Answer 19

immediately!! every hour delay increases mortality by 6-7%

Question 20

In septic shock, low dose ____ improves mortality.

Answer 20

hydrocortisone

Question 21

Who should get pneumococcal vaccine?

Answer 21

1. > 65 y/o
2. 2-64 y/o with immunosuppression
3. 2-64 y/o with heart dis, lung dis, sickle cell, DM, ETOH, CSF leak, cirrhosis, cochlear implant
4. 19-64 y/o smoker or asthma
5. residents of NH or long term care facility

Question 22

Resuscitation fluid of choice?

Answer 22

saline

Question 23

T/F: Early goal directed therapy improves mortality

Answer 23

T, duh.

Question 24

Preventive measures in sepsis:

Answer 24

1. hand washing
2. DVT prophylaxis
3. stress ulcer prophylaxis (H2 blocker or PPI)
4. Head of bed elevation to prevent VAP
5. Remove foley and central lines ASAP
6. Early ambulation and PT
7. Target glu <150, hand washing, elevate head, DVT prophylaxis

(LAUGHED: lines, ambulation, ulcers, glu, hands, elevate, DVT)

Question 25

What are the criteria for SIRS.

Answer 25

RR >20; HR >90; Temp >38 and less than 36; wbc >12000 or 10%bands