Sepsis

Question 1

Staphylococcus
Gram N rods
pseudomonas

Answer 1

Proinflammatory and procoagulant response in response to an infection

1. increassed tnf alpha, interleuking 1beta
2. upregulation of adhesion molecules on neutrophils and endothelial cells
3. increased permeability due to inc Nitrious Oxide
4. coagulation cascade activate: formation of microvasc thrombi
5. protein C, S, Antithrombin are reuduced in sepsis, so reduceds anticoagulation
6. decreased ciruculation can lead to anaerobic metabolism

Question 2

what are the signs and symptoms of sepsis?

Answer 2

1. CNS: altered mental status, confusion, septic encephalopathy
2. Resp: tachypnea, hypoxia SaO2< 90%, hypoxemia PaO2<70, reduced preload
3. Renal: oliguria, decreased urine output, inc creatinine
4. Liver: inc LFTs and Tbili, decr albumin
5. Hematologic: decr platelets, increast Pt/PTt
6. Tissue hypoperfusion leading to increased lactate

Question 3

what defines systemic inflammatory response syndrome? SIRS

Answer 3

1. temperature less than 36 and more than 38
2. HR more than 90
3. RR more than 20 or PaCO2 < 32 or needs mechanical ventilation
4. WBC > 12k or 10% immature forms

Question 4

what defines sepsis?

Answer 4

1. patient must have SIRS meetint 2 out of 4 of the criteria for SIRS.
2. patient must have presumed or documented infection

Question 5

what defines severe sepsis?

Answer 5

1. patient must have sepsis.

2. patient must have signs of acute organ dysfunction

Question 6

what defines septic shock?

Answer 6

1. patient must have severe sepsis
2. SBP<65 or SBP decreass more thant 40
3. hypotension despite fluid reuscitation

Question 7

what defines multiple organ dysfuncion syndrome? MODS?

Answer 7

fauilure of multiple organs requiring itnervention to maintain homeostasis.

Question 8

what is the general treatment (whole) for sepsis?

Answer 8

1. antibiotics
2. fluids
3. pressors/inotropes
4. steroids
5. glucose control
6. supportive care: mechanical ventilation, sedation/analgesia, renal replacement therapy, nutrition, DVT & stress ulcer prophylaxis

Question 9

how soon should you start antibiotics once you recognize that they have symptoms of severe sepsis or shock?

Answer 9

1 hour

Question 10

how long should you take to have the person’s blood pressure under control?

Answer 10

6 hours

Question 11

how long should it take you to have their glucose under control?

Answer 11

24 to 72 hours

Question 12

what monitoring parameters should you monitor in sepsis?

Answer 12

1. blood pressure: SBP, DBP, MAP or CVP

2. tissue hypoxia or hypoperfusion: central venous oxygen saturation, mixed venous oxygen hypoperfusion, lactate levels

Question 13

what are your goals for CVP, MAP, UOP, ScvO2 for sepsis?

Answer 13

1. CVP 8-12mmHg
2. MAP>65
3. UOP > 0.5ml/kg/hr
4. ScvO2 >70%, mixed venous >65%

Question 14

which crystalloids and colloids can you use for fluid resuscitation in sepsis?

Answer 14

1. crystalloids: Normal Saline, Lactates Ringer’s

2. colloids: albumin 4% and 5%

Question 15

what is the blood pressure equation?

Answer 15

SVR X CO

Question 16

what is the Cardiac output equation?

Answer 16

HR x SV

Question 17

which possible pressors should you use to increase blood pressure?

Answer 17

1. NE *
2. DA*
3. Epi
4. Phenyleph
5. Vasopressin
   Order of choice above
   NE and DA have most evidence. DA more SEs
   vasopressin can be added to NE

Question 18

what is the rationale that people use to justify the use of steroids in sepsis?

Answer 18

decrease synthesis of iNOS leading to vasodilation
increased sensitivity of vascular catecholamine receptors
decreased transcritpon of inflammatory cytokines

Question 19

which corticosteroid can you give and what dose?

Answer 19

hydrocortisone less that or equal to 300mg per day

Question 20

when treating hyperglycemia from sepsis , when should you start therapy and what is your goal approximately?

Answer 20

when blood sugar is >180mg/dl

Goal: ~150mg/dl

Question 21

which medication should you use to control hyperglycemia in sepsis?

Answer 21

IV insulin