Sepsis and Antimicrobials I and II - DONE

what is the vet med definition of sepsis?

clinical manifestation of an infection that results in a systemic inflammatory repsonse by the host

what is the human med definition of sepsis?

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

what is systemic inflammatory response syndrome (SIRS)?

constellation of clinical signs of systemic inflammation noted in response to infectious or noninfectious cause

what is septic shock?

persistent hypotension despite volume resuscitation associated with sepsis (or a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities substantially increase mortality)

they already received fluid bolus and are still hypotensive

what is multiorgan dysfunction (MODS) ?

physiologic abnormalities of the endothelial, respiratory, renal, CV, hepatobiliary, coagulation, nervous, endocrine, and GI systems associated with systemic inflammation

what is compensatory anti-inflammatory response syndrome (CARS)?

systemic deactivation of the immune system tasked with restoring homeostasis from an inflammatory state

what is speticemia?

infection within bloodstream

what are the trigger molecules of sepsis (PAMPs)?

lipopolysaccharide (gram neg bacteria)

lipoteichoic acid (gram pos bacteria)

peptidoglycan

bacterial DNA or RNA

mannan - from fungal

what are the trigger molecules of sepsis (DAMPs)?

(our own cells)

cell free DNA/RNA

heat shock proteins

HMGB1

hyaluronan

ATP

histones

heparan sulfae

diagram

diagram

what are the parts of the SIRS competing syndromes?

tumor necrosis factor - alpha

interluekin (IL) - 1 beta

IL-6

IL-8

interferon gamma

marked in inflammation,coagulation, vasodilation

what are the parts of the CARS competing syndromes?

IL-4

IL-10

IL_13

transforming gorwth factor beta

immunosuppression

what are the systemic effects of sepsis?

fever

vasodilation

systolic dysfunction

glycocalyx destruction

fluid and WBC extravasation

acute phase proteins

-->inc fibrinogen

-->dec albumin

disseminated intravascular coagulation (DIC)

critical illness-related corticosteroid insufficiency (CIRCI)

what are the different types of shock?

distributive shock

-->hypoperfusion due to pooling of blood

hypovolemic shock

-->vomiting, diarrhea (dec volume)

cardiogenic shock

-->dec diastolic function

metabolic shock

-->non-circulatory (normal perufsion), sepsis inhibits mitochondrial function

shock = dec ATP production

what is the compensatory/hyperdyanamic phase of shock?

QAR to dull

normal T to febrile

tachycardia

tachypnea

normal to hypermeic MM

notmal to hyperdynamic pulse

<1 sec CRT

normal to hypertensie BP

normal extremity T

what is the decompensatroy/hypodynamic phase of shock?

obtunded

hypothermic

tachycardia or bradycardia

tachypnea

pale MM

weak to absent pulse

>2 sec CRT

hypotensice

cold extremities

most cats that come in

what are the sources of shock?

septic peritonitis

pyothorax

pneumonia

urogenital sepsis

speticemia

endocarditis

dermal sepsis

hepatobiliary spesis

how do we recognize sepsis in dogs? (SIRS)

T: <100.6 or >102.6

HR: >120 bpm

RR: >20 rpm

WBC: <6 or >16

band %: >3

must meet at least 2

how do we recognize spesis in cats? (SIRS)

T: <100 or >103.5

HR: <140 or >225 bpm

RR: >40 rpm

WBC: <5 or >19.5

band %: >5

must meet at least 3

what is sequneital organ failure assessment (SOFA) score?

CV: mean arterial P +/- vasopressor therapy

respiratory: PaO2/FiO2 ratio (low)

hepatobiliary: bilirubin (high)

coagulation: platelets +/- PT/aPTT

renal: creatinine and urine output

neuro: modified glasgow coma scale (low)

leaves out GI tract

what is qSOFA (quick SOFA)?

respiratory rate (>22)

altered mentation

blood pressure (<100 mmHg)

lactate?

capillary refill time?

what are the biomarkers used for sepsis?

lactate (inc)

glucose (dec)

leukogram (high or low neuts)

cell free DNA

procalcitonin

C-reactive protein ( best factor to use for dogs)

cytokines

what are the first tier diagnostics for sepsis?

BP

ECG

pulse oximetry

venous blood gas

blood smear

point of care ultrasound

what are the second tier diagnostics for sepsis?

biochem profile

CBC

urinalysis

coagulation testing

rads

what are the third tier diagnostics for sepsis?

abdominal ultrasound

CT

echo

exploratory surgeyr

what is characteristic of antimicrobial testing?

blood cultures (endocarditis)

urine culture

joint effusion culture (spetic joint)

wound cultures

cavitary effusion culture

respiratort sampling (endotracheal wash' infectious pneumonia)

PCR

serology

if we identify effusion, how do we analyze that?

cytology (usually neutrophillic; look for intracellular bacteria)

glucoe

--> 20 mg/dL lower in effusion compared to blood

lactate

--> 2 mmol/L higher in effusion compared to blood

pushes us in direction of sepsis, BUT is not always diagnostic

how do we treat sepsis?

isotonic crytalloids (for hypovolemic)

--> 30 mg/kg in first hour

colloids for those with large fluid volumes

synthetic colloids?

restrictive use of blood products

what is stressed vs unstressed volume?

stressed volume: blood volume that creates a positive pressure within the vessel (arterial)

unstressed volume: blood volume that fills the vascular bed without creating pressure (venous)

how do we decreased unstressed volume?

give vasopressors (norep)

-->arterial constrictionto bring up BP

-->venousconstriction

what are the vasopressors to use in vasoplegia treatment?

1st: norepinephrine

-->mostly alpha 1 agonism

-->0.1-2 mcg/kg/min

2nd: vasopressin

-->V1 and V2 agonism

-->0.5-5 mU/kg/min

-->start when at 0.3 for norepinephrine

3rd: epinephrine

-->alpha and beta agonist

-->0.05-1 mcg/kg/min

give these if BP does not improve with fkuid bolus***

what are the septic cardiomyopathy treamtents?

1st (dog): dobutamine

-->beta agonism

-->5-20 mcg/kg/min

1st (cat): dopamine

-->dose-dependent

-->5-10 mcg/kg/min

alternative: epinephrine

-->alpha and beta agonism

-->0.05-1 mcg/kg/min

alternative: pimobendan

-->PDE3 inhibtion

-->0.25 mg/kg q8

what are the principles of abx therapy?

escalation therapy

de-escalation therapy

what is escalation therapy?

narrow abc selection

covers likely pathogen

-->e. coli for urinary

changed based on C/S

what is de-escalation therapy?

empiric, broad-spectrum

cover all pathogens often associated with infection

narrowed based on C/S

pneumonia, spesis (more serious stuff)

nosocomial infection

when do we give abx?

mortality decreased from 38.5 to 19% with abx within 1 hour of triage

MRSA: survival higher if app abx within 24 hours

every hour delat for the first 6 hours with septic shock, mortality increased by 7.6%

what do you do if shock is present and sepsis is probable?

administer antimicrobials IMMEDIATELY, ideally wihtin 1 hour of recognition

what do you do if shock is present and sepsis is possible?

administer antimicrobials IMMEDIATELY, ideally wihtin 1 hour of recognition

what do you do if shock is absent and sepsis is probable?

administer antimicrobials IMMEDIATELY, ideally wihtin 1 hour of recognition

what do you do if shock is absent and sepsis is possible?

rapid assessment of infectious vs noninfectious causes of acute illness

administer antomicrobials WITHIN 3 HOURS if concern for infection persists

what are some factors that lead to multi drugresistance?

abx within last 3 months

hospitalization >5 days

env with lots of resistance

immunosuppression

infection related to health care

GI translocation

invasive procedures

indwelling catheters

what can tissue penetration be limited by?

perfusion

permeability

urine vs renal tissue

intracellular

anaerobic env

acidic env

hemoglobin

what are the different types of bacterial killing patterns?

concentration dependent

time dependent

-->cell wall inhibitors

examples of empiric therapy

examples of empiric therapy

what are some other treatment considerations?

oxygen

hydrocortison (0.25-1 mg/kg q6h) for CIRCI

GI support

early enterla feeding

dextrose PRN

pain med PRN

antithrombotics?

how do we practice source control for sepsis?

prompt surgical intervention

thoracic tube placement

point of care debridement

what is the prognosis of different sepsis?

septic peritonitis: 36-84%

pneuomonia: 77%

pyothorax: 83% dogs, 62% cats

endocarditis: 20-30%

necrotizing fasciitis: 35%

cases

cases