Sepsis and Septic Shock

what is a clinical syndrome characterized by systemic inflammation and a dysregulated host response to infection

Sepsis

what defines "early sepsis"?

infection, bacteremia

what are the sepsis-3 criteria for sepsis?

suspected Infection + acute organ dysfunction

what is the sepsis-3 criteria for septic shock?

- sepsis

- need for vasopressor therapy (to keep MAP 65+)

- serum lactate >2.0

does a person with sepsis always have multiple organ dysfunction sundrome or systemic inflammatory response syndrome

no MODS can by caused by a noninfectious procsses

SIRS is frequently present without any infection

what is the most common type of infection to cause sepsis?

pneumonia

what are the gram positive organisms that can cause sepsis?

s. aureus, s. pneumo

what are the most common gram negative organisms that can cause sepsis?

e. coli (most common)

klebsiella

p. aeruginosa

sepsis or septic shock?

signs of infection, plus altered mentation, oliguria, cool peripheries, hyperlactemia

septic shock

what are some risk factors for developing sepsis

- immunosuppression

- chronic disease

- ICU admission

- previous hospitalization

- age, male sex, black race

sepsis or septic shock?

signs of infection, with organ dysfunction, plus altered mentation; tachypnea; hypotension; hepatic, renal, or hematologic dysfunction

sepsis

no mention of increased lactate or the need for pressers

is gram-negative or gram-positive sepsis most common?

gram-negative

are blood cultures always positive in patients with sepsis?

no (only ⅓ of cases)

host's ability to ____________ direct and ____________ damage determines whether uncomplicated infection becomes sepsis

resist/tolerate, immunopathologic

what is the body's inflammatory response when developing sepsis

- infection trigger host response depending on pathogen virulence

- proinflammatory reaction tries to eliminate pathogens but causes collateral tissue damage

what is the general pathogenesis at the cellular and tissue level with sepsis?

- decreased O2 delivery to tissue

- inflammation

- leukocyte activation

all lead to tissue damage

what is a common coagulation abnormality in sepsis?

DIC

what does the body respond to sepsis with DIC

goal is to isolate invading microorganism and or to prevent the spread of infection

what type of infections are more likely to cause deadly DIC with sepsis?

bacteria that attack the endothelium (meningococcemia)

what are the most common secondary infections in sepsis patients who become immune suppressed due to prolonged intensive care?

- catheter related bloodstream infections

- ventilator associated infections

- abdominal infections

what are the symptoms of sepsis and septic shock?

• Hypotension

• Temp > 38.3 or < 36 C

• Tachycardia

what are clear signs of end organ perfusion

oliguria --> decreased perfusion to the kidneys

AMS --> decreased perfusion to the brain

what are the key contributing factors to organ dysfunction in sepsis (4)?

abnormal inflammatory response

cellular alterations

endothelial dysfunction

circulatory issues

how may the gut be involved in organ dysfunction in sepsis?

bacterial translocation due to impaired mucus integrity

what is the neuroinflammatory reflex?

1. sensory input through the afferent vagus nerve travels to the brain

2. efferent vagus nerve activate the splenic nerve in the celiac plexus

3. NE secreted by spleen and CD4 cells secrete acetylcholine

what is the most commonly affected organ system in sepsis?

cardiorespiratory

if the respiratory system begins to fail in a patient with sepsis, what syndrome does it usually manifest as

acute respiratory distress syndrome

how is the severity of ARDS determined?

decreasing PaO2/FIO2 ratio

Mild: 201-300

Moderate: 101 - 200

Severe: <100

if a person develops cardiovascular collapse what type of shock is this

distributive shock

heart is working fine and so is the amount of blood.

problem: diameter of the vessels suddenly expands

what is the clinical presentation of cardiovascular shock

- decreased SVR

- increased CO

presenting with hypotension and tachycardia and potentially need vasopressors

acute kidney injury (AKI) is documented in ____% of septic patients

50

having kidney injury (oliguria) with sepsis increased risk of in-hospital death by _____ fold

6-8

what is the main presentation of CNS dysfunction in sepsis?

coma, delirium

who is polyneuropathy and myopathy more likely to occur in as a neurologic complication of sepsis?

patients with prolonged critical illness

what is post-sepsis syndrome?

long-term cognitive impairment and functional disability after sepsis (affects 25-50% of sepsis survivors)

what can happen to blood sugar with bad infection or sepsis in a diabetic patient? (may be the earliest sign of bad infection in these patients)

higher and harder to control

what does SOFA stand for?

sequential organ failure assessment: determines organ dysfunction

evaluates 6 organ systems:

- respiration

- coagulation

- liver

- cardiovascular

- CNS

- renal

with ___ new SOFA points, the infected patient is considered septic

≥2 points means the infected patient is septic and has a ≥10% risk of in-hospital death

what are the parts of the quick SOFA and what does it indicate?

bedside tool:

3 points total

1 each for: systolic BP <100, RR >22, AMS

what is a positive result using the qSOFA and what is the main concern with it

≥2 predicts sepsis

conflicting evidence bc it can miss early sepsis

what are the 6 parameters of the national early warning score (NEWS) for sepsis?

- RR

- O2 sat

- systolic BP

- HR

- altered mentation

- temperature

what is the recommended labs to get on a patient with sepsis

• Lactate

• CBC w/ diff

• CMP

• LFTs

• Coags (PT/INR, PTT)

before starting abx in a patient with sepsis what must your do

get cultures from 2 different sites

ex: UA, site specific based on clinical suspcion

what levels of aPTT and INR indicate coagulopathy (in a patient who is not on anticoagulants)?

impaired clotting process

aPTT >60s, INR >1.5

what other non-sepsis conditions may lactic acidosis occur in?

alcohol intoxication, liver disease, DM, antiretrovirals

what are the Biomakers of sepsis

- lactate

- procal

- c-reactive protein

lactate is a marker of __________ ___________

tissue hypoperfusion

Hyperlactatemia and delayed lactate clearance are associated with

a greater

incidence of organ failure and death in sepsis

what is the thought behind procalcitonin

- determine whether or not to stop abx

- discriminates if the systemic response is due to a bacteria or a virus

C-reactive protein is a marker of

Marker of inflammation and infection (acute-phase reactant)

what is the early treatment/management for sepsis/septic shock?

rapid restoration of perfusion

blood cultures

empiric antibiotics

all within the first hour of presentation

what is the minimum IV bolus given to patients with sepsis as part of early goal directed therapy

30mL/kg started by the first hour

what are the 5 components that the Surviving Sepsis Campaign suggest to get completed within the first hour of a septic patients presentation

1. Measurement of serum lactate

2. Collection of blood culture before antibiotic administration

3. Administration of broad-spectrum antibiotics

4. Initiation of 30 mL/kg crystalloid bolus for hypotension or lactate > 4 mmol

5. Treatment with vasopressors for persistent hypotension or shock

if there is a known infection source in a patient who is showing signs of sepsis what is the initial tx

abx tx

when would you not use IV bolus as part of the initial sepsis treatment

patient has significant pulmonary edema

what are the fluids of choice for patients with sepsis

• Crystalloid infusion for large volume

• Crystalloid and/or colloid for bolus

purpose of giving colloids to patients with sepsis

ex: albumin or fresh frozen plasma

why: pull the fluid from extravascular back to intravascular spaces

who should receive empiric antifungal therapy for sepsis?

people with high risk of invasive candidiasis

what are some invasive monitoring modalities for septic patient?

central venous catheter (for CVP, SCVO2), arterial catheter (for MAP)

what are some noninvasive monitoring tools to help determine a patient's volume responsiveness?

arterial pulse contour analysis (PCA)

echo

passive leg-raise maneuvers

IVC collapsibility on US

what is the first choice vasopressor in septic shock?

norepinephrine

why would vasopressin be added to the treatment regimen of patients with sepsis

can be added to reduce the required norepinephrine dose

what is the blood transfusion threshold for septic patients (what does their hgb need to be below)?

hemoglobin <7

when would glucocorticoids given to patients with sepsis

if the patient is refractory to fluids or vasopressors (5-7 days)

give immediately to patients with adrenal insufficiency

what are some indications for ventilatory support in septic patients?

PaO2 <60 mmHg

SaO2 sat <90%

hypoventilation

pH <7.2 (inadequate compensation for metabolic acidosis)

what is the target tidal volume for patients with ARDS that is being mechanically ventilated

Target tidal volume of 6 mL/kg of predicted body weight

what positioning should patients with severe ARDs (PaO2/FIO2 < 150) be placed in

prone positioning

what are supportive adjuncts for patients with sepsis

- stress ulcer prophylaxis

- VTE prophylaxis

- glycemic control (insulin when 2 consecutive BS are >180)

once the septic patient is stabilized, what should be focused on

- determine which therapies to dc

- focus their abx therapy

what is post-intensive care syndrome?

worsening in cognitive, psychiatric, and physical function after critical illness

post-intensive care syndrome excludes patients with _______ and _______

TBI, stroke

what are some ways to prevent sepsis and septic shock?

- avoid unnecessary antibiotic use

- limit use of indwelling devices

- minimize immune suppression

- increase adherence to infection control programs