Sepsis and Septic Shock

sepsis

_____ is life-threatening organ dysfunction caused by a dysregulated host response to infection

septic shock

_____ _____ is persistent hypotension requiring vasopressors to maintain mean arterial pressure (MAP) >65 mmHg and serum lactate >2 mmol/L despite having adequate volume resuscitation

-brain: altered mental status

-lungs: mechanical ventilation, hypoxemia

-heart: SBP <90, MAP <65 mmHg

-liver: T bilirubin >2 mg/dL, platelets <100,000, INR >1.5, aPTT >60

-kidneys: acute oliguria, UOP <0.5 ml/kg/hr despite fluids, elevated SCr

-gut: absent bowel sounds (ileus), abdominal pain

-skin: mottled and dusky

-lactate: >2 mmol/L

markers of organ dysfunction include:

-identify infection + organ dysfunction

-vitals: fever/hypothermia, tachycardia, hypotension, tachypnea, low SpO2

-perfusion: altered mentation, low UOP, mottled skin

-find source: lungs, urine, abdomen, skin/soft tissue

-labs: CBC, CMP, lactate, cultures x2, UA, procalcitonin, imaging as needed

-reassess frequently: MAP, mental status, UOP, repeat lactate

assessment of the septic patient includes:

leaky vessel syndrome, preload, vasodilation

_____ _____ _____ occurs in sepsis when inflammatory mediators damage endothelium; fluid and proteins shift out of the bloodstream and into tissues, leading to decreased intravascular volume (decreased ______); combined with sepsis-induced _______, SVR decreases and results in hypotension

performance improvement program

it is recommended to use a _____ _____ _____ for sepsis, including sepsis screening for acutely ill, high risk patients and standard operating procedures for treatment

SIRS, qSOFA

______ can be used as a single screening tool; the Surviving Sepsis Campaign does not recommend using ______ alone to screen for sepsis; instead, it supports using broader, systematic institutional screening approach to ensure early identification of patients with potential sepsis

lactate, 2

blood ______ should be measured in patients who are suspected of having sepsis; elevated level (>=___) increases likelihood of sepsis diagnosis

-temperature >100.4F (38C) or <96.8F (36C)

-heart rate >90 bpm

-respiratory rate >20 breaths per minute or PaCO2 <32 mmHg

-WBC >12,000 or <4,000/microliters or over 10% immature forms or bands

meeting SIRS criteria include 2 of the following, PLUS a suspected source of infection:

qSOFA

_______ is a bedside tool used to rapidly identify patients at risk for poor outcomes from infection

-RR >22 breaths/min

-altered mental status

-SBP < 100 mmHg

qSOFA criteria include:

2, assessment, intervention, diagnose

____ or more qSOFA points plus a suspected source of infection indicates that a patient is high risk; may indicate need for urgent ______, rapid _______, and sepsis bundle activation; doesn't ______ sepsis, but identifies patients at risk of poor outcomes

1 hour, 3 hours, procalcitonin, blood cultures

antibiotics should be administered within ____ _____ for patients in septic shock, and within ____ _____ for patients suspected of sepsis but not in shock; obtain ______, _____ ______, and work to get source control

empiric

______ antimicrobial selection is based on patient-specific risk factors

MRSA

if a patient is at high risk, ______ coverage should be included in empiric regimen; low risk do not need coverage; drugs include vancomycin, daptomycin (not in lungs!), or linezolid

-prior history of MRSA infection

-recent IV antibiotics

-history of recurrent skin infections or chronic wounds

-presence of invasive devices

-hemodialysis

-recent hospital admissions

-severity of illness

factors that put patients at high risk for MRSA:

false; you only double-cover if a patient is at high risk

true or false: you should double-cover for gram negative agents for all patients suspected of sepsis

pathogen, susceptibilities

in high risk patients, use two antimicrobials with gram-negative coverage for empiric treatment; however, do not double cover once causative _______ and _______ are known

-proven infection or colonization with resistant organisms in last year

-local prevalence of antibiotic resistant organisms

-hospital acquired infection

-broad spectrum antibiotic used in last 90 days

-travel to highly endemic country in last 90 days

-hospitalization within the last 90 days

-selective digestive decontamination (SDD)

factors that put patients at risk for MDR organisms, so require double coverage for gram negatives:

-piperacillin/tazobactam

-ceftazidime

-cefepime

-aztreonam

-imipenem

-meropenem

-doripenem

-ciprofloxacin

-levofloxacin

-polymyxin B

anti-pseudomonal agents include:

ciprofloxacin, levofloxacin

_______ and _______ can be used orally to treat Pseudomonas

antifungal, fluconazole, micafungin, amphotericin

for patients at high risk for Candida sepsis, initiate empiric therapy with ______ agent; do not initiate in low-risk patients; drugs include ______, ______, and ______; guidelines also include risk factors for endemic yeast and invasive mold infections

true

true or false: immunocompromised patients should receive bacterial, fungal, and viral empiric coverage if septic

small, influenza, SARS-CoV2

viruses comprise a _____ number of sepsis cases; causative infections include ______ and _______; no recommendation on use of antiviral therapy

-neutropenia

-HIV

-hematological malignancies

-stem cell or solid organ transplant

-recent travel to tropical regions

special populations to consider for antiviral therapy:

aminoglycosides, vancomycin

TDM is required for _______ and _______

daily, narrow, shorter

assess sepsis patients ______, and ______ spectrum as soon as possible using culture results; prefer _______ duration of therapy

procalcitonin

______ thresholds (% change in concentration) for discontinuation very across literature; obtain levels and use clinical evaluation

30, balanced crystalloid

____ mL/kg of IV ______ ______ fluid should be given within the first 3 hours

65

the MAP goal is >_____ to maintain perfusion

true

true or false: balanced crystalloids are preferred over normal saline for fluid resuscitation

albumin

_______ is indicated after patients have received large volumes of crystalloids

-passive leg raise

-fluid bolus

-stroke volume

-pulse pressure variation

-echocardiography

use dynamic measures such as these to guide fluid resuscitation:

-lactated ringers

-Plasmalyte

-Normosol

-Electroly S/R

balanced crystalloids include:

colloids

_______ contain larger molecules that may cause kidney injury if administered for fluid resuscitation

-hetastarch

-albumin

-dextran

-blood (PRBCs)

colloids include:

norepinephrine, vasopressin

our first-line vasoactive agent is going to be ________, and our second-line agent will be ________

a1, b1, arrythmia, extravasation

norepinephrine targets _____ receptors more than _____ receptors; it is indicated in most shock states besides _______; half-life is 1-2 minutes; decreases renal and splachnic perfusion, and has minimal adverse effect of _______; has a BBW for ______ reactions; available at most institutions as a pre-mixed infusion

epinephrine, arrythmia

______ targets B1, B2, and alpha receptors depending on dosage; second-line therapy in septic shock; half-life <5 minutes; more potential for _______ than norepinephrine

-V1: constriction of systemic, splanchnic, renal, and coronary arteries

-V2: antidiuretic effect

-V3: located on anterior pituitary and cause secretion of adrenocorticotropin hormone

Which receptors does vasopressin act on, and what are the effects?

second, 10-20

vasopressin is _____-line in septic shock and has a half-life of _____-_____ minutes

norepinephrine, vasopressin, dobutamine, epinephrine

use _______ as first-line agent for low MAP; consider adding ______ if map is still inadequate; consider adding _______ or switching to _______ (monotherapy) if cardiac dysfunction with persistent hypoperfusion is present despite adequate volume status and blood pressure

invasive, peripherally

use ______ monitoring (arterial line) over non-invasive monitoring; if no central access, consider initiating vasopressors ________ for a short amount of time (24-72 hours)

steroids, 4 hours

_______ are suggested for patients with septic shock and ongoing requirement for vasopressors; initiate at a dose of norepinephrine or epinephrine >0.25 mcg/kg/min at least _____ _____ after initiation

hydrocortisone

you can use IV corticosteroids, such as ______ 50 mg IV Q6H or continuous IV infusion (200 mg/day)

vitamin c

IV ____ ____ is not recommended for sepsis as there is low quality of supporting evidence