What is an infection?
Inflammatory response to microorganisms or invasion of normally sterile tissues
What is Systemic Inflammatory Response Syndrome?
A systemic response arising from a nonspecific insult
What is the criteria for SIRS?
> 2 or more of the following: Temp > 38 C or < 36 C, HR > 90 bpm, RR > 20 or PaCO2 < 32 mmHg, WBC count > 12K or < 4k, or > 10% bands
What is the criteria for sepsis?
Infection + > 2 SIRS criteria
What is the criteria for severe sepsis/
Sespsis + organ disfunction
What is the criteria for septic shock?
Sepsis + hypotension despite fluid resuscitation
What is Multiple Organ Dysfunction Syndrome (MODS)?
Altered organ function in an acutely ill patient
Does SIRS always = infection?
What factors effect the outcomeof sepsis?
Underlying disease (neutropenia, diabetes, alcoholism/cirrhosis, renal failure, respiratory failure), and Treatment complications (enormous endotoxin release, inadequate antimicrobial therapy/time)
What is gram negative sepsis?
The endotoxin of the gram negative cell wall triggers a release of primary and 2ndary inflammatory mediators, thus the body's response to the endotoxin causes the problem as the endotoxin is not toxic itself
What is gram positive sespis?
Release of exotoxin from gram + cell wall which causes an immune response.
In the pathophysiology of sepsis, at what points can healthcare professionals intervene?
At the point of infection by eradicating micro-organisms, and at shock and multiorgan failure by providing intensive care and life support.
What are the 3 domains of response to the infection?
Inflammatory repsonse/systemic inflammation, Overproduction of thrombin/over coagulation, Impaired fibrinolytic function
During severe sepsis what are signs of CNS disfunction?
Altered conciousness, confusion, Psychosis
During severe sepsis what are signs of Lung disfunction?
Tachypnea, PaO2 < 70 mm Hg, SaO2 < 90%
During severe sepsis what are signs of liver disfunction?
Jaundice, ↑ enzymes, ↓ albumin, ↑ PT/INR
During severe sepsis what are signs of Cardiac disfunction?
During severe sepsis what are signs of renal disfunction?
Oliguria, anuria, ↑ Creatinine
During severe sepsis what are signs of hematologic disfunction?
↓ Platelets, ↑ PT/APPT, ↑ D-dimer, ↓ Protein -C
What is common therapy for sepsis?
Source control, giving antibiotics within 1 hour of identifying sepsis
What G - organisms are associated with sepsis?
E. Coli, Klebsiella sp., Psuedomonas aeruginosa, Serratia species, enterobacter species, proteus species
What G + organisms are associated with sepsis?
S. aureus, S. pneumoniae
What is the 3 drug regimen used for sepsis?
Zosyn (G - and anerobes), levofloxacin (G -), vancomycin (G +)
What are the drugs of choice for Extended Spectrum Beta Lactamase producing organisms?
Drugs used to treat e. Coli
Ampicillin, bactrim, fluoroquinolones (cipro most G-, levo), Aminoglycosides (gentimycin, tobramycin), monobactam (aztreonam), carbepenem
Drugs used to treat Klebsiella?
All but vanco (G +), aminopenicillins (ampicillin)
Drugs used to treat pseudomonas aeruginosa?
Use double coverage until ID sensitivities to it, combo of different mechanisms such as a beta lactam and aminoglycoside or quinolone, or quinolone and aminoglycoside
Drugs used to treat Serratia species or enterobacter species?
Extended spectrum beta lactamase PCN such as Zosyn, 3rd or 4th generation cephalosporin (ceftazidime or cefepime)
Drugs used to treat Proteus species?
Ampicillin, 1st or 2nd generation cephalosporin
Drugs used to treat G + organisms?
Always start with vancomycin until we know what we are treating and what the sesitivities are.
What is used for early goal directed therapy for sepsis?
Initial resuscitation (within 6 hrs), fluid tx (NS most common), Vasopressors, inotropic therapy, Glucose control (<150), IV corticosteroids (low dose), DVT prophylaxis, Stress ulcer prophylaxis (PPIs)
What are signs of early septic shock state?
Sepsis induced hypotension due to increased Cardia output and decreased systemic vascular resistance, Systolic BP < 90 mm Hg or a reduction of >40 mm from baseline without other causes of hypotension
What is the clinical presentation of late septic shock state?
Normalized or decreased cardiac output, hypotention persists despite adequate fluid resuscitation, presence of perfusion abnormalities
What are complications that can arise from inadequately treated septic shock?
MODS including: renal failure, liver failure, cardio-respiratory failure, Adulte Respiratory Distress Syndrome (ARDS)
What are the common therapies for septic shock?
Fluid resuscitation (crystaloid or colloid infusion), Vasactive drug therapy (Patient/disease driven dosing), Corticosteroids (may be usedin pts with 2ndary adrenal insufficiency
What vasoactive agents are used 1st line?
Dopamine and Norepinephrine
Dobutamine acts as an?
Inotrope, thus not used 1st line, used as add on
alpha 1 acts as a vasocontrictor, is this good or bad for hypotensive pts?
Beta 2 acts as a vasodilator in the periphery, is this good are bad in hypotensive pts?
Which drug is a pure alpha agonist?
What is the initial dose and titration intervals for dobutamine and dopamine?
5 mcg/kg/min titrationinterval is 2.5-5 (common dosing is 20 mcg/kg/min)
What is the initial dose and titration intervals for norepinephrine?
2 mcg/min titration interval 1-2 (common dosing is 20 mcg/min)
What is the initial dose and titration intervals for phenylephrine?
20 mcg/min titration interval is 10-20 (common dosing is 300 mcg/min)
What are other supportive measures for septic shock?
Mechanical ventilation, sedation/analgesia, renal replacement therapy, adequate nutrition, hematological support (blood)