Sepsis and Septic Shock
How is SIRS defined?
2 or more of the following: Temp >38 (100.4) or < 36 (96.8) HR >90 RR > 20 or PaCO2 <32 WBC > 12,000 or <4000 or >10% bands
How long should patients be treated with antibiotics?
7-10 days (should D/C if non-infectious)
What is the goal for CVP?
8-12 mmHg
what is the BG goal in patients with shock?
<180
what is the goal for UOP?
>0.5 ml/kg/hr
Above what dose of corticosteroids can be harmful?
>300mg
What is the hallmark sign of sepsis?
Hypotension
What are common empiric antibiotic choices?
IV B-lactamase inhibitor combos (Unasyn, Zosyn) Carbapenem 4th generation cephalosporin (cefepime)
Where is the most common source of infection?
Lungs
As the dose of vasopressors increases, what types of side effects increase?
Side effects caused by alpha effects
When is dobutamine used?
in low CO
What is a significant side effect of corticosteroids in sepsis?
secondary infections
Can D5W be used in shock?
NO! can increase edema
What is the Vasopressor DOC?
Norepinephrine
What is an example of a crystalloid fluid?
Normal saline (0.9%)
How should NS be given?
1L over 30 minutes (minimum of 30ml/kg in the first 4-6hrs)
What is used to treat MRSA?
Vancomycin
What are alternative vasopressors?
Vasopressin, Epinephrine, dopamine, dobutamine
How is severe sepsis defined?
sepsis associated with organ dysfunction, hypoperfusion and hypotension
What is the dose of norepinephrine that should be used?
0.1-0.5 mcg/kg/min
When is dopamine not used?
As a renal protective agent (low dose)
When should vancomycin be added to regimens?
If MRSA is prevalent based on resistance patterns
Can epinephrine be used initially?
NO! can be used as add on therapy
which antibiotics can be used for gram negative infections?
Pip/tazo cefepime/ceftazadime imipenem/meropenem (good if penicillin allergy) Ciprofloxacin/Levofloxacin Aminoglycosides
How is sepsis defined?
SIRS + documented infection
True or false: There is currently no cure for sepsis
True (all care is supportive)
When should BG be treated and what agent should be used?
When the patient is stabilized use IV insulin infusion 0.1 unit/kg/hr
When are corticosteroids used in shock?
after fluid and vasopressors if BP is still non-responsive (severe refractory hypotension)
Why is dobutamine preferred over dopamine in low CO?
it only has Beta effects while dopamine has both beta and alpha 1 effects
What does a high lactate level indicate?
lack of tissue O2 and anaerobic metabolism
What is a side effect of prolonged vasopressor administration?
significant peripheral tissue ischemia (gangrene in fingers and toes)
What other treatments should sepsis patients undergo?
stress ulcer and DVT prophylaxis, respiratory and renal support, protocol driven sedation/analgesia monitoring, BG control
what are signs and symptoms of early sepsis?
fever, chills, tachycardia, tachypnea, hyperglycemia, altered mental status, oliguria, hypotension, low CV O2 saturation
When is dopamine reserved for?
low CO
what is the average amount of fluid needed?
4-6L
What is an example of a colloid fluid?
5% albumin solution
What is the goal for MAP?
>65 mmHg
What are the important points about antibiotic therapy?
It should be prompt (within 1 hour)! it should start broad (empiric), should assess and de-escalate daily if possible
What are the signs and symptoms of late sepsis?
Lactic acidosis, pulmonary edema, myocardial depression, hypoglycemia, thrombocytopenia, DIC, coma
How is septic shock defined?
Sepsis induced hypotension, despite fluid resuscitation (requires vasopressors, MAP <65)
How do you calculate MAP?
[(2 x DBP) + SBP] / 3
