Fluids
What types of fluids are preferred in sepsis?
Balanced Crystalloids
What lab do we get that helps indicate tissue perfusion?
Lactic acid
What is the preferred vasopressor in sepsis?
Norepinephrine 5 to 15 mcg/min (0.05 to 0.15 mcg/kg/min)
What microorganisms can cause sepsis? (broadly speaking)
Gram negative bacteria
Gram positive bacteria
Fungi
Viruses
What is our MAP goal in sepsis?
>= 65 mm Hg
What is the dose of fluids for initial volume resuscitation?
30 ml/kg within the first 3 hours
When would you consider repeating a lactate?
If the initial lactate is elevated (> 2 mmol/L)
After initiating first line vasopressor of choice, what other vasopressors could you consider next?
Vasopressin (0.04 units/min)
Epinephrine (1-15 mcg/min)
How soon should we start antibiotics for a patient in septic shock?
Ideally within the first hour
What type of shock is septic shock?
distributive shock
How much K is in lactated ringers?
4 mEq/L
What are some non-specific lab markers (levels) of inflammation
Erythrocyte Sedimentation Rate (ESR)
C-Reactive Protein (CRP)
Procalcitonin (PCT)
Ferritin
Name some medications that can be used for salvage therapy or refractory shock?
Methylene Blue, angiotensin II, steroids, cyanocobalamin
What are common antibiotic regimens to start a patient on for septic shock?
Vancomycin + cefepime
Vancomycin + piperacillin-tazobactam
What are the different types of shock?
1) Distributive shock
2) Hypovolemic shock
3) Cardiogenic shock
4) Obstructive shock
How much Na is in normal saline?
154 mEq/L
What are the components of the SIRS criteria?
Temperature >38C (100.4F) or <36C (96.8F)
HR > 90 bpm
RR > 20 or PaCo2 < 32 mm Hg
WBC >12000/mm^3 or <4000/mm^3
What are some adverse effects of norepinephrine?
tachycardia, cardiac arrhythmia, peripheral vascular insufficiency
A patient arrives to your ED and is being worked up for sepsis. The provider orders vancomycin 2gm and piperacillin-tazobactam 4.5gm. You are helping the nurse with medications, which antibiotic should you try to hang and start first?
Piperacillin-tazobactam
What are some signs of poor end-organ perfusion?
- cool skin/extremities
- cyanosis
- decreased capillary refill
- mottling
- ileus or absent bowel sounds
What percent of our total body fluid is intracellular vs. extracellular and if a patient is given 1L of NS, how much of it will go to the intravascular space?
Intracellular: 60% of fluid
Extracellular: 40% of fluid (75% interstitial, 25% intravascular)
1L of NS --> 750mL goes to interstitial space and 250 mL stays in blood vessels
What are the components of qSOFA?
AMS (GCS < 15)
SBP < 100 mm Hg
RR >= 22 breaths/min
Which pressor is not in the surviving sepsis guidelines and has potent, direct alpha-adrenergic agonist activity?
Phenylephrine
Your patient was given the piperacillin-tazobactam 4.5gm load at 1400. You are verifying orders - what is dosing frequency and what time should the maintenance be started?
q8h with CrCl >= 20 ml/min
Start maintenance dose at 2000 (6 hours after loading due to PK)
What are the components (5) of the 1-hour bundle?
1) Measure lactate level
2) Obtain blood cultures before administering antibiotics
3) Administer broad spectrum antibiotics
4) begin rapid administration of 30ml/kg crystalloid for hypotension or lactate >= 4 mmol/L
5) Apply vasopressors if hypotensive after fluid resuscitation to maintain MAP >= 65 mmHg