Tools
What is the difference between MEWS and PEWS?
Both are ways to measure a patient’s risk of sepsis. MEWS is used for adults. PEWS is used for pediatrics.
Define sepsis.
A life-threatening organ dysfunction caused by a dysregulated response to infection.
Bonus Q: what is septic shock?
Are mortality rates higher for bacteria or fungal caused sepsis?
Fungal. Antifungal medications are less effective.
T/F: SIRS is not always caused by infection.
True!
What does SOFA stand for and what is it used for?
SOFA: sepsis-related organ failure assessment
SOFA scores are used in the ICU/critical care setting to calculate those at high risk of poor outcomes due to sepsis
Bonus Q: what is the difference between qSOFA and SOFA?
Why are gram positive organisms becoming a more common source of sepsis?
Antibiotic therapies are less effective at treating gram positive organisms.
How does the accumulating edema seen in sepsis contribute to cell hypoxia?
It increases the diffusion distance for oxygen and glucose.
What are potential causes of SIRS besides infection?
Trauma, burns, pancreatitis.
What qSOFA criteria will flag a patient as being at higher risk of developing sepsis or potentially being in the early stages of sepsis?
2 or more of the following:
-respiration rate of 22 or more / minute
-altered mental status
-systolic blood pressure </= 100 mm Hg
List at least 3 risk factors that increase someone’s risk of developing sepsis?
-age (premature infants, <1 year, older adults)
-hospitalization (previous or current)
-immunosuppression
-bacteremia
-infection with an antibiotic resistant organism
Why might a patient experience decreased oncotic pressure in their vasculature if they have sepsis?
The systemic inflammation causes increased capillary permeability. This allow protein, such as albumin, to leak out of the vasculature, decreasing the oncotic pressure and resulting is systemic edema and hypovolemia.
What is anasarca?
Severe, generalized/systemic edema
What is assessed when using the MEWS tool?
-Systolic blood pressure
-heart rate
-respiratory rate
-temperature
-AVPU score (alert, or reacts to voice, or reacts to pain, or unresponsive)
Why is it essential to make sure septic patients are receiving adequate nutrition?
Their body is experiencing hypermetabolism to compensate for how much energy it is using to fight sepsis. It will start to break down significant amounts of proteins and lipids, and then muscles and organs if caloric needs are not met.
Sepsis is associated with decreased levels of activated protein C. How does this affect the clotting cascade?
Activated protein C normally inactivates important steps in the clotting cascade and inhibits the production of cytokines. Without it, our body will have a hard time telling the clotting system to stop, leading to the systemic, continued activation of the clotting system seen in sepsis.
What is the difference between exotoxins and endotoxins?
Exotoxins are secreted by bacteria while they are still alive.
Endotoxins are released when the bacteria dies/is lysed. Both cause an inflammatory response..
What is measured for a SOFA score (not qSOFA)?
Respiratory system (the ratio of arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2))
-Cardiovascular system (the amount of vasoactive medication necessaryto prevent hypotension)
- Hepatic system (bilirubin level)
-Coagulation system (platelet concentration)
-Neurologic system (Glasgow coma score)
-Renal system (serum creatinine, urine output)
Why is a continuous insulin infusion often necessary in patients with sepsis?
The body’s stress response will raise blood glucose levels to ensure it is readily available for the brain. However, in sepsis, this will lead to persistent hyperglycemia which will cause more endothelial cell injury and other complications. Thus these patients often need glycemic control using a continuous insulin infusion.
List at least 4 of the 8 ways our normal inflammatory response becomes dysregulated in sepsis.
1. Increased release of pro-inflammatory mediators
2. Malignant intravascular inflammation
3. Injury to endothelial cells
4. Clotting in the microvasculature
5. Systemic changes (vasodilation, increased capillary permeability
6. Hyperdynamic circulation (high CO, low SVR)
7. Hypermetabolism
8. Micro-clot formation (decreased activated protein C)
Why would it be harder to diagnose sepsis in an immunosuppressed patient?
Their body can’t mount a full response so you probably won’t see the symptoms (fever, HR, etc…) until they’re already in a late stage of sepsis.
What is assessed when using a PEWS tool?
-behavior (playing/appropriate vs irritable vs lethargic/confused
-cardiovascular (skin color, cap refill)
-respiratory (RR, O2 sats, work of breathing
List at least 3 things included in the sepsis bundle.
-serum lactate
-blood cultures
-broad spectrum abx
-rapid fluid administration if pt is hypotensive or has increased lactate
-vasopressors as need to keep MAP above 65 (norepinephrine preferred)
Bonus Q: Does the antibiotics or the blood culture come first?
What are the two negative consequences of having hyper-dynamic circulation?
1. Decreased time for gas and nutrient exchange in the capillaries (the velocity of the blood through the capillaries has greatly increased and become too fast)
2. A significant increase in myocardial workload
How does anaerobic metabolism affect pH?
It leads to lactic acid production, which will lower the pH (make it more acidic) and eventually cause metabolic acidosis.