General Sepsis Questions
The qSOFA uses variables to predict death and prolonged ICU stay in patients with known or suspected sepsis. When any two of these variables are present simultaneously, the patient is considered qSOFA positive.
What are those variables?
Glasgow Coma Score < 15
Respiratory rate ≥ 22 breaths/min
Systolic blood pressure ≤ 100mm Hg
84 year old female presents in septic shock secondary to pyelonephritis. Physician turns to you and says "Quick! We need 30ml/kg of hetastarch now! The patient is dying!"
Should you give it to the patient?
For adults with sepsis and septic shock, we suggest against using gelatin for resuscitation
What receptors does norepinephrine, epinephrine, and vasopressin exert its actions on?
Norepinephrine: Alpha (mostly), Beta (slightly)
Epinephrine: Beta (mostly), Alpha (at higher doses)
Vasopressin: V1 (Peripheral vasculature), V2 (Kidneys), V3 (anterior pituitary)
In a patient with possible sepsis without septic shock, how quickly should you administer antibiotics
A) Within 1hr
B) Within 3hr
C) Within 6hr
B) Within 3hr
For adults with possible sepsis without shock, we suggest a time-limited course of rapid investigation and if concern for infection persists, the administration of antimicrobials within 3 hours from the time when sepsis was first recognized.
What comprises the Systemic inflammatory response syndrome (SIRS) criteria?
Temperature >38°C or <36°C
Heart rate >90 beats/minute
Respiratory rate >20 breaths/minute
WBC >12,000/mm3 (12 x 109/L) or <4000 cells/mm3 (4 x 109/L) or > 10% (0.10) immature bands
When do you start fluid resuscitation on a septic patient?
Immediately upon identification of sepsis, rate of 30 mL/kg IV fluid within the first 3 hr of resuscitation
What is the first and second line vasopressor in septic shock
First line: Norepinephrine
Second line: Vasopressin
For adults with possible septic shock or a high likelihood for sepsis, within how many hours should antimicrobials be administered?
a) 1 hour
b) 2 hours
c) 3 hours
d) Defer treatment while continuing to monitor
A. 1 hour
What screening tool should be used to identify patients in sepsis or septic shock
We recommend against using qSOFA compared with SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock
MC is a 58 yo male (Wt. 66kg), with unknown PMH, who was brought to the ED by his neighbor for altered mental status and shortness of breath.
Temp: 39.1°C (102.4°F); BP: 140/90 mmHg; HR: 109 /min; RR: 33 /min; SPO2: 87% (15 L/min non-rebreather); WBC: 22 x 103 /µL; Lactic acid: 3.2 mmol/L
How much fluid should be given? Which fluid would you use?
2L of balanced crystalloid within the first 3hr
True or False:
For patients with septic shock on vasopressors, we should target a MAP of >75 mm Hg
False.
We should target a MAP of >/= 65
Name at least 2 patient related risk factors that would warrant antimicrobial therapy with MRSA coverage?
Prior history of MRSA infection or colonization
Recent IV antibiotics
History of recurrent skin infections or chronic wounds,
Presence of invasive devices
Hemodialysis, recent hospital admissions and severity of illness
MC is a 58 yo male, with unknown PMH, who was brought to the ED by his neighbor for altered mental status and shortness of breath.
Temp: 39.1°C (102.4°F); BP: 140/90 mmHg; HR: 109 /min; RR: 33 /min; SPO2: 87% (15 L/min non-rebreather); WBC: 22 x 103 /µL; Lactic acid: 3.2 mmol/L
Does this patient meet SIRS criteria? Which ones? Would this patient be in sepsis or septic shock?
1) yes
2) Temp, HR, RR, WBC
3) Sepsis
What type of fluids should you use for the initial fluid resuscitation?
For adults with sepsis or septic shock, we suggest using balanced crystalloids instead of normal saline for resuscitation.
Traditionally, vasopressors are administered via a central line due to concerns of extravasation, local tissue ischemia and injury if administered peripherally.
However, would you risk it all and administer a vasopressor peripherally if needed?
Absolutely.
Name at least two risk factors that would warrant empiric antifungal therapy over no antifungal therapy
Candida Colonization at Multiple Sites
Surrogate Markers Such as Serum Beta-D-Glucan Assay
Neutropenia
Immunosuppression
Longer ICU stay
Should you give corticosteroids to patients with sepsis
No.
For adults with septic shock and an ongoing requirement for vasopressor therapy we suggest using IV corticosteroids
What measures should you use to guide fluid resuscitation beyond the initial 30ml/kg fluid bolus.
Temperature of the extremities, skin mottling, and capillary refill time have been validated and shown to be reproducible signs of tissue perfusion
Start vasopressin when norepinephrine dose is in the range of ________ mcg/kg/min
0.25-0.5
what antibiotics cove MRSA
Ceftaroline
Vancomcyin
Clindamycin
Bactrim
Doxycicline
Daptomycin