Sepsis

Definitions

100

Temperature >38C and WBC <4000 are two of four possible findings in this set of criteria

SIRS Criteria 

Temp >38, <36; WBC >12K or <4k or >10% bands

Bonus - what are the other two criteria? 

- OLD criteria for diagnosing sepsis

- felt to be nonspecific - can have changes in these parameters that are not related to sepsis and in fact are an appropriate/adaptive systemic response 

- NOW the definition of sepsis relies on the organ dysfunction that results from the systemic response, essentially, getting out of control 

200

Ongoing hypotension despite adequate fluid resuscitation in the setting of suspected infection 

What is septic shock?

This is the nonspecific, old definition

NOW, more specific: sepsis + vasopressors needed to maintain MAP >65, and having a lactate>2 despite adequate volume resuscitation (document!)

Bonus: Why MAP 65? 

300

This is the new scoring criteria as defined by the most recent (2016) international conference on sepsis which defines sepsis by organ dysfunction

What is the SOFA score?

Bonus: Sepsis is defined by ____ point change in sofa score? 

--> reflects mortality risk of 10% in general hospital population

400

These three criteria are used to quickly evaluate those with likely sepsis at the bedside

1. Altered Mental Status (GCS </= 13)

2. SBP </= 100

3. RR >/= 22 

-having 2 of these in the setting of suspected infection has been associated with greater risk of death or prolonged ICU stay (qSOFA)

500

Components of SOFA score (5) 

Respiration (PaO2/FiO2) 

Coagulation (platelets) 

Liver (bilirubin)

Cardiovascular (BP)

Brain (GCS)

Kidney (Creatinine, UOP)

https://www.mdcalc.com/sequential-organ-failure-assessment-sofa-score

Septic Tank

100

First line/preferred fluids for resuscitation 

Crystalloids (lactated ringers, normal saline) 

 - no studies that directly compare NS with balanced salt solutions in sepsis 

200

You have reached appropriate resuscitation after patient has received ____ amt of fluids 

30ml/kg 

Bonus - over what time frame? 

300

True/False: albumin is an equally appropriate resuscitation fluid in the setting of septic shock 

TRUE
- technically, colloids (albumin) could be used (no mortality differences noted in studies) - but more expensive 

--> could be beneficial adjunct, however, in those patients with low oncotic pressure/hypoalbuminemia

400

Lactated ringers has this potential benefit over normal saline, particularly when massive amounts of fluids are required 

Lower chloride --> less AKI, less renal replacement therapy in some studies

500

You have adequately resuscitated your patient with IV fluids and are pleased that his mental status is improving, HR is coming down, lactate and creatinine all improving. However, he remains hypotensive. You are reluctant to start pressors in this setting - then you remember a tool that could help you predict whether or not he might respond to more fluids. What is it? 

Most likely -- IVC assessment

but ANY dynamic evaluation (i.e. passive leg raise)

Bonus: What are you looking for on the IVC evaluation? What finding might prompt you to give more fluids (What might prompt you to start pressors)? 

Monitor/Tx

100

Frequency of lactate draws when your patient is acutely septic

Use your judgement!!

Often start with at every 4-6 Hours

but if they are getting worse - may need (i.e.) Q2H, if getting better, may need less frequent 

Goal: normalization (then stop checking!)

200

These three things are considered the cornerstone therapies for treating sepsis 

Early antibiotics

Volume Resuscitation

Vasopressors 

300

70yo gentleman presents to the ED with nausea, vomiting, diarrhea for 3 days. PMH HTN, T2DM, COPD, atrial fibrillation. Meds include warfarin, amlodipine, metformin. Endorses dysuria, shortness of breath. 

Temp 98.3F, HR 130, BP 90/40, RR 26, 96% on RA

Appears drowsy, but oriented. Exam largely normal with exception of tachycardia and diffuse abdominal tenderness. 

Labs notable for WBC 21K, Na 132, HCO3 21, Creat 2.2 (Bl ~1.0)  Lactic 4.2. UA with 36 RBC, >180 WBC, + LE. CT abd w/o contrast shows large obstructing calculus in the right ureter with hydronephrosis and possible forming abscess. 

Fluids and antibiotics are started, blood cultures are pending. In this patient, what else do you need to consider? 

surgery

This is an example of source control - another important pillar in managing sepsis. 

The mnemonic "SLASH" can help you remember to rule out "stones, lines, abscess, surgical conditions, and hardware" when thinking about source control in a patient

400

Your patient is persistently hypotensive despite three pressors, massive amounts of fluids and appropriate antibiotic therapy. What medication might be worth trying at this point? 

Stress dose steroids

(hydrocortisone 50mg IV Q6H = total 200mg/day)

- steroids in septic shock are controversial

- current recommendation is to only use them when you cannot maintain BP despite adequate resuscitation and vasopressor use 

500

This pressor is a useful adjunct to norepinephrine when you need a second

Vasopressin 

- acts on V1, V2 receptors (different mechanism than norepi) 

Bonus: what might you add instead if your patient is having tachyarrhythmias? 

Case

100

52yo with PMH notable for HTN, HLD, alcohol use and IVDU presents with fevers, sweats, cough, and malaise for the last 2 days.

Does not take any medications. Last hospitalization was for EtOH withdrawal last year. Lives at a homeless shelter or on the streets. Has had a few episodes in prison throughout his life. Unknown vaccination history.

102F.    HR 120.   BP 100/60.   RR 18.   92% on room air. 

Thin, tired appearing gentleman. Exam notable for appearing uncomfortable. Poor dentition. Palpable cervical LAD. Normal heart and lung sounds. No HSM. 

1. What labs do you want? 

Basic: CBC with diff, CMP, UA, CXR, Blood cultures

Could also get HIV, Hepatitis labs, procalcitonin, drug  screen...

200

On further exam -- any other studies to add? 

Echocardiogram; evaluate for endocarditis

300

WBC 17 (80% PMN), Hgb 13, Plt 400K

Na 135, Cl 100, BUN 15, K 3.7, HCO3 23, Creatinine 1.3

Alk Phos 120, AST 80, ALT 41, Albumin 2.7

CXR with cavitary lesions bilaterally. TTE with tricuspid vegetation. Blood cultures pending. Started on vancomycin.

Awaiting transfer to the floor, he becomes more sleepy. Recheck of vitals show ongoing temp of 102, BP now 72/40. The ER provider appropriately starts normal saline boluses, and you are told his pressure improves. He arrives to the floor with a pressure of 85/50 (MAP 62), and you note he's now requiring 3L of oxygen. Hard to figure out how much fluids he got,  repeat lactate pending. 

... What is your plan: 

things to note:

- fluids helped his BP, but now he is likely developing pulmonary edema 

- time to start thinking about pressors

- could (maybe) try albumin in the interim -- small volume, will stay in the vessels and he has low albumin (recall, albumin 2.7)

400

You appropriately transfer him to the ICU and place a central line. He's sleepy. Vitals 100F, HR 110, BP 78/45, RR 22, on 3L o2, saturating 92%. 

What is his Q Sofa Score? 

3 

altered, increased respiratory rate, SBP <100

500

The patient largely stabilizes and remains in the ICU.  Cultures grow out staph aureus. 

On hospital day five, you get a call from the nurse the this HR is now in the 50s, all other vitals are acceptable. You get an EKG that shows a new 1st degree heart block. You note that he continues to be febrile, blood cultures are persistently positive.

Plan? 

needs source control = surgery

has persistent bacteremia and now heart block, indicating possible abscess formation 

Rapid InfectFUN

100

What additional intervention is needed when you find strep bovis bacteremia

Strep bovis -- patient needs a colonoscopy

What about Candidemia?  

200

type of renal stone associated with recurrent urinary tract infections 

struvite / staghorn 

300

Pt presents to ED confused, complaining of shortness of breath, productive cough, and explosive diarrhea, found to have temp 102, HR 45, sodium of 132 What test do you want? What treatment? 

Legionella urinary antigen

azithromycin or levofloxacin 

400

Previously healthy patient presents to ED with abdominal pain, diarrhea (intermittently bloody) x10 days.

Labs notable for Hgb 8, Plt 55, Creatinine 2.4. LDH and bili are elevated. Smear shows evidence of hemolysis.

What bug caused this? 

This is HUS. Caused by E.coli 0157:H7

500

These four blood stream infections always require removal of central venous catheter removal

- staph aureus

- pseudomonas

- fungi (i.e. candida)

- mycobacteria

Shock NOS

100

Shock differential - four big categories 

Distributive (septic, neurogenic, anaphylactic, drug/toxin, endocrine)

Cardiogenic 

Hypovolemic (hemorrhage)

Obstructive (PE)

200

Hemodynamic (RA pressure, PCWP, Cardiac Index, SVR) findings in septic shock 

RA - normal to low

PCWP - normal to low

Cardiac Index - typically high

SVR - low

Bonus: expected mixed venous? 

300

68yo gentleman with h/o CHFpEF, HTN, gout presents from home with chief complaint of shortness of breath. Found to be febrile and hypoxic to the upper 80s.  Labs and imaging suggestive of pneumonia. Otherwise stable. Started on ceftriaxone and doxy and admitted to the floor. Sputum culture obtained in ED>

Overnight developed increasing oxygen requirements along with decreasing pressures. In addition to clinically assessing patient at bedside, starting fluids and increasing supplemental oxygen - what else are you going to do? 

broaden antibiotics

get blood cultures, lactate, ABG, consider repeat CXR

- start with appropriate abx based on clinical history (in this case CAP)

- broaden if needed 

What if patient had a history of ESBL and was presenting in urosepsis - which antibiotic would start with then? 

400

39yo woman presents with extreme fatigue. Notes sore throat, runny nose, cough x3 days. 

H/o hypothyroid for which she takes levothyroxine. No tobacco/drugs/etoh.

99F.   87/60. HR 110. 97% on room air. Exam unremarkable. 

WBC 9, Na 131, K 4.9, Cl108, Bicarb 20, Creatinine 1.4, Glucose 64. UA 3-5 WBC, 1-2RBC. 

Most likely etiology for patient's hypotension? 

adrenal insufficiency

often present with NAGMA, hyponatremia, hypoglycemia. AKI due to hypovolemia. 

500

Patient is admitted with acute heart failure exacerbation due to medication noncompliance. He requires inotropes (dobutamine) due to evidence of cardiogenic shock. He subsequently improves (creatinine downtrends, weight comes down, decreased oxygen needs). On hospital hospital day 6, you notice his mixed venous jumps from 50 to 80%. What are you worried about? 

Infection 

Recall normal mixed venous (normal, functioning human) 60-80. 

Will be LOW in cardiogenic shock, and often a bit on the low end at baseline for those with CHF.

if it JUMPS suddenly, and patient has an indwelling CVC -- be concerned for brewing infection (blood cultures, urine cultures, etc)

Mixed venous in SEPTIC shock will be ELEVATED 

Antibiotic review

100

empiric treatment for c diff 

oral vancomycin 

bonus: treatment of fulminant disease? 

200

Empiric CAP treatment on the wards? CAP treatment in the ICU?

ward: beta lactam + (azithro or doxy)

ICU: beta lactam + (azith or fluoroquinolone)

300

empiric antibiotics for bacterial meningitis in a patient with HIV

vancomycin + ampicillin + cefepime

400

What is the OUTpatient regimen for febrile neutropenia?

ciprofloxacin, augmentin

- allows to be outpatient if neutropenia isn't expected to last more than 7 days, if they are clinically stable and without significant complications

500

61 yo with h/o of CAD, HTN, COPD is evaluated in the ICU. Recent CABG six days ago. Still ventilated. He developed fever, increased oxygen requirements and abundant secretions are being suctioned from his ET tube every hour. He was started on zosyn. 

Temp 102, BP 124/84, HR 96, RR 18, O2 90% on 60% FIO2, 5 of PEEP. 

WBC 19 with neutrophil predominance. CXR with infiltrate. Blood cultures negative. 

There is a vancomycin shortage. What therapy are you going to recommend? 

linezolid

Patient has ventilator associated pneumonia (defn onset of pneumonia 48-72h after intubation)

need to cover for hospital acquired organisms -- including MRSA, MSSA, pseudomonas, stenotrophomonas, etc. 

Vanco often go to - but many hospitals have a portion of MRSA isolates that vanco isn't great for (MIC >2) -- so linezold!