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SepsisBy Izzy PinesBR-- = board relevantWhat is SIRS? What is the criteria that comprises SIRS?Systemic Inflammatory Response SyndromeNeed 2 of the following:RR> 20 OR PaCO2<32HR>90Temp< 96.8 or >100.4WBC>12,000 OR <4,000 OR bands >10%Based on the old definition, clinically, what is sepsis?SIRS + suspected source of infectionWhy has SIRS come out of favor for diagnosing sepsis?Too much of a focus on inflammationInadequate sensitivity (50-70%)and specificity (~30%)BR -- What is sensitivity and specificity?Sensitivity: true positive rate. Proportion of all people with disease who test positive.Highly sensitive test means that negative rules out disease (SN-N-OUT) Specificity: true negative rate. Proportion of all people without disease who test negative.Highly specific test means that positive rules in disease (SP-P-IN)Based on the Sepsis-3, what is sepsis?“Life-threatening organ dysfunction cause by a dysregulated host response to infection.”Based on the Sepsis-3, how is organ dysfunction defined?Change in SOFA score 2If no baseline SOFA score exists assume 0 if there is no known organ dysfunction at baselineBR -- What is validity and reliability?Validity = accuracy -> the trueness of the test measurement (e.g., hitting the bull’s eye)Systematic error decreases validityReliability = precision -> consistency and reproducibility of the test measurement (e.g., clustering of shots)Random error decreases reliabilityBased on the Sepsis-3, what clinical criteria do health care providers use to determine if sepsis is present? Organ Failure Assessment (SOFA) score includes the following:PaO2/FiO2Platelet countGlasgow Coma Scale scoreBilirubinMAPAdministration of vasopressors with type and rate of infusionSerum creatinine or urine outputQuick Sequential Organ Failure Assessment (qSOFA) score includes the following: RR 22Altered mentation (GCS<15)SBP 1002 should prompt completing full SOFA scoreBased on the Sepsis-3, how is septic shock defined?“Sepsis with persisting hypotension requiring vasopressors to maintain MAP 65 and having a serum lactate >2 despite adequate volume resuscitation”Mortality>40%!BR -- How do you calculate mean arterial pressure (MAP)?MAP = CO*TPRCO = SV*HR = rate O2 consumption/(arterial O2 content – venous O2 content)MAP = 2/3 diastolic pressure + 1/3 systolic pressureMAP approximates afterloadBR -- What drugs decrease afterload?Vasodilators: hydralazine, nitroprusside, nitroglycerinACE inhibitors: lisinoprilARBs: losartanDihydropyridine calcium channel blockers: amlodipine, nifedipineBR -- What are the class side effects for the following?Hydralazine – drug-induced lupus (anti-histone antibody mediated)Nitroprusside – cyanide toxicityNitroglycerin – reflex tachycardiaACE inhibitors – dry cough, angioedemaARBS – angioedemaCCBs – AV block, flushingWhat groups of people are most at risk of developing sepsis?1. older adults2. immunocompromisedWhat are the most common infections that lead to sepsis?PneumoniaUTIAbdominalOtherSkinWoundCatheterBR – What are the most common organisms for pneumonia?Typical: S. pneumonia, S. aureus, H. influenzae Atypical: viruses, mycoplasma, legionella, chlamydiaBR – What are the most appropriate empiric antibiotics for pneumonia?Typical: penicillin/cephalosporin – MOA = binds PBP, blocks transpeptidase. SE = hypersensitivityAtypical: macrolide – MOA = block translocation by binding to 23S rRNA of 50S subunit. SE = QT prolongationBR – What are the most common organisms for UTI?E. coliS. saprophyticusK. pneumoniaProteus morabilisCandidaBR – What are the most appropriate empiric antibiotics for uncomplicated cystitis?Nitrofurantoin – TMP-SMX – MOA = TMP inhibits dihydrofolate reductase. SMX inhibits dihydropteroate synthase. SE = Stevens-Johnson syn, teratogenFosfomycinFluoroquinolones – Inhibit DNA gyrase and topoisomerase IV. SE = tendon rupture, myalgia, QT prolongationAminopenicillins – MOA = binds PBP, blocks transpeptidase. SE = hypersensitivityWhat is the Surviving Sepsis resuscitation bundle?TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION: 1. Measure lactate level 2. Obtain blood cultures prior to administration of antibiotics 3. Administer broad spectrum antibiotics 4. Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/LWhat is the Surviving Sepsis management bundle?TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION: 5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg 6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion 7. Re-measure lactate if initial lactate elevated.Resources: ................
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