Sepsis Worksheet

Taken from my sepsis worksheet from the 3/30 Journal Club on New Sepsis Definitions.

BR– = board relevant


What is SIRS? What is the criteria that comprises SIRS?

Systemic Inflammatory Response Syndrome

Need 2 of the following:

  • RR> 20 OR PaCO2<32
  • HR>90
  • Temp< 96.8 or >100.4
  • WBC>12,000 OR <4,000 OR bands >10%

Based on the old definition, clinically, what is sepsis?

SIRS + suspected source of infection

Why has SIRS come out of favor for diagnosing sepsis?

Too much of a focus on inflammation

Inadequate 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 2

If no baseline SOFA score exists assume 0 if there is no known organ dysfunction at baseline

BR — What is validity and reliability?

Validity = accuracy -> the trueness of the test measurement (e.g., hitting the bull’s eye)

Systematic error decreases validity

Reliability = precision -> consistency and reproducibility of the test measurement (e.g., clustering of shots)

Random error decreases reliability

Based on the Sepsis-3, what clinical criteria do health care providers use to determine if sepsis is present?

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

Sequential Organ Failure Assessment (SOFA) score includes the following:

  • PaO2/FiO2
  • Platelet count
  • Glasgow Coma Scale score
  • Bilirubin
  • MAP
  • Administration of vasopressors with type and rate of infusion
  • Serum creatinine or urine output

Quick Sequential Organ Failure Assessment (qSOFA) score includes the following:

  • RR 22
  • Altered mentation (GCS<15)
  • SBP 100
  • 2 should prompt completing full SOFA score

Based 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*TPR

CO = SV*HR = rate O2 consumption/(arterial O2 content – venous O2 content)

MAP = 2/3 diastolic pressure + 1/3 systolic pressure

MAP approximates afterload

BR — What drugs decrease afterload?

Vasodilators: hydralazine, nitroprusside, nitroglycerin

ACE inhibitors: lisinopril

ARBs: losartan

Dihydropyridine calcium channel blockers: amlodipine, nifedipine

BR — What are the class side effects for the following?

Hydralazine – drug-induced lupus (anti-histone antibody mediated)

Nitroprusside – cyanide toxicity

Nitroglycerin – reflex tachycardia

ACE inhibitors – dry cough, angioedema

ARBS – angioedema

CCBs – AV block, flushing

What groups of people are most at risk of developing sepsis?

  1. older adults
  2. immunocompromised

What are the most common infections that lead to sepsis?

  1. Pneumonia
  2. UTI
  3. Abdominal
  4. Other
  5. Skin
  6. Wound
  7. Catheter

BR – What are the most common organisms for pneumonia?

Typical: S. pneumonia, S. aureus, H. influenzae

Atypical: viruses, mycoplasma, legionella, chlamydia

BR – What are the most appropriate empiric antibiotics for pneumonia?

Typical: penicillin/cephalosporin – MOA = binds PBP, blocks transpeptidase. SE = hypersensitivity

Atypical: macrolide – MOA = block translocation by binding to 23S rRNA of 50S subunit. SE = QT prolongation

BR – What are the most common organisms for UTI?

  • E. coli
  • S. saprophyticus
  • K. pneumonia
  • Proteus morabilis
  • Candida

BR – What are the most appropriate empiric antibiotics for uncomplicated cystitis?

  1. Nitrofurantoin –
  2. TMP-SMX – MOA = TMP inhibits dihydrofolate reductase. SMX inhibits dihydropteroate synthase. SE = Stevens-Johnson syn, teratogen
  3. Fosfomycin
  4. Fluoroquinolones – Inhibit DNA gyrase and topoisomerase IV. SE = tendon rupture, myalgia, QT prolongation
  5. Aminopenicillins – MOA = binds PBP, blocks transpeptidase. SE = hypersensitivity

What 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/L

What is the Surviving Sepsis management bundle?

TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:

  1. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
  2. 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
  3. Re-measure lactate if initial lactate elevated.

Resources:

http://lifeinthefastlane.com/ccc/sepsis-definitions/

http://www.idsociety.org/IDSA_Practice_Guidelines/

http://www.survivingsepsis.org/Pages/default.aspx

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