Id Therapeutics Exam 2 Set 7

Front 1

SIRS definition
two or more of the following: (4)

Back 1

1. temp: 38 or more; 36 or less
2. HR: greater than 90 bpm (norm 60-100)
3. RR: greater than 20 (norm 15-20)
4. WBC: greater than 12k or less than 4k or greater than 10% immature forms (bands)

Front 2

SIRS caused by infection

Back 2

sepsis

Front 3

Sepsis + organ dysfunction, hypoperfusion, hypotension (lactic acidosis, oliguria, altered mental status)

Back 3

severe sepsis

Front 4

sepsis with hypotension that is not responsive to fluid resuscitation. Patients who need vasopressors

Back 4

septic shock

Front 5

infectious sources (3)

Back 5

Respiratory tract
Intra-abdominal
Urinary Tract

Front 6

causes (organisms) that lead to sepsis (4 classes)

Back 6

1. Gm positive (S. aureus, S. pneumoniae, Coagulase negative staphylococci, Enterococci
2. Gm negative (E. coli, Klebsiella, Serratia, Enterobacter, Proteus, Pseudomonas)
3. Anaerobs – less common
4. Fungal

Front 7

pro-inflammatory mediators (3)

Back 7

TNF-alpha***, interleukin 1B, interleukin-6 (IL6)

Front 8

anti-inflammatory mediators (3)

Back 8

IL-1 receptor antigens, IL-4, IL-10

Front 9

complications of sepsis (5)

Back 9

1. Shock – hypotension non-responsive to fluid bolus
2. Disseminated Intravascular Coagulation(DIC)--Excessive fibrin formation, inhibited fibrin removal, microvascular thrombosis
3. Acute Respiratory Distress Syndrome (ARDS)--Respiratory failure from pulmonary edema
4 .Hemodynamic effects: High cardiac output, low systemic vascular resistance
5. Acute Renal Failure: acute oliguric or anuric renal failure secondary to hypoperfusion

Front 10

vasoactive medication

1. May increase renal perfusion at low doses
2. Vasoconstriction at high doses by alpha receptors
3. Goals: increase MAP, increase cardiac output, increase urine output
4. 2-20 mcg/kg/min intravenous infusion

Back 10

dopamine

Front 11

vasoactive mediation

1. Increases blood pressure by vasoconstriction and increased heart rate
2. Alpha and beta agonist
3. 5-20 mcg/min

Back 11

epinephrine

Front 12

vasoactive medication

Alpha > beta agonist effects as increase dose
5-20 mcg/min

Back 12

norepinephrine

Front 13

vasoactive medication

Pure alpha agonist
2-20 mcg/min

Back 13

phenylephrine

Front 14

vasoactive medication

1. Increases contractility of the heart thereby increasing cardiac output
2. Disadvantage, also causes vasodilation
3. Beta agonist
4. 5-15 mcg/kg/min intravenous infusion

Back 14

dobutamine

Front 15

vasoactive medication

1. Used in refractory septic shock at doses of 0.01 to 0.04 units/min
2. Often started after large doses of norepinephrine are ineffective

Back 15

vasopressin

Front 16

antimicrobial therapy: urinary tract source

community acquired
1. likely pathogens (3)
2. treatment

Back 16

1. e. coli, staph. saprophyticus, enterococci
2. 3rd generation cephalosporin + aminoglycoside or quinolone

Front 17

antimicrobial therapy

urinary tract source: hospital acquired
1. likely pathogens (4)
2. treatment

Back 17

1. e.coli, klebsiella, pseudomonas, proteus, enterococci
2. pip/tazo or antipseudomonal cephalosporin (3rd generation) + aminoglycoside or quinolone

Front 18

antimicrobial therapy: respiratory tract source

community acquired
1. likely pathogens (2)
2. treatment

Back 18

1. s. pneumo, H. influenzae
2. 3rd generation cephalosporin + aminoglycoside or quinolone

Front 19

antimicrobial therapy: respiratory tract source

hospital acquired
1. likely pathogens (2)
2. treatment

Back 19

1. gram neg rods (think pseudomonas), s. aureus
2. pip/tazo or antipseudomonal ceph (3rd generation) + aminoglycoside or quinolone

Front 20

antimicrobial therapy: intra-abdominal infection source

1. likely pathogens (2)
2. treatment (2 regimens)

Back 20

1. gram neg rods, anaerobes
2.
ampicillin + aminoglycoside or quinolone + clindamycin or metronidazole

beta-lactam/beta-lactamase inhibitor combination or carbapenem + aminoglycoside or quinolone

**may need to consider fungal coverage

Front 21

antimicrobial therapy: catheter associated

1. likely organisms (3)
2. treatment

Back 21

1. s. aureus, s. epidermidis, gram neg rods
2. extended spectrum pen or 3rd gen cephalo + aminglycoside + penicillinase resistant penicillin (ex nafcillin) or vancomycin

Front 22

PK concepts in critically ill (3)

Back 22

1. larger than normal volume of distribution
2. hepatic or renal dysfunction or both
3. assess risk to benefit ratio when dosing medications

Front 23

analgesia options for supportive therapy in critically ill (3)

Back 23

1. fentanyl: for hemodynamically unstable (no histamine release)
2. morphine: hemodynamically stable
3. hydromorphone: alternative to morphine

**avoid use of codeine and meperadine

Front 24

sedative options for supportive therapy in critically ill (5)

Back 24

1. Propofol: short acting, lipid based, costly
2. Midazolam: short acting unless used as continuous infusion, water soluble, active metabolite with longer half life that lorazepam
3. Lorazepam: preferred continuous infusion per Society of Critical Care Medicine Guidelines
4. Diazepam: not indicated for continuous infusion
5. Dexmedetomidine: May be morphine sparing and have sedative effects without respiratory depression

Front 25

stress ulcer prophylaxis options for supportive therapy in critically ill (4)

Back 25

1. H2 antagonists
2. PPI
3. sucralfate
4. antacids

Front 26

Sepsis Resuscitation Bundle: 7 tasks begun immediately and completed within 6 hours

Back 26

1. Measure serum lactate
2. Obtain blood cultures prior to antibiotic admin
3. Administer antibiotic within 3 hrs of ED admission and within 1 hr of non-ED admission

Treat hypotension of elevated lactate with fluids
Hypotension or serum lactate greater than 4 mmol/L
4. Initiate 20 ml/kg of crystalloid or equivalent
5. Apply vasopressors for hypotension not responding to fluid resuscitation to maintain mean arterial pressure (MAP) >65 mm Hg

Persistent hypotension despite fluid resuscitation
6. Achieve central venous pressure > 8 mm Hg
7. Achieve central venous oxygen saturation > 70%

Front 27

Sepsis management bundle (3 steps)

Back 27

1. Administer low dose steroids (< 300 mg/day hydrocortisone)
2. Consider initiation of insulin when blood glucose level exceeds 180 mg/dL with a goal blood glucose of approx. 150 mg/dL (NICE-SUGAR trial)
3. Maintain median inspiratory plateau pressure (IPP) < 30 cm H20 for mechanically ventilated patients.

Front 28

definition of fever for febrile neutropenia (2)

Back 28

1. oral temp of greater or equal to 38.3 c or 101 f
2. oral temp of greater or equal to 38 c or 100.4 f for ever at least one hour

**in neutropenic patient source of fever is infection until proven otherwise

Front 29

antifungal therapy options for febrile neutropenia (3)

Back 29

1. fluconazole
2. echinocandin
3. amphoteracin B

Front 30

when would you d/c colony stimulating factors? (G-CSF = filgastim; GM-CSF = sargramostim)

Back 30

when ANC is greater than 500-1000/ mm3

Front 31

when would you use colony stimulating factors? (1+5)

Back 31

if worsening of course predicted and long delay in recovery of marrow AND

2. pneumonia
3. hypotensive episode
4. severe cellulitis or sinusitis
5. systemic fungal infection
6. multiorgan dysfunction secondary to sepsis

Front 32

dose of filgastim

Back 32

5-10 mcg/kg (dosed on actual body weight) QD administered SC or IV

* can be diluted with D5W and admin IV (NOT COMPATIBLE WITH NS!!!!)

Front 33

monitoring (2) and SE (3) of filgastim?

Back 33

monitoring
1. CBC with platelets
2. hematocrit

SE
1. n/v
2. alopecia
3. bone pain

Front 34

dose of sargramostim

Back 34

250 mcg/m2/day administered SC or IV

* diluted with NS and admin IV (NOT COMPATIBLE WITH D5W OR DEXTROSE CONTAINING SOLUTIONS!!!!)

Front 35

monitoring (2) and SE (3) of sargramostim?

Back 35

monitoring
1. CBC with platelets
2. renal, hepatic function

SE
1. bone pain
2. alopecia
3. n/v

Front 36

general measures for prevention (prophylaxis) in neutropenic patients (5)

Back 36

1. Reverse isolation
2. Proper handwashing by personnel
3. Avoiding fresh fruits and vegetables during neutropenia
4. Avoid antimicrobial prophylaxis if possible
5. Prevent translocation of gut flora into bloodstream: Selective decontamination (Non-absorbable antibiotics, Absorbable antibiotics)

Front 37

indication for antimicrobial prophylaxis in afebrile neutropenic patients (1+9)

Back 37

if ANC less than 100/mm3 and for duration of greater than one week AND

2. extensive mucous membrane or skin lesions
3. presence of indwelling catheters
4. instrumentation (endoscopy)
5. severe peroidontal disease
6. dental procedures
7. post-obstructive pneumonia
8. malignancy
9. organ engraftment
10. other immune compromise