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127 Cards in this Set
- Front
- Back
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What are goals for fluid therapy?
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central venous pressure 8-12mmHg, MAP greater than or equal to 65mmHg, urine output greater than or equal to 0.5mL/kg/h, central venous or mixed venous oxygen saturation greater than or equal to 70%
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Which vasopressors are mainly used?
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NE and DA
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Why disadvantage from epinephrine?
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tachycardia, disadvantageous effects on splanchnic circulation
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Why disadvantage from phenylephrine?
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decrease stroke volume
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Can low dose DA improve renal function?
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no support
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What is first choice for inotropic therapy?
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dobutamine, increases cardiac output combined with NE
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What is goal for glucose control?
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<150mg/dL
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When is drotrecogin used?
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pts at high risk of death: APACHE II > 25, sepsis induced multiple organ failure, septic shock, sepsis induced ARDS
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What is used for DVT prophylaxis in sepsis?
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low dose unfractionated heparin or LMW heparin
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What is used for stress ulcer prophylaxis?
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H2 antagonist more effective than sucralfate
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When is a lumbar puncture indicated?
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mental alteration, severe HA, seizure, assuming there are no focal cranial lesions identified by CT
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What urinary antigen is tested for in outbreak?
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Legionella serogroup 1
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When should tx for sepsis be started?
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within the first hour of recognition of severe sepsis after cultures
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What pathophysiologic changes in sepsis?
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high creatinine clearance in pts with normal creatinine from increased renal preload
Vd increase from leaky capillaries and altered protein binding clearance of antimicrobial agent is decreased prolonging the t1/2 of antimicrobial |
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What is empiric tx in noneutropenic pt with UTI?
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FQ
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What is most common cause of community acquired pneumonia?
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S. pneumoniae
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What are the "respiratory" FQ?
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levofloxacin, moxifloxacin, gemifloxacin
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What coverage do the "respiratory" FQ have?
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pen resistant pneumococci, aerobic gram negative bacteria, Legionella pneumophila, Mycoplasma pneumoniae, Chlamydia pneumoniae
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Which is least tolerated: clarithromycin, azithromycin, and erythromycin?
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erythromycin
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What are major pathogens in nosocomial pneumonia?
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enteric gram negative (Enterobacter or Klebsiella) and P. aeruginosa are major ones
also S. aureus |
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What is tx if P. aeruginosa is suspected?
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short course AG (5 days) added to antipseudomonal pen or third or fourth gen ceph
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What is used if AG is undesirable for antipseudomonal?
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antipseudomonal FQ - cipro, or levo
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What is preferred if pneumonia caused by MRSA?
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linezolid preferred over vanc because of poor penetration of vanc into lungs
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table 123-4 pg1949
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1949
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What is tx for intraabdominal infection?
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surgical intervention
broad spectrum (B lactamase inhibitor combo like pip/tazo or ticar/clav carbapenems (imipenem and meropenem) used in tx resistant pathogens including Enterobacteriaceae and P. aeruginosa |
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What agents does imipenem cover?
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more potent against gram positive bacteria
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What agents does meropenem cover?
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gram negative rods
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What is metronidazole used for?
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infections caused by anaerobes: Bacteroides, Prevotella, Porphyromonas
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What is concern with skin and skin structure infections?
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growing resistance to macrolide among S. pyogenes
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What is tx for S. pyogenes skin and skin structure infection?
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clindamycin or penicillin
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What is tx for MRSA in community acquired skin and skin structure infection?
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vanc, daptomycin, and linezolid
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When should antimicrobial regimen be reassessed?
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after 48-72 hours based on microbiological and clinical data
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When is combo therapy preferred?
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Pseudomonas and neutropenic pts with severe sepsis or septic shock
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What is tx for invasive candidiasis?
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amphotericin B, azole antifungals, chinocandin antifungal, combo fluconazole plus amphotericin B
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What is advantage of new lipid ampho B?
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less nephrotoxic, increased daily dose, high tissue concentrations in reticuloendothelial organs (lungs, liver, and spleen), decreased infusion associated SE
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When is new ampho B used over old ampho B?
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intolerant of or have infection refractory to old ampho B
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What is often resistant to fluconazole?
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C. albicans in HIV and immunocompetent
C. glabrata has reduced susceptibility |
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Which azole antifungal can be used in fluconazole resistant Candida?
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voriconazole
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What is Caspofungin used against?
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Candida, Aspergillus
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How does casponfungin compare to ampho B?
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equally effective but better tolerated for invasive candidiasis
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What are echinocandins?
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caspofungin, micafungin, anidulafungin
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What should empiric tx for fungal be?
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ampho B or caspofungin
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What is associated with the highest rate of inappropriate initial tx?
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fungal bloodstream infections
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What is empirical tx for nosocomial blood stream fungal infection?
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fluconazole
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What is duration of antimicrobial therapy in sepsis?
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7-10 days
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What is duration of antifungal therapy in sepsis?
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10-14 days
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When can pt start PO meds?
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hemodynamically stable, afebrile for 48-72 hrs, normalizing WBC cound, able to take PO meds
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How long is tx in neutropenic pt?
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until pt is no longer neutropenic and has been afebrile for 72hrs
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What is cardiac output and systemic vascular resistance in septic shock?
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high cardiac output and low systemic vascular resistance
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What causes hypotension in sepsis?
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low systemic vascular resistance and abnormal distribution of blood flow in the microcirculation, resulting in compromised tissue perfusion
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What are categories of hemodynamic support?
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fluid, vasopressor, and inotropic therapy
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Why do septic pts have enormous fluid requirement?
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peripheral vasodilation and capillary leakage
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What is best tx for hypotension in sepsis?
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rapid fluid resuscitation
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How often does fluid alone reverse hypotension in sepsis?
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50%
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What is goal of fluid therapy?
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maximize cardiac output by increasing left ventricular preload which restores tissue perfusion
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Which crystalloids are used in fluid therapy?
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isotonic: NS and LR
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How much isotonic fluid does a pt typically require in first 24 hrs?
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up to 10L
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What % of crystalloids remain in the intravascular space?
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25%
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Which colloids are used in fluid therapy?
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5% albumin and 6% hetastarch
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What is advantage of colloids?
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more rapid restoration of intravascular volume because they produce greater intravascular volume expansion per quantity of volume infused
produce less peripheral edema |
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When should colloid and blood products be used?
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if there is significant blood loss associated with sepsis or if severe preexisting anemia
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What clinical outcome differences between crystalloid and colloid?
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none
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How much more volume is needed for crystalloid vs colloid?
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2-4x
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When is colloid preferred over crystalloid?
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with serum albumin less than 2g/dL
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What are major complications with fluid resuscitation?
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pulmonary edema and systemic edema
can also cause hypoxemia from aggressive volume expansion and increase in pulmonary capillary pressure leading to increase in lung water |
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Does colloids or crystalloids cause more pulmonary edema?
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no difference
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When are vasopressor and inotropic agents used in sepsis?
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when fluid resuscitation doesn't provide adequate arterial pressure and organ perfusion
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What are the inotropic agents?
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dopamine and dobutamine
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When should vasopressor be considered?
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when SBP is less than 900mmHg or MAP is lower than 60-65mmHg after adequate left ventricular preload and inotrope therapy
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What complications caused by inotropes or vasopressors?
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tachycardia and myocardial ischemia and infarction from change in myocardial oxygen consumption in pts with coexisting coronary disease
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What can be used to restore MAP without impairing stroke volume?
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catecholamine infusion trated gradually
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What is first choice vasopressor?
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NE
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What is MOA of NE?
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potent alpha adrenergic agent with less pronounced beta adrenergic activity
increases MAP from vasoconstrictive effects on peripheral vascular beds |
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How does normal dose of NE affect heart rate and cardiac index?
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little change
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Is NE or DA more potent in refractory septic shock?
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NE
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Does NE have effect on renal blood flow and cardiac output?
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demonstrates NE induced renal blood flow as well as urine and cardiac output
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Does NE or DA cause more increase in arterial BP?
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NE
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Does NE, DA, or EPI have a higher rate of survival?
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NE
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What is MOA of DA?
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alpha and beta adrenergic agent with DA activity, increases MAP and cardiac output (from increase in stroke volume and HR)
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What is advantage of DA?
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combined vasopressor and inotropic effects
useful in pts with hypotension and compromised systolic function |
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What is disadvantage of DA?
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cause more tachycardia and more arrhythmogenic
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Does DA maintain renal perfusion?
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no
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What is MOA of dobutamine?
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beta adrenergic inotropic agent
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When is dobutamine preferred drug?
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for improvement of cardiac output and oxygen delivery, particularly in early sepsis before significant peripheral vasodilation
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When should dobutamine be considered?
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severe sepsis with adequate filling pressures and BP but low cardiac index
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What is advantage of using a vasopressor and inotrope?
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can maintain MAP and cardiac output
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What is MOA of phenylephrine?
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selective alpha 1 agonist
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How is onset of phenylephrine?
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rapid
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How is duration of phenylephrine?
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short
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What are the primary effects from phenylephrine?
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vascular effects
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Which vasopressor/inotrope is least likely to cause tachycardia?
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phenylephrine
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When is phenylephrine useful?
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when tachycardia limits use of other vasopressors
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What effect does phenylephrine have on cardiac or renal function?
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none
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What is MOA of epinephrine?
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nonspecific alpha and beta adrenergic agonist
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What is action of phenylephrine?
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increase BP modestly in fluid resuscitated pts
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What is action of EPI?
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increasing CI and producing significant peripheral vasoconstriction
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What AE from EPI?
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propensity to increase lactate level and impair blood flow to splanchnic system
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When should EPI be used?
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pts who fail to respond to traditional therapies for increasing BP
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What is action of endogenous vasopressin in hypotension?
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maintain arterial BP, direct vasoconstrictor without inotropic or chronotropic effects
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How or vasopressin levels in septic shock?
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deficient
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What is action of vasopressin?
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low dose produces significant increase in MAP in septic shock, and can d/c other vasopressors
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What SE from high dose of vasopressin?
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myocardial ischemia, significant decrease in CO, cardiac arrest
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When is vasopressin usually used?
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in pts requiring high dose vasopressors
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What is preferred agent after fluids for increasing BP?
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NE
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What is used for refractory hypotension?
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EPI
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Which vasopressors/inotropes cause more tachycardia?
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dopamine and epinephrine
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What is used in pt with low CI and adequate MAP?
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dobutamine first line, dopamine can also be used
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table 123-5 pg 1952
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1952
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What are the goals in the first 6hrs of therapy?
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central venous pressure of 8-12mmHg, MAP 65 or more, urine output of 0.5mL/kg/h or more, central venous or mixed venous oxygen saturation of 70% or more
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What is goal for RBC transfusions?
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HCT 30% or more
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What is oxygen saturation goal?
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greater than 90%
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What is goal blood glucose in sepsis?
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less than 150mg/dL
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What is role of insulin in sepsis?
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control blood glucose
reduced rate of death from multiple organ failure among pts with sepsis regardless of presence of diabetes prior to sepsis |
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Is routine use of corticosteroids in sepsis recommended?
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no
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When are corticosteroids used?
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severe septic shock
pts with adrenal insufficiency, requiring high dose or increasing vasopressor therapy within the first 8 hours of septic shock |
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Which CS are used and duration?
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fludrocortisone and hydrocortisone for 7 days in 3-4 divided doses
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Was there a benefit for CS in pts without adrenal insufficiency?
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no
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What is used for DVT prophylaxis?
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low dose unfractionated heparin or LMW heparin
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When should DVT prophylaxis be used?
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genreal ICU pts, including sepsis pt
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What should be used for stress ulcer prophylaxis in sepsis?
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PPI and H2 antagonists
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What immunotherapeutic is used to treat inflammatory process initiated during sepsis?
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recombinant human activated protein C (rhAPC; drotrecogin alfa)
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What is drotrecogin alfa?
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an endogenous anticoagulant with antiinflammatory properties
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What is action of drotrecogin alfa?
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promotes fibrinolysis and associated antiinflammatory mechanisms
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What is a major risk with rhAPC?
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hemorrhage
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When is rhAPC recommended?
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pts at high risk of death, APACHE II score of 25 or more, sepsis induced multiple organ failure, septic shock, or sepsis induced ARDS with no CI for bleeding risk
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Why is rhAPC used less in elederly?
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bleeding, high drug cost, clinician's tendency to tx elderly less aggressively
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Why is rhAPC not used if APACHE II is less than 25?
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no difference in 28 day mortality and increased risk of bleeding
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