Therapeutics Id Exam 2- Sepsis

Front 1

SIRS definition (4 paramters)

Back 1

two or more of the following: T greater than 38 or less than 36; HR greater than 90 bpm;
RR greater than 20;
WBC greater than 12K, less than 4K or greater than 10% immature forms (bands)

Front 2

sepsis definition

Back 2

SIRS caused by infection

Front 3

severe sepsis (3)

3 other sx/signs of severe sepsis

Back 3

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

Front 4

septic shock definition

Back 4

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

Front 5

what does MODS stand for

Back 5

multiple organ dysfunction syndrome

Front 6

infectious sources for sepsis (3)

Back 6

Respiratory tract
Intra-abdominal
Urinary Tract

Front 7

bacterial/fungal etiology for sepsis (bugs/categories) (4)

Back 7

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

Front 8

pathophys of sepsis

Back 8

Invading organism activates immune response initiating pro- and anti-inflammatory cytokine cascade

Front 9

pro inflammatory mediators (3)

Back 9

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

Front 10

other mediators of sepsis (4)

Back 10

IL-9, platelet-activating factor (PAF), leukotrienes, thromboxane A2

Front 11

anti inflammatory mediators of sepsis (3)

Back 11

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

Front 12

shock definition

Back 12

hypotension non-responsive to fluid bolus

Front 13

complications of sepsis (5)

Back 13

shock
Disseminated Intravascular Coagulation(DIC)
ARDS
Hemodynamic effects: High cardiac output, low systemic vascular resistance
Acute Renal Failure: acute oliguric or anuric renal failure secondary to hypoperfusion

Front 14

what is DIC

Back 14

Excessive fibrin formation, inhibited fibrin removal, microvascular thrombosis

you clot so much you use up all your fibrin and bleed

Front 15

why do people with sepsis get ARDS

Back 15

Respiratory failure from pulmonary edema

Front 16

s/sx of sepsis

Back 16

look at list

Front 17

mainstays of sepsis tx (2)

Back 17

Respiratory Support (oxygen, ventilator)
Hemodynamic support

Front 18

3 options for hemodynamic support

Back 18

Fluid bolus, vasopressor, inotropic therapy

Front 19

drugs used for hemodynamic support (5)

Back 19

dopamine, dobutamine, norepinephrine, phenylephrine, epinephrine

Front 20

Dopamine mechanism in sepsis (2)

Back 20

May increase renal perfusion at low doses
Vasoconstriction at high doses by alpha receptors

Front 21

goals of using dopamine (3)

Back 21

increase MAP, increase cardiac output, increase urine output

Front 22

dopamine dosing and route

Back 22

2-20 mcg/kg/min intravenous infusion

Front 23

epinephrine moa and what receptors it targets derr

Back 23

Increases blood pressure by vasoconstriction and increased heart rate
Alpha and beta agonist

Front 24

dosing of epi/norepi/phenylephrine

Back 24

5-20 mcg/min

Front 25

norepi moa/receptors vs. epi

Back 25

Alpha > beta agonist effects as increase dose

Front 26

phenylephrine receptor

Back 26

Pure alpha agonist

Front 27

dobutamine moa and receptor

Back 27

Increases contractility of the heart thereby increasing cardiac output

Beta agonist

Front 28

dobutamine main disadvantage

Back 28

Disadvantage, also causes vasodilation

Front 29

dobutamine dosing and route

Back 29

5-15 mcg/kg/min intravenous infusion

Front 30

when is vasopressin used? (2)

Back 30

Used in refractory septic shock

Often started after large doses of norepinephrine are ineffective

Front 31

vasopressin dosing range

Back 31

doses of 0.01 to 0.04 units/min

Front 32

prognosis of sepsis based on...(2)

Back 32

underlying disease and appropriate antimicrobial therapy

Front 33

antimicrobial therapy in sepsis should target what? (2)

Back 33

Empiric therapy should target likely pathogens
Will differ based on likely source of infection

Front 34

UTI community acquired- 3 bugs

Back 34

E. coli, Staph. saphrophyticus, Enterococci

Front 35

CA UTI ppx 2 choices

Back 35

3rd Gen Ceph + Aminoglycoside or Quinolone

Front 36

HA UTI bugs (5)

Back 36

E. coli, Klebsiella, Pseudomonas, Proteus, Enterococci

Front 37

HA UTI ppx

Back 37

Pip/Tazo (may cover enterococcus) or Antipseudomonal cephalosporin + Aminoglycoside or Quinolone

"double cover" pseudomonas: used to have to add aminoglycoside to pencillins because they didn't cover pseudomonas...but now the addition of AG is less clear due to pip/tazo being very broad coverage. some people will also just pick 2 drugs for pseudomonas...but don't need both.

however none of htese cover VRE so you'd have to add something if it did

Front 38

CA RTI bugs (2)

Back 38

S. pneumo, H. influenza

Front 39

HA RTI bugs (2)

Back 39

Gram-negative rods (Think Pseudomonas), Staph. aureus

Front 40

CA RTI ppx

Back 40

3 rd gen Cephalosporin + Quinolone or Aminoglycoside

Front 41

HA RTI ppx

Back 41

Pip/Tazo or Antipseudomonal Ceph + Aminoglycoside or Quinolone

Front 42

mortality in sepsis based on...

Back 42

inadquate therapy is just as much of an issue in preventing mortality as not giving therapy

Front 43

intra-abdominal infxn bugs (2)

Back 43

Gram Negative Rods, Anaerobes

Front 44

IA infxn ppx (2 options) and one consideration

Back 44

Ampicillin + Aminoglycoside or Quinolone + Clindamycin or Metronidazole (anaerobes)
OR
Beta-lactam/beta-lactamase inhibitor combination or carbapenem + Aminoglycoside or Quinolone


maybe fungal coverage

Front 45

Hospital infections- always need to cover what bug

Back 45

pseudomonas

Front 46

catheter associated infections 3 bugs

Back 46

S. aureus, S. epidermidis, Gram- negative rods

Front 47

catheter associated infections- triple therapy ppx

Back 47

Extended spectrum penicillin or 3rd generation cephalosporin + aminoglycoside + penicillinase resistant penicillin or Vancomycin

Front 48

daptomycin inactivated where

Back 48

in the lung?? double check

Front 49

Pharmacokinetic Concepts in the Critically Ill (Vd, renal/liver, dosing)

Back 49

Larger than normal volume of distribution due to fluid overload (from getting fluid boluses to sustain intravascular volume which keeps leading out)
Hepatic or renal dysfunction or both
Assess risk to benefit ratio when dosing medications

Front 50

what is drotegcin alpha

Back 50

recombinant human activated protein C

Front 51

drotrecogin- has what type of properties/mechanisms

Back 51

Has antithrombotic, anti-inflammatory and profibrinolytic properties

Front 52

drotrecogin dosing and duration

Back 52

24 mcg/kg/hr IV infusion x 96 hours

Front 53

PROWESS study showed what

PROWESS SHOCK trial showed what

Back 53

showed lower mortality rate in pt who got drotrecogin alpha (for sepsis?)

serious bleeding was big AE of drug

but failed to show survival benefit in severe sepsis/shock so was withdrawn

Front 54

other supportive therapy in sepsis (6)

Back 54

Analgesia
Sedation
Neuromuscular blockade
Nutrition (NG tube or TPN)
Stress ulcer prophylaxis (in ICU)
DVT prophylaxis

Front 55

3 options for analgesia

Back 55

fentanyl
hydromorphone
morphine

Front 56

fentanyl preferred when

Back 56

Preferred agent for hemodynamically unstable patients since no histamine release

Front 57

Preferred analgesia agent for hemodynamically stable patients

Back 57

morphine

Front 58

analgesia avoid what 2 drugs

Back 58

Avoid use of codeine and meperidine

Front 59

sedation options (5)

Back 59

propofol
midazolam
lorazepam
diazepam
dexmeditomidine

Front 60

propofol properties (3)

Back 60

short acting, lipid based, costly

Front 61

midazolam- metabolite, duration of action, solubility

Back 61

short acting unless used as continuous infusion, water soluble, active metabolite with longer half life that lorazepam

Front 62

ativan preferred to be given in what way

Back 62

preferred continuous infusion per Society of Critical Care Medicine Guidelines

Front 63

diazepam not indicated for what?

Back 63

not indicated for continuous infusion

Front 64

dexmedetomidine- properties (2)

Back 64

May be morphine sparing and have sedative effects without respiratory depression

Front 65

NMJ blockade used for what?

Back 65

Maybe used to facilitate mechanical ventilation

Front 66

NMJ blockade monitoring for CI

Back 66

For continuous infusion, monitor train of four to use lowest effective dose

Front 67

NMJ blockade should we use it a lot?
why or why not

Back 67

Minimize use --polyneuropathy of critical illness

Front 68

what is train of four monitoring

Back 68

Train of four is a test for measuring neuromuscular blockade level, 4 consecutive stimuli are delivered along the path of a nerve

Front 69

nutrition support- route and risks (2)

Back 69

If the gut works use it
Nasogastric tube feeding
TPN has additional risks, such as infection.

Front 70

options for stress ulcer ppx (4)

Back 70

H-2 receptor antagonists
Proton pump inhibitors
Sucralfate
Antacids

Front 71

also consider what other downside when ppx for GI bleed?

Back 71

Consider prevention of upper GI bleed with potential for development of ventilator-acquired pneumonia (pH related)

Front 72

sepsis management bundle (3 things)

Back 72

Administer low dose steroids (less than 300 mg/day hydrocortisone)
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)
Maintain median inspiratory plateau pressure (IPP) less than 30 cm H20 for mechanically ventilated patients.

Front 73

sespsis rescuscitation bundle

Back 73

did not enter