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73 Cards in this Set
- Front
- Back
SIRS definition (4 paramters)
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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) |
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sepsis definition
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SIRS caused by infection
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severe sepsis (3)
3 other sx/signs of severe sepsis |
Sepsis + organ dysfunction, hypoperfusion, hypotension (lactic acidosis, oliguria, altered mental status).
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septic shock definition
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sepsis with hypotension that is not responsive to fluid resuscitation. Patients who need vasopressors
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what does MODS stand for
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multiple organ dysfunction syndrome
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infectious sources for sepsis (3)
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Respiratory tract
Intra-abdominal Urinary Tract |
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bacterial/fungal etiology for sepsis (bugs/categories) (4)
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Gm positive (S. aureus, S. pneumoniae, Coagulase negative staphylococci, Enterococci
Gm negative (E. coli, Klebsiella, Serratia, Enterobacter, Proteus, Pseudomonas) Anaerobes – less common Fungal |
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pathophys of sepsis
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Invading organism activates immune response initiating pro- and anti-inflammatory cytokine cascade
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pro inflammatory mediators (3)
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TNF-alpha***, interleukin 1B, interleukin-6 (IL6)
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other mediators of sepsis (4)
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IL-9, platelet-activating factor (PAF), leukotrienes, thromboxane A2
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anti inflammatory mediators of sepsis (3)
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IL-1 receptor antigens, IL-4, IL-10
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shock definition
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hypotension non-responsive to fluid bolus
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complications of sepsis (5)
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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 |
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what is DIC
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Excessive fibrin formation, inhibited fibrin removal, microvascular thrombosis
you clot so much you use up all your fibrin and bleed |
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why do people with sepsis get ARDS
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Respiratory failure from pulmonary edema
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s/sx of sepsis
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look at list
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mainstays of sepsis tx (2)
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Respiratory Support (oxygen, ventilator)
Hemodynamic support |
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3 options for hemodynamic support
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Fluid bolus, vasopressor, inotropic therapy
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drugs used for hemodynamic support (5)
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dopamine, dobutamine, norepinephrine, phenylephrine, epinephrine
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Dopamine mechanism in sepsis (2)
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May increase renal perfusion at low doses
Vasoconstriction at high doses by alpha receptors |
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goals of using dopamine (3)
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increase MAP, increase cardiac output, increase urine output
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dopamine dosing and route
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2-20 mcg/kg/min intravenous infusion
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epinephrine moa and what receptors it targets derr
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Increases blood pressure by vasoconstriction and increased heart rate
Alpha and beta agonist |
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dosing of epi/norepi/phenylephrine
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5-20 mcg/min
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norepi moa/receptors vs. epi
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Alpha > beta agonist effects as increase dose
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phenylephrine receptor
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Pure alpha agonist
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dobutamine moa and receptor
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Increases contractility of the heart thereby increasing cardiac output
Beta agonist |
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dobutamine main disadvantage
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Disadvantage, also causes vasodilation
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dobutamine dosing and route
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5-15 mcg/kg/min intravenous infusion
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when is vasopressin used? (2)
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Used in refractory septic shock
Often started after large doses of norepinephrine are ineffective |
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vasopressin dosing range
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doses of 0.01 to 0.04 units/min
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prognosis of sepsis based on...(2)
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underlying disease and appropriate antimicrobial therapy
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antimicrobial therapy in sepsis should target what? (2)
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Empiric therapy should target likely pathogens
Will differ based on likely source of infection |
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UTI community acquired- 3 bugs
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E. coli, Staph. saphrophyticus, Enterococci
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CA UTI ppx 2 choices
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3rd Gen Ceph + Aminoglycoside or Quinolone
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HA UTI bugs (5)
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E. coli, Klebsiella, Pseudomonas, Proteus, Enterococci
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HA UTI ppx
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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 |
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CA RTI bugs (2)
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S. pneumo, H. influenza
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HA RTI bugs (2)
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Gram-negative rods (Think Pseudomonas), Staph. aureus
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CA RTI ppx
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3 rd gen Cephalosporin + Quinolone or Aminoglycoside
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HA RTI ppx
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Pip/Tazo or Antipseudomonal Ceph + Aminoglycoside or Quinolone
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mortality in sepsis based on...
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inadquate therapy is just as much of an issue in preventing mortality as not giving therapy
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intra-abdominal infxn bugs (2)
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Gram Negative Rods, Anaerobes
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IA infxn ppx (2 options) and one consideration
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Ampicillin + Aminoglycoside or Quinolone + Clindamycin or Metronidazole (anaerobes)
OR Beta-lactam/beta-lactamase inhibitor combination or carbapenem + Aminoglycoside or Quinolone maybe fungal coverage |
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Hospital infections- always need to cover what bug
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pseudomonas
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catheter associated infections 3 bugs
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S. aureus, S. epidermidis, Gram- negative rods
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catheter associated infections- triple therapy ppx
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Extended spectrum penicillin or 3rd generation cephalosporin + aminoglycoside + penicillinase resistant penicillin or Vancomycin
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daptomycin inactivated where
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in the lung?? double check
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Pharmacokinetic Concepts in the Critically Ill (Vd, renal/liver, dosing)
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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 |
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what is drotegcin alpha
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recombinant human activated protein C
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drotrecogin- has what type of properties/mechanisms
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Has antithrombotic, anti-inflammatory and profibrinolytic properties
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drotrecogin dosing and duration
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24 mcg/kg/hr IV infusion x 96 hours
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PROWESS study showed what
PROWESS SHOCK trial showed what |
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 |
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other supportive therapy in sepsis (6)
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Analgesia
Sedation Neuromuscular blockade Nutrition (NG tube or TPN) Stress ulcer prophylaxis (in ICU) DVT prophylaxis |
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3 options for analgesia
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fentanyl
hydromorphone morphine |
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fentanyl preferred when
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Preferred agent for hemodynamically unstable patients since no histamine release
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Preferred analgesia agent for hemodynamically stable patients
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morphine
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analgesia avoid what 2 drugs
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Avoid use of codeine and meperidine
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sedation options (5)
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propofol
midazolam lorazepam diazepam dexmeditomidine |
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propofol properties (3)
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short acting, lipid based, costly
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midazolam- metabolite, duration of action, solubility
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short acting unless used as continuous infusion, water soluble, active metabolite with longer half life that lorazepam
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ativan preferred to be given in what way
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preferred continuous infusion per Society of Critical Care Medicine Guidelines
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diazepam not indicated for what?
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not indicated for continuous infusion
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dexmedetomidine- properties (2)
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May be morphine sparing and have sedative effects without respiratory depression
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NMJ blockade used for what?
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Maybe used to facilitate mechanical ventilation
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NMJ blockade monitoring for CI
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For continuous infusion, monitor train of four to use lowest effective dose
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NMJ blockade should we use it a lot?
why or why not |
Minimize use --polyneuropathy of critical illness
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what is train of four monitoring
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Train of four is a test for measuring neuromuscular blockade level, 4 consecutive stimuli are delivered along the path of a nerve
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nutrition support- route and risks (2)
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If the gut works use it
Nasogastric tube feeding TPN has additional risks, such as infection. |
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options for stress ulcer ppx (4)
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H-2 receptor antagonists
Proton pump inhibitors Sucralfate Antacids |
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also consider what other downside when ppx for GI bleed?
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Consider prevention of upper GI bleed with potential for development of ventilator-acquired pneumonia (pH related)
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sepsis management bundle (3 things)
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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. |
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sespsis rescuscitation bundle
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did not enter
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