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12.12.03 Sepsis teaching

Indications for dialysis
  • AKI: AEIOU
    • Acidemia 
      • From metabolic acidosis 
      • In situations in which correction with sodium bicarbonate is impractical or may result in fluid overload
    • Electrolyte abnormality
      • e.g. Severe hyperkalemia
    • Intoxication
      • Acute poisoning with a dialyzable substance: SLIME
        • Salicylic acid
        • Lithium
        • Isopropanol
        • Magnesium-containing laxatives
        • Ethylene glycol
    • Overload of fluid 
      • Not expected to respond to treatment with diuretics
    • Uremia complications
      • Pericarditis, encephalopathy, gastrointestinal bleeding
  • Chronic indications for dialysis:
    • Symptomatic renal failure
    • GFR of less than 10-15 mls/min/1.73m2
      • In diabetics, dialysis is started earlier
    • Difficulty in medically controlling fluid overload, serum potassium, and/or serum phosphorus when the GFR is very low

Indications for ventilation
  • Acute lung injury 
    • ARDS, trauma
  • Apnea with respiratory arrest
    • Including cases from intoxication
  • COPD
  • Acute respiratory acidosis with partial pressure of carbon dioxide (pCO2) > 6.65 kPa and pH < 7.25
    • e.g. Paralysis of the diaphragm due to Guillain-Barré syndrome, Myasthenia Gravis, spinal cord injury, or the effect of anaesthetic and muscle relaxant drugs
  • Increased work of breathing 
    • As evidenced by significant tachypnea, retractions, and other physical signs of respiratory distress
  • Hypoxemia with arterial partial pressure of oxygen (PaO2) < 7.3 kPa on 100% oxygen
  • Hypotension
    • Including sepsis, shock, congestive heart failure
  • Neurological diseases 
    • e.g. Muscular Dystrophy, Amyotrophic Lateral Sclerosis

Indications for extended courses of antibiotics
  • Rheumatic fever
  • Post-Strep GN

CURB-65 score
  • Items
    • Confusion of new onset (AMTS of 8 or less)
    • Urea greater than 7 mmol/l
    • Respiratory rate > 30 
    • Blood pressure less than 90 mmHg systolic or diastolic blood pressure 60 mmHg or less
    • age 65 or older
  • Admit if score >1

Hospital-acquired pneumonia
  • Two classes:
    • MRSA
    • Gram negatives
      • E. coli
      • Klebsiella
      • Psudomonas
  • Can travel up lymphatics from the gut

Treatment of pneumonia
  • CURB-65 >2
    • Tazocin 
  • CURB-65 1 or 2
    • Ampicillin
  • Atypicals
    • Clarythromycin or tetracycline

HACEK endocarditis (Kids)
  • Haemophilus
    • Haemophilus parainfluenzae, Haemophilus aphrophilus, Haemophilus paraphrophilus
  • Actinobacillus
    • Actinobacillus actinomycetemcomitans, Aggregatibacter aphrophilus
  • Cardiobacterium hominis
  • Eikenella corrodens
  • Kingella
    • Kingella kingae

Indications for transfusion
  • Hb <7
  • Hb <9 if  ischaemic heart disease

NIV
  • CPAP is for type I respiratory failure
    • Also useful in pulmonary oedema - Drives fluid out of alveoli
  • BiPAP is for type II failure

Monitoring fluid challenges
  • Stroke volume variation
  • CVP
  • Mixed venous sats
  • Urine output
  • BP

Inotropes
  • Inodilators
    • Dobutamine
    • Dopexamine
  • Inoconstrictors
    • Noradrenaline
    • Vasopressin

Multiple myeloma
  • Diagnostic criteria
    • Symptomatic myeloma:
      • Clonal plasma cells >10% on bone marrow biopsy or (in any quantity) in a biopsy from other tissues (plasmacytoma)
      • Paraprotein in either serum or urine (except in cases of true non-secretory myeloma)
      • Evidence of end-organ damage felt related to the plasma cell disorder (CRAB):
        • HyperCalcemia (corrected calcium >2.75 mmol/L)
        • Renal insufficiency attributable to myeloma
        • Anemia (hemoglobin <10 g/dL)
        • Bone lesions
    • Asymptomatic (smoldering) myeloma:
      • Serum paraprotein >30 g/L AND/OR
      • Clonal plasma cells >10% on bone marrow biopsy AND
      • NO myeloma-related organ or tissue impairment
    • Monoclonal gammopathy of undetermined significance (MGUS):
      • Serum paraprotein <30 g/L AND
      • Clonal plasma cells <10% on bone marrow biopsy AND
      • NO myeloma-related organ or tissue impairment
  • Complications
    • Infection, due to immune paresis

Neurogenic shock 
  • Distributive shock, featuring hypotension, occasionally with bradycardia
  • Due to disruption of the autonomic pathways within the spinal cord
    • Hypotension occurs due to decreased systemic vascular resistance resulting in pooling of blood within the extremities lacking sympathetic tone
    • Bradycardia results from unopposed vagal activity

C. diff
  • "Treatment-associated infection"
  • Treatment
    • Metronidazole
    • Oral vancomycin
    • Stool transplant
    • Fidaxomycin?
    • IVIG
    • Toxin binders
  • Rectal catheter
  • Complications
    • Diarrhoea
    • Pseudomembranous colitis


Sepsis bundles
  • Sepsis Resuscitation Bundle
    • Measure serum lactate
    • Obtain blood cultures prior to antibiotic administration
    • Administer broad-spectrum antibiotic within 3 hours of ED admission and within 1 hour of non-ED admission
    • Treat hypotension and/or elevated lactate with fluids; Apply vasopressors for ongoing hypotension
    • Maintain adequate central venous pressure and central venous oxygen saturation
  • Sepsis Management Bundle
    • Administer low-dose steroids for septic shock in accordance with a standardized ICU policy.
    • Maintain glucose control lower limit of normal, but <10 mmol/L
    • Maintain a median inspiratory plateau pressure (IPP) <30 cm H20 for mechanically ventilated patients


Notes
  • 1/3 of the world has TB
    • So check for it, even if something else has been isolated!
  • Staph pneumonia
    • IVDUs
    • Secondary infection on top of 'flu
  • Hypercalcaemia => Nephrogenic diabetes insipidus
  • Liver perfusion can drop to 1% in sepsis
  • Anticoagulation (warfarin) required if albumin is <20
  • Fusidic acid is good for penetrating bone and pus
  • Carbohydrates in ORT / Rice water reactivates gut wall cells
  • ITU: Brush their teeth!
  • > 60% O2 damages lungs
    • Permissive hypercapnia
  • Surviving sepsis campaign
  • Acinetobacter = New, deadly, resistant
  • ESBL organisms
    • Plasmid-spread
  • New Delhi metalo-beta lactamase
    • Breaks down carbapenams
  • Linezolid
    • Last-line, vs Gram +ve organisms
    • VRSA, Vancomycin resistant enterococcus
  • Sentinel flocks for bird flu
  • Smallpox is the most infectious thing ever
  • Clinical sign of thrombocytopaenia = Bleeding from mouth / blood blisters

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