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-BarrĂ© 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