Sepsis

Sepsis US Medical PG Question 1: A 70-year-old woman is on hospital day 2 in the medical intensive care unit. She was admitted from the emergency department for a 2-day history of shortness of breath and fever. In the emergency department, her temperature is 39.4°C (103.0°F), the pulse is 120/min, the blood pressure is 94/54 mm Hg, the respiratory rate is 36/min, and oxygen saturation was 82% while on 4L of oxygen via a non-rebreather mask. Chest X-ray shows a right lower lobe consolidation. She was intubated, sedated, and started on broad-spectrum antibiotics for sepsis of pulmonary origin and intravenous norepinephrine for blood pressure support. Since then, her clinical condition has been stable, though her vasopressor and oxygen requirements have not improved. Today, her physician is called to the bedside because her nurse noted some slow bleeding from her intravenous line sites and around her urinary catheter. Which of the following most likely represents the results of coagulation studies for this patient?

• A. D-dimer: negative, fibrinogen level: low, platelet count: low
• B. D-dimer: elevated, fibrinogen level: normal, platelet count: normal
• C. D-dimer: elevated, fibrinogen level: low, platelet count: low (Correct Answer)
• D. D-dimer: negative, fibrinogen level: elevated, platelet count: elevated
• E. D-dimer: negative, fibrinogen level: normal, platelet count: normal

Sepsis Explanation: ***D-dimer: elevated, fibrinogen level: low, platelet count: low*** - The patient's presentation with **sepsis** requiring intubation and vasopressors, along with diffuse **bleeding from IV sites and urinary catheter**, strongly suggests **disseminated intravascular coagulation (DIC)**. - In DIC, widespread activation of the coagulation cascade leads to consumption of **platelets** and **clotting factors (including fibrinogen)**, resulting in thrombocytopenia and hypofibrinogenemia. The breakdown of clots produces **elevated D-dimer** levels. *D-dimer: negative, fibrinogen level: low, platelet count: low* - A **negative D-dimer** would contradict the diagnosis of DIC, as D-dimer is a product of fibrin degradation and is almost always elevated in DIC due to extensive clot formation and subsequent fibrinolysis. - While low fibrinogen and platelet count are characteristic of DIC, the negative D-dimer makes this option unlikely in the context of active bleeding from multiple sites. *D-dimer: elevated, fibrinogen level: normal, platelet count: normal* - While an **elevated D-dimer** is consistent with fibrinolysis occurring in DIC, normal **fibrinogen** and **platelet counts** would argue against the consumptive coagulopathy that defines DIC. - The presence of diffuse bleeding in a patient with sepsis usually indicates significant depletion of clotting factors and platelets. *D-dimer: negative, fibrinogen level: elevated, platelet count: elevated* - This profile suggests an **inflammatory state** or a hypercoagulable state without significant fibrinolysis or consumption of clotting factors. - A **negative D-dimer** and **elevated fibrinogen/platelets** contradict the signs and symptoms of DIC with active bleeding. *D-dimer: negative, fibrinogen level: normal, platelet count: normal* - This result would be inconsistent with **DIC** and the patient's clinical picture of widespread bleeding. - In DIC, there is active coagulation and fibrinolysis, leading to consumption of platelets and fibrinogen and production of D-dimers.

Sepsis US Medical PG Question 2: A 45-year-old homeless man is brought to the emergency department by the police. He was found intoxicated and passed out in a library. The patient has a past medical history of IV drug abuse, diabetes, alcohol abuse, and malnutrition. The patient has been hospitalized previously for multiple episodes of pancreatitis and sepsis. Currently, the patient is minimally responsive and only withdraws his extremities in response to painful stimuli. His temperature is 99.5°F (37.5°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 95% on room air. Physical exam is notable for tachycardia, a diastolic murmur at the left lower sternal border, and bilateral crackles on pulmonary exam. The patient is started on IV fluids, vancomycin, and piperacillin-tazobactam. Laboratory values are ordered as seen below. Hemoglobin: 9 g/dL Hematocrit: 30% Leukocyte count: 11,500/mm^3 with normal differential Platelet count: 297,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 4.0 mEq/L HCO3-: 28 mEq/L BUN: 33 mg/dL Glucose: 60 mg/dL Creatinine: 1.7 mg/dL Ca2+: 9.7 mg/dL PT: 20 seconds aPTT: 60 seconds AST: 1,010 U/L ALT: 950 U/L The patient is admitted to the medical floor. Five days later, the patient's neurological status has improved. His temperature is 99.5°F (37.5°C), blood pressure is 130/90 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 99% on room air. Laboratory values are repeated as seen below. Hemoglobin: 10 g/dL Hematocrit: 32% Leukocyte count: 9,500/mm^3 with normal differential Platelet count: 199,000/mm^3 Serum: Na+: 140 mEq/L Cl-: 102 mEq/L K+: 4.3 mEq/L HCO3-: 24 mEq/L BUN: 31 mg/dL Glucose: 100 mg/dL Creatinine: 1.6 mg/dL Ca2+: 9.0 mg/dL PT: 40 seconds aPTT: 90 seconds AST: 150 U/L ALT: 90 U/L Which of the following is the best description of this patient’s current status?

• A. Recovery from acute renal failure
• B. Acute renal failure
• C. Recovery from ischemic liver disease
• D. Fulminant liver failure (Correct Answer)
• E. Recovery from acute alcoholic liver disease

Sepsis Explanation: ***Fulminant liver failure*** - The patient's **prolonged PT (40 seconds)** and **aPTT (90 seconds)** after 5 days, despite improvements in other parameters, indicate a severe impairment in hepatic synthesis of clotting factors, which is a hallmark of **fulminant liver failure**. - The initial presentation with **elevated AST/ALT (over 1000 U/L)** coupled with **encephalopathy (minimally responsive)** and subsequent worsening coagulopathy points towards acute liver failure, even if transaminases are improving. *Recovery from acute renal failure* - While the initial **creatinine (1.7 mg/dL)** was mildly elevated, it remained largely unchanged (1.6 mg/dL) after 5 days, indicating no significant acute renal failure or subsequent recovery. - The patient’s fluid resuscitation and improved hemodynamics would likely lead to a more pronounced improvement in creatinine if significant acute renal failure had occurred and was recovering. *Acute renal failure* - The creatinine level, while slightly elevated, does not meet the criteria for significant **acute renal failure** (e.g., a >50% increase from baseline or a >0.3 mg/dL increase within 48 hours relative to his baseline, which is unknown but likely lower than 1.7 mg/dL given his other conditions). - Furthermore, if true acute renal failure was present on admission, 5 days later with improved vitals, we would expect a clearer trend of either worsening or recovering creatinine, neither of which is strongly evident here. *Recovery from ischemic liver disease* - While the initial very high transaminases (AST 1010, ALT 950) could suggest **ischemic liver injury**, the subsequent significant prolongation of **PT and aPTT** (from 20 to 40 seconds and 60 to 90 seconds, respectively) indicates worsening synthetic dysfunction, not recovery. - Recovery from ischemic liver disease would typically show improving coagulation parameters alongside decreasing transaminases. *Recovery from acute alcoholic liver disease* - Similar to recovery from ischemic liver disease, recovery from **acute alcoholic liver disease** would involve an improvement in liver synthetic function, reflected by a **shortening of PT/aPTT**, not a progressive prolongation as seen here. - The patient's initial presentation is consistent with acute alcoholic hepatitis or other acute liver injury given his history and high LFTs, but the subsequent worsening coagulopathy rules out recovery.

Sepsis US Medical PG Question 3: A 77-year-old woman is brought to the emergency department from her nursing home because she was found down overnight. On presentation she was found to be delirious and was unable to answer questions. Chart review shows that she is allergic to cephalosporins. Her temperature is 102.2°F (39°C), blood pressure is 105/52 mmHg, pulse is 94/min, and respirations are 23/min. Physical exam reveals a productive cough. A metabolic panel is obtained with the following results: Serum: Na+: 135 mEq/L Cl-: 95 mEq/L K+: 4 mEq/L HCO3-: 19 mEq/L BUN: 40 mg/dL Creatinine: 2.5 mg/dL Glucose: 150 mg/dL Based on these findings two different drugs are started empirically. Gram stain on a blood sample is performed showing the presence of gram-positive organisms on all samples. One of the drugs is subsequently stopped. The drug that was most likely stopped has which of the following characteristics?

• A. Resistance conveyed through acetylation
• B. Associated with red man syndrome
• C. Single-ringed ß-lactam structure (Correct Answer)
• D. Causes discolored teeth in children
• E. Accumulates inside bacteria via O2-dependent uptake

Sepsis Explanation: ***Single-ringed ß-lactam structure*** - The patient presents with **sepsis** due to **pneumonia** likely caused by **gram-positive organisms**. Given a cephalosporin allergy, **aztreonam** (a monobactam) would be an initial empirical antibiotic choice to cover gram-negative bacteria, alongside a drug for gram-positive coverage (like vancomycin). - Since the **blood cultures** confirmed **gram-positive organisms**, the drug covering gram-negative bacteria (aztreonam) would be stopped. Aztreonam is characterized by its **single-ringed β-lactam structure**. *Resistance conveyed through acetylation* - This mechanism of resistance is typical of **aminoglycosides** (e.g., gentamicin) and **chloramphenicol**. - Aminoglycosides were unlikely to be one of the empirically started drugs, as they are often used in combination with β-lactams, and this patient has a cephalosporin allergy. *Associated with red man syndrome* - **Red man syndrome** is a common adverse effect associated with **vancomycin** administration, especially with rapid infusion. - Vancomycin would likely be continued, as it effectively targets gram-positive organisms, including **MRSA**, and is a suitable alternative given the cephalosporin allergy. *Causes discolored teeth in children* - This is a characteristic side effect of **tetracyclines** (e.g., doxycycline), which are contraindicated in young children and pregnant women due to their effects on bone and teeth development. - Tetracyclines are not typically first-line empiric therapy for severe pneumonia or sepsis, especially in an elderly patient. *Accumulates inside bacteria via O2-dependent uptake* - This describes the mechanism of uptake for **aminoglycosides**. Their entry into bacteria is an **energy-dependent process** requiring oxygen. - As mentioned, aminoglycosides are less likely to be the initial drug stopped in this scenario, as they target gram-negative bacteria.

Sepsis US Medical PG Question 4: A 75-year-old male arrives by ambulance to the emergency room severely confused. His vitals are T 40 C, HR 120 bpm, BP 80/55 mmHg, RR 25. His wife explains that he injured himself about a week ago while cooking, and several days later his finger became infected, oozing with pus. He ignored her warning to see a doctor and even refused after he developed fever, chills, and severe fatigue yesterday. After being seen by the emergency physician, he was given antibiotics and IV fluids. Following initial resuscitation with IV fluids, he remains hypotensive. The ED physicians place a central venous catheter and begin infusing norepinephrine. Which of the following receptors are activated by norepinephrine?

• A. Alpha 1, Alpha 2, Beta 1, Beta 2
• B. Alpha 1, Alpha 2, Beta 1 (Correct Answer)
• C. Alpha 2
• D. Alpha 1, Beta 1, Dopamine 1
• E. Alpha 1, Beta 1

Sepsis Explanation: ***Alpha 1, Alpha 2, Beta 1*** - **Norepinephrine** primarily activates **alpha-1** (peripheral vasoconstriction), **alpha-2** (presynaptic inhibition and some vasoconstriction), and **beta-1** (increased heart rate and contractility) adrenergic receptors. - These are the **primary receptors** responsible for norepinephrine's clinical effects: vasoconstriction (alpha-1, alpha-2) and positive inotropic/chronotropic effects (beta-1). - This receptor profile makes norepinephrine an ideal **vasopressor** in septic shock, as seen in this patient. *Alpha 1, Alpha 2, Beta 1, Beta 2* - While **norepinephrine** does activate alpha-1, alpha-2, and beta-1 receptors, it has **negligible affinity for beta-2 receptors**. - **Epinephrine** (not norepinephrine) is the catecholamine with significant **beta-2 activity**, causing bronchodilation and vasodilation in skeletal muscle. - Including beta-2 is a common mistake when confusing norepinephrine with epinephrine. *Alpha 2* - This option is far too incomplete as **norepinephrine** has significant action on **alpha-1** and **beta-1** receptors, which are crucial for its vasoconstrictive and inotropic effects. - Activating only alpha-2 receptors would primarily lead to presynaptic inhibition and limited vasoconstriction, not the broad cardiovascular support required in septic shock. *Alpha 1, Beta 1, Dopamine 1* - While **norepinephrine** does activate **alpha-1** and **beta-1** receptors, it does **not** activate **dopamine 1 (D1) receptors**. - Only **dopamine** itself or specific **dopamine agonists** stimulate D1 receptors, leading to renal and mesenteric vasodilation. - This option incorrectly attributes dopaminergic activity to norepinephrine. *Alpha 1, Beta 1* - This option correctly identifies two of the main receptors activated by **norepinephrine**: alpha-1 (vasoconstriction) and beta-1 (positive inotropy and chronotropy). - However, it **omits alpha-2 receptors**, which norepinephrine also activates, contributing to both presynaptic feedback inhibition and additional vasoconstriction. - While not completely wrong, this is an incomplete answer.

Sepsis US Medical PG Question 5: A 38-year-old female presents to the emergency room with fevers, fatigue, and anorexia for over a month. Past medical history includes mild mitral valve prolapse. She underwent an uncomplicated tooth extraction approximately 6 weeks ago. Her vital signs include a temperature of 100.8 F, pulse of 83, blood pressure of 110/77, and SpO2 of 97% on room air. On exam, you note a grade III/VI holosystolic murmur at the apex radiating to the axilla as well as several red, painful nodules on her fingers. Which of the following is the next best course of action?

• A. Blood cultures are not needed. Start empiric antibiotics
• B. Start anticoagulation with heparin
• C. Consult cardiothoracic surgery for mitral valve replacement
• D. Obtain blood cultures x3 sites over 24 hours and start antibiotics after culture results are available
• E. Obtain blood cultures x3 sites over 1 hour and start empiric antibiotics (Correct Answer)

Sepsis Explanation: ***Obtain blood cultures x3 sites over 1 hour and start empiric antibiotics*** - The patient's presentation with **fever, fatigue, anorexia, new murmur, and painful finger nodules (Osler's nodes)** after a recent dental procedure strongly suggests **infective endocarditis**. Prompt initiation of **empiric antibiotics** after obtaining adequate blood cultures is crucial to improve outcomes and prevent further complications like septic emboli or valvular damage. - Obtaining **multiple blood cultures rapidly (e.g., three sets over 1 hour)** from different sites maximizes the chance of isolating the causative organism before antibiotics are given, enabling targeted therapy later, while minimizing delay to treatment. *Blood cultures are not needed. Start empiric antibiotics* - **Blood cultures are essential** for diagnosing infective endocarditis, identifying the causative organism, and guiding appropriate antibiotic therapy. Skipping blood cultures could lead to inappropriate antibiotic selection and treatment failure. - While empiric antibiotics are warranted, they should always be initiated **after blood cultures** have been drawn to avoid sterilizing the blood and making microbial identification difficult. *Start anticoagulation with heparin* - **Anticoagulation is generally contraindicated** in infective endocarditis due to the increased risk of hemorrhagic complications, especially in cases of septic emboli to the brain. - While patients with endocarditis can form vegetations that may embolize, the risks of **bleeding outweigh the benefits** of routine anticoagulation. *Consult cardiothoracic surgery for mitral valve replacement* - While **mitral valve prolapse** is a risk factor for endocarditis and severe valvular damage may eventually require surgery, primary management involves **antibiotic therapy**. - Surgical intervention is typically reserved for cases with **severe valvular regurgitation/stenosis leading to heart failure**, uncontrolled infection despite antibiotics, or recurrent emboli, and is not the immediate next step. *Obtain blood cultures x3 sites over 24 hours and start antibiotics after culture results are available* - Waiting for **24 hours to collect blood cultures** would significantly delay the initiation of antibiotics, which is dangerous in a potentially life-threatening infection like endocarditis. - Delaying antibiotics until **culture results are available** could take several days, leading to worsening infection, organ damage, and increased mortality. **Empiric antibiotics** must be started promptly after initial blood collection.

Sepsis Flashcard 1 of 5

Question: Medi-_____ is state/federal assistance for people with limited income/resources

Answer: caid

Sepsis Flashcard 2 of 5

Question: Disinfestation of Scabies is achieved by laudering clothing and bedding in _____ water

Answer: hot

Sepsis Flashcard 3 of 5

Question: Which healthcare payment model involves physicians receiving a set amount per patient assigned to them per period of time? _____

Answer: Capitation

Sepsis Flashcard 4 of 5

Question: Is IDR a dynamic measure? _____

Answer: Yes

Sepsis Flashcard 5 of 5

Question: Which healthcare payment model involves patients paying for each individual service at a pre-determined, discounted rate?_____

Answer: Discounted fee-for-service