Chapter 12 Shock, Sepsis, and multiple organ dysfunction syndrome Flashcards
1
Q
Shock is a clinical syndrome
A
◦ Life-threatening response to alterations in circulation
◦ Inadequate tissue perfusion
◦ Imbalance between cellular oxygen supply and demand
2
Q
Shock Impacts all body systems
A
◦ Can lead to organ failure and death
◦ Influenced by compensatory mechanisms
◦ Influenced by successful interventions
3
Q
Cardiovascular system
◦ Closed system:
◦ Vascular bed:
A
◦ Closed system: heart, blood, vascular bed
◦ Vascular bed: arteries, arterioles, capillaries, venules, and veins
4
Q
Microcirculatory system
A
◦ Portion of the vascular bed between the arterioles and venules.
5
Q
Pathophysiology
- Shock begins with?
- Alterations in at least one of four components:
A
- Shock begins with cardiovascular system failure - Alterations in at least one of four components: ◦ Blood volume ◦ Myocardial contractility ◦ Blood flow ◦ Vascular resistance
6
Q
Stages of Shock
Stage I:
A
- Stage I: Initiation
- Hypoperfusion: inadequate delivery or extraction of oxygen
- No obvious clinical signs
- Early, reversible
7
Q
Stages of Shock
Stage II:
A
- Stage II: Compensatory
- Sustained reduction in tissue perfusion Initiation of compensatory mechanisms
◦ Neural: baroreceptors and chemoreceptors
◦ Endocrine: ACTH and ADH
◦ Chemical
◦ Low oxygen tension
◦ Hyperventilation and respiratory alkalosis
8
Q
Stages of Shock
- Stage III:
A
- Stage III: Progressive
- Failure of compensatory mechanisms
- Profound cardiovascular effects
◦ Hypoperfusion
◦ Vasoconstriction
◦ Extremity ischemia
◦ Cellular hypoxia
◦ Anaerobic metabolism
◦ Lactic acid production (metabolic acidosis)
◦ Failure Na+/K+ pump
9
Q
Stages of Shock
- Stage III: Cont
A
- Stage III: Progressive (Cont.)
- Increased capillary hydrostatic pressure
- Intravascular fluid shifts
◦ Interstitial edema
◦ Decreased circulating intravascular volume - Decreased coronary perfusion
◦ Myocardial Depressant Factor (MDF) released
◦ Decreased myocardial contractility
10
Q
Stages of Shock
- Stage IV:
A
- Stage IV: Refractory
- Prolonged inadequate tissue perfusion
◦ Unresponsive to therapy
◦ Dysrhythmias
◦ Pulmonary edema
◦ Respiratory Distress Syndrome (RDS)
◦ Cerebral changes
◦ Renal decreased GFR
◦ Contributes to multiple organ dysfunction and death
11
Q
Systemic Inflammatory Response Syndrome (SIRS)
A
- Widespread systemic inflammatory response
- Associated with diverse disorders
◦ Infection
◦ Trauma
◦ Shock
◦ Pancreatitis
◦ Ischemia - Most frequently associated with sepsis
- Upsets balance between proinflammatory and antiinflammatory processes
- Normally localized process becomes systemic
- Release of mediators
◦ Increased permeability of endothelial wall
◦ Fluid shifts into intravascular spaces
◦ Depletion of intravascular volume = relative hypovolemia
12
Q
Shock Assessment for CNS
A
Central nervous system ◦ Most sensitive to early changes ◦ Initial stage ◦ Anxiety/restlessness ◦ Late stage: Coma
13
Q
Shock Assessment for Cardiovascular System
A
Cardiovascular system ◦ Blood pressure • Initial compensatory stages ◦ Slightly elevated ◦ Narrow pulse pressure • Late stages ◦ Pulses
14
Q
Shock Assessment for Pulmonary System
A
Pulmonary system
◦ Early stages
◦ Rapid, deep respirations
◦ Late stages: Shallow respirations, Poor gas exchange
15
Q
Shock Assessment for Renal System
A
Renal system ◦ Decreased glomerular filtration ◦ Activated renin- angiotensin-aldosterone system ◦ Sodium retention ◦ Water reabsorption ◦ Oliguria
16
Q
Shock Assessment for GI System
A
Gastrointestinal (GI) system
◦ Slowing intestinal activity
◦ Decreased bowel sounds, distension, nausea, and constipation
17
Q
Shock Assessment for Hepatic
A
Hepatic
◦ Altered liver enzymes
◦ Clotting disorders
◦ Increased susceptibility to infection
18
Q
Shock Assessment for Hematological System
A
Hematological ◦ Consumptive coagulopathy (DIC) ◦ Enhanced clotting/inhibited fibrinolysis ◦ Depletion of clotting factors ◦ Clotting in the microcirculation
19
Q
Shock Assessment for Integumentary System
A
Integumentary
◦ Skin color, temperature, texture, and turgor
◦ Cyanosis-late/unreliable sign
◦ Skin turgor evaluation
20
Q
Laboratory Values
- Various laboratory studies
- Serum lactate level
A
- Various laboratory studies ◦ Hemogram ◦ Serum chemistry ◦ Coagulation studies - Serum lactate level ◦ Measure of overall state of shock ◦ Indicator of decreased oxygen to cells ◦ Indicator of adequacy of resuscitation
21
Q
Management of Shock Domains
General management of shock
A
- Treat underlying cause ◦ Reverse altered circulatory component ◦ Maintain circulatory volume and organ perfusion - Domains-Combination treatment/therapy ◦ Fluids ◦ Oxygenation ◦ Pharmacotherapy ◦ Temperature ◦ Nutrition ◦ Skin integrity ◦ Psychological support ◦ Mechanical therapy ◦ Minimize oxygen consumption
22
Q
IV Access and Fluid Challenge
- Rapid infusion of a?
- Hemodilution of?
- Blood products
- Complications
A
- Two Peripheral IV catheter sites 14 or 16 Gauge OR Central Line
- Rapid infusion of a crystalloid solution
◦ Lactated Ringer’s or normal saline
◦ 250 mL up to 2 liters - Hemodilution of plasma protein
- Blood products
◦ IV access of a 20-gauge and higher
◦ Infuse with only normal saline
◦ Transfusion reaction; keep vein open with normal saline solution - Complications
◦ Pulmonary edema
◦ Transfusion reaction
23
Q
Oxygenation for shock/sepsis
A
- Maintain airway
- Oxygenation
- Mechanical ventilation
◦ Sedation
◦ Neuromuscular blockade
24
Q
Pharmacological Support for shock/sepsis
- Based on
- Central venous access
A
- Based on
- Cardiac output
- Heart rate
- Preload, afterload, and contractility
- Central venous access
- Administration
- Hemodynamic monitoring
25
Pharmacological Management for Cardiac output
- Chronotropic drugs
- Dysrhythmia agents
- Bradycardia in neurogenic shock may require atropine
26
Pharmacological Management for Preload
- Hypovolemic and distributive shock — IV fluid challenge - Cardiogenic shock — venous vasodilators
27
Pharmacological Management for Afterload
- Distributive shock — vasoconstriction
| - Cardiogenic shock — arterial vasodilators
28
Pharmacological Management for Contractility
- Cardiogenic shock — dobutamine
| - Beta blockers
29
Pharmacological Management (Cont.)
- Sedatives
- Analgesics
- Insulin (two consecutive glucose readings are above 180 mg/dL)
- Corticosteroids
- Antibiotics
- Low–molecular-weight heparin to prevent DVTs
- H2-receptor antagonist or protein pump inhibitor to prevent gastric stress ulceration
30
Body Temperature Regulation
- Rapid administration of IV fluids may reduce temperature
- Hypothermia
* Depresses cardiac contractility
* Impairs cardiac output
* Impairs oxygenation
- Fluid warmer
- Warm blankets
31
Nutritional Support
- Enteral nutrition
- Parenteral nutrition
- Enteral nutrition
◦ Within 24 to 48 hours of admission
◦ Preferred route of nutritional support
◦ Hindered by paralytic ileus
- Parenteral nutrition
◦ Given if enteral nutrition is not tolerated
32
Skin Integrity
| - Skin care
```
◦ Turn every 2 hours
◦ Protective barrier cream
◦ Pressure-relieving devices
◦ Elevate heels off the surface of the bed
◦ Foley catheter if indicated
```
33
Psychological Support
- Provide information to patient and family
| - Advance directive discussions
34
Classifications of Shock
- Hypovolemic shock
◦ Inadequate intravascular blood volume
- Cardiogenic shock
◦ Heart fails to act as an effective pump
- Obstructive shock
◦ Physical impairment to adequate circulating blood flow
- Distributive shock
◦ Widespread vasodilation and decreased vascular tone resulting in a relative hypovolemia
◦ Neurogenic
◦ Anaphylactic
◦ Septic
35
The nurse admits a 35-year-old patient to the emergency department following a 3-day history of nausea and vomiting. Vital signs assessed by the nurse include a BP of 70/50 mm Hg, HR 145 beats/min, RR 36 breaths/min, and SpO2 of 92% on room air. The nurse recognizes which classification of shock?
D. Hypovolemic
36
- Inadequate circulating volume
| - Causes
```
- Inadequate circulating volume
◦ Internal or external losses of blood or fluid
- Causes
◦ History
◦ External or internal loss of fluid
- Clinical manifestations
```
37
Hypovolemic Shock Management
- Identify underlying cause
- Restore circulating volume
- Appropriate fluid replacement
```
- Identify underlying cause
◦ Eliminate underlying cause
- Restore circulating volume
◦ Appropriate fluid selection
◦ Blood
◦ Isotonic crystalloids
◦ Fluid challenge (3-for-1 rule, 300-mL replacement for 100-mL blood loss)
- Appropriate fluid replacement
◦ Blood pressure (MAP 65-70 mm Hg)
◦ Hemodynamic values
◦ Urine output
◦ Laboratory results
```
38
Cardiogenic Shock
- Heart fails to act as an effective pump
◦ Decreased cardiac output; impaired perfusion
- Causes
◦ Left ventricular myocardial infarction
- Clinical manifestations
◦ Left ventricular failure
◦ Right ventricular failure
39
Cardiogenic Shock Management
- Pharmacological
- Increase cardiac output
- Decrease afterload
- Mechanical
```
- Pharmacological
◦ Decrease preload
◦ Diuretics, venous vasodilators
- Increase cardiac output
◦ Positive inotropes
- Decrease afterload
◦ Arterial vasodilators
- Mechanical
* IABD
* VAD
```
40
The nurse is caring for a patient being treated with an intraaortic balloon pump. Which intervention is most important to include in the patient’s plan of care?
A. Turning side to side every 2 hours
B. Assessing peripheral pulses
C. Padding bony prominences
D. Applying splint to affected limb
B. Assessing peripheral pulses
41
Obstructive Shock
- Physical impairment to adequate circulatory blood flow
- Causes
- Clinical manifestations
```
- Clinical manifestations
◦ Chest pain
◦ Dyspnea
◦ Jugular venous distension
◦ Hypoxia
◦ Cause-dependent findings
```
42
Management of Obstructive Shock
| Treat the cause
Treat the cause
◦ Cardiac tamponade (pericardiocentesis)
◦ Tension pneumothorax (thoracentesis)
43
Distributive Shock
```
Widespread vasodilation and decreased systemic vascular resistance
◦ Relative hypovolemia
- Types
◦ Neurogenic
◦ Anaphylactic
◦ Septic
```
44
Distributive Shock— Neurogenic
Interruption of?
Causes
- Interruption of sympathetic nervous system impulse transmission
- Causes
◦ Upper spinal cord injury
◦ Spinal anesthesia
◦ Nervous system damage
◦ Vasomotor depression
45
Distributive Shock—Neurogenic
| Clinical manifestations
◦ Bradycardia with hypotension
◦ Warm, dry, and flushed skin
◦ Hypothermia due to impaired thermoregulation
46
Distributive Shock—Neurogenic
| Management
Management
◦ Immobilization of spinal injuries
◦ Positioning of spinal- blocked patients
◦ IV fluids for hypotension
◦ Vasopressors (only after
volume is replaced)
◦ Slow rewarming to prevent further vasodilation
47
Distributive Shock—Anaphylactic
Introduction of an?
Causes
```
Introduction of an antigen into a sensitive individual, initiating an antigen-antibody response
◦ Release of vasoactive mediators
◦ Histamine
Causes
◦ Severe allergic reaction
```
48
Distributive Shock—Anaphylactic
| Clinical manifestations
```
Clinical manifestations
◦ Airway
◦ Upper
◦ Lower
◦ Angioedema
◦ Cardiovascular
◦ Integumentary
```
49
Distributive Shock—Anaphylactic
| Management
```
Management
◦ Removal of offending agent
◦ Airway
◦ Pharmacology
◦ Medications
◦ Fluid replacement
```
50
Distributive Shock—Septic
Follows invasion of a?
Causes
Clinical manifestations
```
- Follows invasion of a host by a microorganism
◦ Progressive
- Causes
◦ Immunosuppression
◦ Significant bacteremia
- Clinical manifestations
◦ Metabolic acidosis
◦ Acute encephalopathy
◦ Oliguria
◦ Hypoxemia
◦ Coagulation disorders
◦ Hypotension
◦ Decreased skin perfusion/mottling
◦ Petechiae
```
51
Distributive Shock—Septic
| Management – Prevention
Management – Prevention
◦ Hand hygiene
◦ Aseptic technique
◦ Identification of infection risk
52
Distributive Shock—Septic
| Management – Treatment
```
Management – Treatment
◦ Antibiotic therapy
◦ Early goal-directed therapy
◦ First 6 hours
◦ ACTH
◦ Glycemic control
◦ Temperature control
```
53
```
Multiple Organ Dysfunction Syndrome (MODS)
Progressive dysfunction of?
- Most common causes
- Can occur after any?
- Mortality rates
```
- Progressive dysfunction of two or more organ systems
- Most common causes
◦ Sepsis
◦ Septic shock
- Can occur after any severe injury or illness
- Mortality rates
◦ 45% to 55% with failure of two organ systems
◦ 80% with three or more
◦ 100% with three or more for more than 4 days
54
Multiple Organ Dysfunction Syndrome
- Maldistribution of?
- Organs severely affected
```
- Maldistribution of blood flow to various organs
◦ Impaired tissue perfusion
◦ Decreased oxygen supply to cells
- Organs severely affected
◦ Lungs
◦ Splanchnic bed
◦ Liver
◦ Kidneys
```
55
Multiple Organ Dysfunction Syndrome
| - Clinical manifestations
```
- Clinical manifestations
◦ Tachypnea/hypoxemia
◦ Petechiae/bleeding
◦ Jaundice
◦ Abdominal distension
◦ Oliguria>anuria
◦ Tachycardia
◦ Hypotension
◦ Change in level of consciousness
```
56
Multiple Organ Dysfunction Syndrome
| Management
```
- Management
◦ Control infection
◦ Antibiotics
◦ Provide adequate tissue oxygenation
◦ Maintain 88% to 92% arterial oxygen saturation
◦ Maintain hemoglobin above 7 to 9 g/dL
◦ Restore intravascular volume
◦ Aggressive fluid resuscitation
◦ Isotonic crystalloids
◦ Support organ function
```
57
Shock, Sepsis, and MODS
| - Patient outcomes
```
- Patient outcomes
◦ Improved tissue perfusion
◦ Alert, oriented
◦ Normotensive
◦ Warm, dry skin
◦ Adequate urine output
◦ Normal hemodynamics
◦ Lab values within normal limits
◦ Absence of infection
◦ Intact skin
```
