class 1 Flashcards
septic shock
what is shock?
A condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organ and cellular function
what is Sepsis?
life-threatening organ dysfunction caused by a dysregulated host response to infection (immune response is way too dramatised)
what is septic shock?
severe sepsis with hypotension and perfusion abnormalities *DESPITE fluid resuscitation
what is distributive shock?
occurs during septic shock
blood volume pools peripherally and there is dec blood flow to organs which causes decreased tissue perfusion
what causes distributive shock
decrease SVR d/t arterial dilation allowing blood to pool peripherally
required for blood pressure regulation in sepsis
adequate blood volume
cardiac pump
vasculature
MAP and blood pressure regulation
tissue and organ perfusion depend on MAP
-Must maintain a MAP of 65 or greater for organ perfusion.
what is MAP?
average calculated blood pressure during 1 cardiac cycle
MAP= SBP + 2(DBP) /3
signs and symptoms of septic SHOCK
-tachycardia
-tachypnea
-hypotension
-hyperthermia
-WBC changes (inc or dec)
-cognitive/behavioural changes
-s & s of infection
-dec urine output
-N/V, dec bowel sounds/motility
-hyperglycemia/insulin resistance
-skin is mottled
diagnostic criteria for sepsis (SOFA assessment)
-#1 infection (documented or suspected) plus one or more:
-altered mental status
-Fever
-HR >90
-hyperglycemia (>7.77) with NO DM
-hypothermia (<36)
-edema or positive fluid balance (>20mL/Kg over 24h)
-tachypnea (>22)
-inc CRP
-inc procalcitonin
-leukocytosis (WBC>12)
-leukopenia (WBC <4)
-normal WBC BUT >10% immature forms
-SBP <90 or MAP <70, or dec SBP in >40
-acute oliguria despite fluids
-arterial hypoxemia (<300)
-abnormal coags (INR >1.5 OR PTT >60s)
-bilirubin >68.4
-ileus
-serum creatinine inc (>44.2)
-thrombocytopenia (plts <100)
-dec cap refill
-inc lactate
what is used to diagnose septic shock
SOFA & qSOFA
-lab values (WBC, neutrophils, BUN, lactate, CRP, procalcitonin)
-clinical manifestations
-TREWS
interprofessional care in successful sepsis management
-identification of patients at risk for shock and prompt intervention
-integration of the patient’s history, physical exam, clinical fidnings
management of shock
-#1 ensure patient airway
-maximize oxygen delivery (inc supply dec demand)
-lab draw/cultures
-large bore iv access and aggressive fluid resus w isotonic crystalloids (30ml/kg)
-art line for BP monitoring, CVAD for pressors
-pressors if non responsive to fluids
-catheter
-PPI or h2 receptor antagonist for stress ulcer prophylaxis
-neuromuscular block for sedation + dec metabolic demand
fluid resus in septic shock
-6-10L crystalloids (wont alter electrolytes in plasma but can cause hyperchloremia) and 2-4L colloids (lit doesn’t show inc outcomes) in first 6 hours to get target CVP (30mL/kg)
-after 8L or more can add pressors
how is fluid responsiveness assessed in shock management
-clinic assessment (vitals q15, reactive BP, perfusion pressures, cap refill, I&O, Cardiac output, skin temp,
-hemodynamic parameters
-monitor trends in BP
-foley for I&O
-goal: restore tissue perfusion
medications in shock management
-broad spectrum ABX AFTERR cultures are drawn, then abx can be changed w sensitivity
-pressors if unresponsive to fluid resus/ achieve & maintain MAP >65
-IV steroids to dec immune response (caution for hyperglycemia)
-stress ulcer prophylaxis (PPI or H2RA)
-DVT prophylaxis with lovenox
-insulin to keep glucose <10
nutrition in shock management
-intiate enteral feeds within first 24h (ideal)
-initiate parenteral feeds if enteral is not tolerated or they fail to meet caloric requirements
-monitor weight (reflects fluid status mostly), protein, nitrogen balance, BUN, glucose, electrolytes, serum protein
assessment when caring for a known septic shock pt
-ABCs
-assessments around tissue perfusion:
-vitals q15
-peripheral pulses
-cardio & pulmonary assessment
-LOC
-Cap refill
-skin temp/colour/moisture
-strict I&O
-brief history :(events prior/onset/duration), details of care received before hospitalization, allergies, vaccinations (?source, R/O causative viruses)
goals for patient with septic shock
-restore adequate tissue perfusion
-normal vital signs, MAP >65
-return/recovery of organ function
-prevention of progress to prolonged states of hypoperfusion
acute interventions for septic shock tx
-evaluate response to therapies
-identify trends to detect changes in condition
-provide emotional support (pts are usually not sedated)
-collaborate with HC team PRN
-monitor ongoing physical and emotional status to detect subtle changes in pt condition
-plan to implement nursing interventions and therapies
implementation of assessment for neuro system in shock
orientation
LOC
implementation of assessment for cardiac system in shock
-continous EKG
-vital signs, cap refill
-hemodynamic parameters
-heart sounds: murmur S3 and S4
implementation of assessment for respiratory system in shock
-resp rate, depth, rhythm
-breath sounds (pulm edema)
-continous o2 monitor (ear d/t blood shunting)
-ABGs
-intubation/vent assessments if needed
implementation of assessment for GI system in shock
-NG drainage (if not used for feeds) and stools for occult blood
-I&O, fluid and lytes balance
-oral care if o2 req allow
-passive/active ROM to dec muscle wasting
