Pulmonary Artery Pressure To assess the left ventricular end-diastolic pressure indirectly To evaluate the hemodynamic response to fluid therapy, rx, & other treatments

To obtain accurate central vascular pressures in the presence of low CO To obtain mixed venous blood samples To measure CO

Critical Care Flashcards by Kaylie Krauzyk

Concepts

☆ Gas exchange
☆ Perfusion
☆ Clotting

Conditions characterized by (any or all):

Profound alteration of homeostasis
Serious instability of vital functions
Threat to life

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Examples of critical illness

GSWs
Traumatic injuries
Shock
Surgery
Cardiovascular
Cancer

Nurse’s Role

✯ Patient assessment
✯ Monitor ventilator
✯ Prevent complications
✯ Manage complications

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Critical care includes:

Hemodynamic monitoring
Mechanical ventilation
Critical illnesses
Assessment

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Critical Care

✪ The nurse must continuously assess a critically ill patient

✪ Pts will be monitored & may be intubated

Some problems that can occur also are:

Infection
Nutrition
Anxiety
Sleeping
Immobility
Complications
Communication
Family

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Sensory overload ☞ ICU psychosis

! Is a temporary cond that can be treated; is no diff b/t ICU psychosis & delirium

! An incr prevalent problem & may occur @ any time during recovery from an acute illness or traumatic event; can be dangerous

! May last 24 hrs or even up to 2 wks w/various sx’s occurring @ diff times

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What is ICU psychosis?

A disorder in which pts in an ICU or a similar setting experience a cluster of serious psychiatric sx’s; aka ICU synd; is also a form of delirium, or acute brain failure

What causes ICU psychosis?

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Environmental Causes

☞ Sensory deprivation
- A pt being put in a room that often has no windows, & is away from family, friends, & all that is familiar & comforting

☞ Sleep dist & deprivation
- The constant dist & noise w/the hosp staff coming @ all hrs to check VS, give rx’s, etc.

☞ Continuous light lvls
- Continuous disruption of the normal biorhythms w/lights on continually (no ref to day or night)

☞ Stress
- Pts in an ICU freq feel the almost total loss of control over their life

☞ Lack of orientation
- A pt’s loss of time & date

☞ Medical monitoring
- The cont monitoring of the pt’s VS, & the noise monitoring devices make can be disturbing & create sensory overload

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Medical Causes

☞ Pain
- Which may not be adequately controlled in an ICU

☞ Critical Illness
- The pathophysiology of the dz, illness, or traumatic event - the stress on the body during an illness can cause a variety of sx’s

☞ Medication reaction or s/e’s
- The admin of rx’s typ given to the pt in the hosp setting that they have not taken before

☞ Infection
- Creating fever & toxins in the body

☞ Metabolic dist
- Electrolyte imbalance, hypoxia (low blood O2 lvls), & elevated LFT’s

☞ Heart failure
- Inadequate CO

☞ Cumulative analgesia
- The inability to feel pain while still conscious

☞ Dehydration

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Critical Care: Assessment

Respiratory
Cardiac
Complications
> Watch for subtle changes

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Respiratory Assessment

How is the patient?
- What is the rate?
- Is breathing normal?
- What are the breath sounds?
- What are the ABGs?

☆ Pts who already have chronic resp dz, when there’s a minor change in resp problems, it can mean a severe gas exchange problem

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Normal ABG’s

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Cardiac Assessment

What is the HR?

What is the rate/rhythm?

What is the BP?

MAP

Must be @ least 60 mmHg to maintain adequate blood flow through coronary arteries

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Unable pt may need -
- Hemodynamic monitoring
- Mechanical ventilation
- Pacemaker
- Foley catheter and/or dialysis
- IABP or VAD
- Medications

Hemodynamic Monitoring

⭐ Invasive
- Arterial line
- CVP monitoring
- Pulmonary artery catheter
- Cardiac assist devices
- Intra Aortic Ballon Pump
- VAD
- ICP monitoring

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Central Venous Pressure

Used to assess right ventricular function systemic fluid status

Normal CVP is __-__ mmHg

0-8

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CVP is elevated by

! over hydration
! HF
! positive pressure breathing, straining

CVP decreases with

hypovolemic shock from hemorrhage, fluid shift, dehydration
negative pressure breathing which occurs when the pt demonstrates retractions or mechanical negative pressure which is sometimes used for high spinal cord inj

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Nurse’s Role

Dressing changes
Pressure monitoring
Assess for complications
> Infection
> Pneumothorax

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Pulmonary Artery Pressure

To assess the left ventricular end-diastolic pressure indirectly
To evaluate the hemodynamic response to fluid therapy, rx, & other treatments

To obtain accurate central vascular pressures in the presence of low CO
To obtain mixed venous blood samples
To measure CO

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Pulmonary Artery Catheter

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Nursing Responsibilities Post-Insertion

✓ Make sure that PAC cap is in the lock position so catheter will not migrate

✓ Secure catheter to pt w/tape

✓ Apply occlusive drsg

✓ Set high & low alarms on monitor as appropriate for pt

✓ Double check to assure that physician has disposed of all sharps

✓ Double check to see that cxray was ordered

✓ VS, pulm artery pressures, SvO2 saturation (immediately after insertion & per standard)

✓ PAC insertion site & how far it was advanced (in cm)

✓ Amt of air req’d to inflate balloon to obtain PAWP pressure

✓ Verification of xray placement of PAC

✓ Print & place waveform strips on nursing flowsheet

✓ Pt tolerance of procedure & rx’s given during procedure

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Complications of Catheter Placements

❌ Hemorrhage (on warfarin, clotting disorders)
❌ Arrhythmias
❌ Perforations

❌ Catheter occlusion (by a blood clot or kinked tube)
❌ Infection (asepsis needed)
❌ Air embolus (air entering venous system)
❌ Catheter displacement (if CVC moves into chambers of the heart)

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Pulmonary Artery Catheter: Nurse’s Role

☞ Site care

☞ Monitor for infection

☞ Monitor for complications
- PA rupture, thromboembolism, air embolism

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Using a manometer

☞ CVP is usually recorded @ the mid-axillary line where the manometer arm or transducer is lvl w/the phlebostatic axis

This is where the 4th ICS & mid-axillary line cross each other allowing the measurement to be as close to the right atrium as possible

Using a transducer

☞ Transducer is used to convert the pressure from right atrium into electrical signal

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Swan Ganz Catheter

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Parameters

CVP: 0-8 mmHg

PAP (mmHg)
Systolic: 15-30
Diastolic: 4-12
Mean: 9-16
PAWP: 2-12

CO: 4-6 L/min

PVR: 22-180

SVR: 800-1400

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Intra Aortic Balloon Pump ☞ Catheter w/an inflatable balloon @ the end; 30-40 cc ☞ Inserted via the femoral artery & the balloon is positioned in the descending thoracic aorta

☞ Uses internal counterpulsation through the regular inflation & deflation of the balloon to augment the pumping action of the heart ☞ Ballon inflates during diastole & deflates before systole; timing of the inflation & deflation is initially done using the EKG & fine tuning timing using the arterial pressure wave

*What does this do?* Helps with pumping action of the heart to decrease workload of heart (decrease after load); also increases CO, perfusion

Ventricular Assist Device * Mechanical pump * "Bridge to transplant" * Alternative to heart transplant

Acute Respiratory Failure: ABGs **Oxygenation Failure** PaO2 < ___ mmHg (hypoxemic/oxygenation failure)

OR **Ventilation Failure** PaCO2 > ___ mmHg with pH < ___ = ventilatory failure (hypercapnic ventricular failure)

45 7.35

SaO2 is <90% in both cases

Oxygenation failure, ventilatory failure, or BOTH ventilatory/oxygenation failure patient is always hypoxemic

Ventilatory Failure ☞ Physical problem of lungs or chest wall ☞ Defect in resp control center in brain ☞ Poor function of resp muscles, esp diaphragm ☞ Extrapulmonary & intrapulmonary causes

☞ CNS depression (opioid overdose) ☞ COPD ☞ Brain trauma ☞ High SCI's ☞ Neuromuscular diseases like ALS

Oxygenation Failure ☞ Insuff oxygenation of pulmonary blood @ alveolar lvl ☞ Ventilation normal, lung perf decreased ☞ Right to left shunting of blood ☞ V/Q mismatch ☞ Low partial pressure of O2 ☞ Abn Hgb

☞ Low atmospheric oxygen conc ☞ High altitudes, closed spaces, smoke inhalation, CO poisoning ☞ PNA ☞ CHF w/pulm edema, PE ☞ ARDS ☞ Interstitial pneumonitis - fibrosis ☞ Hypovolemic shock ☞ Hypoventilation ☞ Complications of nitroprusside therapy: thiocyanate toxicity, methemoglobinemia

Combined Ventilatory/Oxygenation Failure > Often occurs in pts w/abn lungs - Chronic bronchitis - Emphysema - Asthma attack - CF

> Diseased bronchioles & alveoli cause oxygenation failure; work of breathing increases; resp muscles unable to function effectively

Manifestations: ARF ABG studies are reviewed to most accurately identify the degree of hypoxia & hypercarbia

Impending Resp Failure ✏ Restlessness, irritability, confusion ✏ Dyspnea, orthopnea ✏ Resp rate/pattern changes ✏ Lung sound changes ✏ O2 sats may/may not be decr / End tidal CO2 may be more accurate

Signs of Deterioration ✏ Positioning of pt ✏ Inability to speak ✏ Change in I/E ratio ✏ Muscle retractions/access muscle use

✏ Incr breath effort ✏ Crackles/rhonchi ✏ Absent/dim lung sound ✏ Pleural friction ✏ Bronchial sounds/lung periphery

Dyspnea Interventions ✐ Oxygen therapy ✐ Position of comfort ✐ Breathing exercises ✐ Relaxation, diversion, guided imagery ✐ Energy-conserving measures ✐ Meds: MDI's, corticosteroids, diuretics, analgesics, neuromuscular blockade drugs

Resp Failure/Mechanical Ventilation *Goal is to normalize ABG through adequate oxygenation & ventilation*

Endotracheal Tube Verify tube placement: - End-tidal CO2 lvls - Cxr - Assess for breath sounds bilaterally, symmetrical chest movement, air emerging from ET tube

Stabilizing the Tube If there is a nasotracheal intubation, do not tape the tube too tightly to the nose or skin breakdown will occur on the naris

Critical Care - Mechanical Ventilation * (+) or (-) pressure breathing device * Maintains ventilation & oxygen delivery for an extended period of time

Modes of Ventilation Mechanism of support - Pressure mode - Volume mode Amount of support - Assist control - SIMV - CPAP

Common Terms

? Is the conc of O2 in the inspired gas; between 0.21-1.0

FiO2 (fraction of inspired oxygen)

? Is the volume of gas, either inhaled or exhaled, during a breath & commonly expressed in milliliters; 8-12 mL/kg

Vt (tidal volume)

? Is the # of breaths per minute that the ventilator delivers

Respiratory rate (RR) or frequency

? Is the average volume of gas entering or leaving the lungs per minute, commonly expressed in liters per minute; normal is between 5-10 L/min

VE (minute ventilation) VE = Vt x RR

? Is the highest flow or speed that is set to deliver the Vt during inspiration, usually measured in liters per minute When it's set higher, the speed of gas delivery is faster & inspiratory time is shorter

Peak flow rate or peak inspiratory flow

? Is the amt of positive pressure that is maintained @ end expiration Is expressed in centimeters of water; purpose is to increase end- expiratory lung volume & reduce air-space closure @ end-expiration

PEEP

? Is continuous pressurization of the breathing circuit when a pt breathes spontaneously

CPAP

Indications for Mechanical Ventilation ✐ Treat actual or impending hypoxemia & hypoxia ✐ Maintain positive pressure in airways ✐ Lessen the WOB ✐ Provide ventilation for pts w/ineffective ventilation

Indications for Intubation ✐ Respiratory failure ✐ Airway maintenance ✐ Prevention of aspiration ✐ Removal of secretions ✐ Provision of large O2 concentrations

PaO2 < 50 mmHg & FiO2 > 0.60 PaCO2 > 50 mmHg w/pH <7.25

Vital capacity <2x tidal volume TV = air forced out, VC = maximum amt of gas expelled before a full inspiration Negative inspiratory force <25 cmH2O Resp rate >35/min

Classifications of Ventilators ✐ Negative pressure ventilators - Iron Lung (Drinker Respirator Tank) - Body Wrap (Pneumo wrap) & Chest Cuirass (tortoise shell)

✐ Positive pressure ventilators - Pressure cycled ventilators - Time cycled ventilators - Volume cycled ventilators - Noninvasive positive pressure ventilator

Endotracheal Tube Intubation * Sedation * Loose teeth * Assess cuff * Ambu 100% O2 * Suction equipment

* Breath sounds * Chest movement * Cxr * Documentation * Secure tape

Mechanical Ventilation ⭒ Behavior ⭒ Breathing ⭒ Color ⭒ Pulse

⭒ pH 7.35-7.45 ⭒ PaO2 90-100 mmHg ⭒ PaCO2 35-45 mmHg ⭒ Bicarb 21-26 mEq/L

**Acute Respiratory Failure is defined as a decrease of arterial oxygen tension < _ mmHg & an increase in arterial CO2 tension > _ mmHg with an arterial pH of < _**

50 50 7.35

ET Tube Position: Types of artificial airways ➙ Oropharyngeal airway ➙ Nasopharyngeal airway ➙ Endotracheal tube ➙ Tracheostomy

Ventilator Settings ➩ Respiratory rate - # breaths ventilator will deliver/min ➩ Tidal volume - Volume chosen based on body wt; 10-15 cc/kg body wt ➩ FiO2 - 21-100% possible but conc <50% are most desirable & prevent O2 toxicity ➩ Sighs - A periodic deep breath delivered by the ventilator; often 1.5-2x the preset Vt

➩ PEEP - Maintains pressure in the airways @ the end of expiration preventing alveolar collapse; usually used to treat persistent hypoxemia that doesn't improve w/acceptable O2; PEEP added w/FiO2 60% or > ➩ CPAP - Used only w/spontaneous ventilation; pt breathes spontaneously through ventilator @ an elevated baseline pressure throughout breathing cycle ➩ Alarms

Troubleshooting the Mechanical Ventilator ➵ Increased peak airway pressure - Coughing, plugged airway tube, tube kinked, decreased lung compliance, pneumothorax, atelectasis, bronchospasm

➵ Decrease in pressure or loss of volume - Increased compliance, leak in ventilator or tubing, cuff on tube/humidifier not tight

***IF THE VENTILATOR SYSTEM MALFUNCTIONS AND THE PROBLEM CANNOT BE IDENTIFIED AND/OR CORRECTED IMMEDIATELY, THE NURSE MUST VENTILATE THE PATIENT WITH A MANUAL RESUSCITATION BAG UNTIL THE PROBLEM IS RESOLVED***

Complications of Mechanical Ventilation ⌦ Infection r/t invasive procedures ⌦ Ineffective breathing pattern r/t pulmonary barotrauma ⌦ Decreased CO r/t decreased venous return; altered preload ⌦ Fluid vol imbalance r/t retention of sodium & water

⇩ venous return = ⇩ BP, ⇩ u/o, ⇩ LOC Cardiac problems = hypotension & fluid retention ! avoid Valsalva maneuver ADH production also < exercise, < muscle tone - FLUID VOLUME DISTURBANCE < REM sleep > Breathing is hard work - NUTRITION concern

Lung problems from mechanical ventilation include... ➢ Barotrauma ➢ Volutrauma ➢ Atelectrauma

➢ Biotrauma (inflammatory response-mediated damage to alveoli) ➢ Ventilator-associated lung inj/ventilator-induced lung inj (damage from prolonged ventilation causing loss of surfactant, incr inflammation, fluid leakage, & noncardiac pulm edema) ➢ Acid-base imbalance

Complications

VAP Intubation bypasses & impairs many of the resp system's normal defense mechanisms & also provides a direct path for pathogens into the lungs

Volutrauma aka alveolar overdistension; results from high tidal volumes during mechanical ventilation

Barotrauma Accompanied by increased microvascular permeability If alveoli rupture d/t incr pressure, air can leak into pulm interstitial tissue Severity depends on the amt of air released & may range from benign SC emphysema to pneumothorax or pneumopericardium resulting in cardiac tamponade

Cardiovascular compromise (+) pressure incr intrathoracic pressure & reduces venous return to the right side of the heart, impairing cardiac function When preload falls, so does CO This can lead to hepatic & renal dysfunction

GI complications Mucosal ischemia & 2° bleeding may result from decr CO & incr gastric venous pressure Incr vent pressure may overcome the resistance of the lwr esophageal sphincter, causing gastric distention & vomiting

Patient-ventilator dyssynchrony Pt fighting ventilator Intrinsic PEEP, excessive Vt, & reduced expiratory time If doesn't resolve dyssynchrony, consider obtaining order for mild sedation

Oxygen toxicity Lit suggests attaining an FiO2 of 60% or less within the first 24 hrs of MV If nec, PEEP should be considered a means to improve oxygenation while a safe FiO2 is maintained

Endotracheal Tube Suctioning *Monitor HR, EKG, pulse ox, BP* 100% O2 Ambu NS Suction Sterile gloves Goggles 80-120 mmHg suction; 10-15 sec suction ↓

**Suctioning Complications** Hypoxemia Airway trauma Cardiac dysrhythmias Bronchospasm Infection Atelectasis

Hypoxemia Prevention 1) Supplemental O2 2) Hyperoxygenation 3) Hyperinflation > TV 4) Hyperventilation > RR 5) < O2 ventricular dysarrhythmia assess before & after suctioning

Suctioning

Monitor Ventilator

Patient Assessment ☞ Frequent body assessment - pulmonary ☞ VS, pulse ox ☞ ABGs ☞ Check for tracheal deviation ☞ Monitor airway ☞ Assess secretions ☞ Assess mouth ☞ Monitor gastric distention ☞ Assess breakdown ☞ Monitor for hemodynamic compromise

Prevent Complications ☞ Secure ET ☞ Maintain cuff pressure (**20 mmHg**) ☞ Document position at lips using cm ☞ Soft restraints as needed ☞ Oral care ☞ Suctions prn ☞ Bedside resuscitation bag w/face mask

Mediastinal Chest Tubes

Acute Respiratory Distress Syndrome (ARDS) Is acute resp failure w/these features ☞ Hypoxemia that persists even when 100% O2 is given (refractory hypoxemia, a cardinal feature) ☞ Decreased pulmonary compliance ☞ Dyspnea ☞ Noncardiac-associated bilat pulm edema ☞ Dense pulm infiltrates seen on xr (ground-glass appearance)

☞ Lower PaO2 value on ABG ☞ Refractory hypoxemia ☞ No cardiac involvement on ECG ☞ Low-to-normal PCWP

PCWP, pulmonary capillary wedge pressure, less than ___ mmHg, favors lung inj over pulm edema

***ARDS, an intense form of hypoxemic resp failure, may be one of the most elusive diagnoses encountered in the ICU***

No sensitive or spec markers for ARDS inj & no pharmacologic therapeutic protocol effectively modifies its clinical course or decreases assoc mortality rates

✨ Acute onset ✨ Diffuse pulm infiltrates ✨ No evidence of elevated left atrial pressure ✨ Severe hypoxemia

✨ Decrease pulmonary compliance ✨ Non-cardiogenic form of pulm edema: PCWP <18 mmHg

Common Causes of Acute Lung Injury ☠ Shock / trauma ☠ Serious nervous system inj ☠ Pancreatitis ☠ Fat & amniotic fluid emboli ☠ Pulm infections / sepsis

☠ Inhalation of toxic gases (smoke, oxygen) ☠ Pulm aspiration (esp of stomach contents) ☠ Drug ingestion (e.g., heroin, opioids, asa) ☠ Hemolytic disorders ☠ Multiple blood transfusions ☠ Cardiopulmonary bypass ☠ Submersion in water w/water aspiration (esp in fresh water)

ARDS can occur after an acute lung inj in people who have no pulmonary disease, as a result of sepsis, burns, pancreatitis, trauma, & transfusion reactions; mortality rate ~60% TRIGGER is the systemic inflammatory response

Site of the inj is @ the capillary-alveolar lvl; normally only permeable to very small molecules; w/inj the membrane becomes MORE permeable & thus lets in all kinds of molecules, debris, proteins, fluids, etc. & causes problems Surfactant reduced & alveoli become unstable & fill w/fluid; then are no longer able to create a gas exchange

Lung compliance reduced, more fluid leaks in, hypoxemia results & V/P mismatch

⭐ **Diffuse, non-uniform structural damage to the alveolar-capillary membrane** remains the *hallmark pathophysiologic conseq of ARDS* Can involve endothelial, epithelial, or both layers concurrently

☠ alcohol consumption ☠ cirrhosis ☠ cigarette smoking ☠ advanced age ☠ DM ↓

Have been implicated as incr risk of ARDS

**The hallmark clinical manifestation of ARDS is severe, progressive, refractory hypoxemia, indicating a right-to-left intrapulmonary shunt through atelectatic & consolidated lung units & a low V/Q ratio**

May also be a worsening PaO2/FiO2 ratio

Assessment Findings ☞ Dyspnea ☞ Tachycardia ☞ Fine crackles ☞ Accessory muscles ☞ Fatigue ☞ Restlessness ☞ Apprehension ☞ Agitation

☞ Hyperpnea ☞ Noisy respirations ☞ Cyanosis ☞ Pallor ☞ Retractions/intercostal or substernal

ARDS PAP (pulmonary artery pressure) ⇧ PAWP ⇩ or = 12 mmHg [indirect measurement of LAP] no clinical evidence of ⇧ LAP

ABG ⇩ PaO2 despite ⇧ in supplemental O2 PaCO2 initially low d/t hyperventilation then ⇧ PaCO2 Cxr Normal leading to infiltrates, consolidation, "white out"

Interventions ✽ ET intubation, conventional mechanical ventilation w/PEEP or CPAP ✽ Drug & fluid therapy, abx, antioxidants, surfactant replacement

✽ Nutrition therapy - enteral or parenteral ✽ Case management - 3 phases - Exudative, fibroproliferative, resolution

___ phase Incr lung damage leads to pulm HTN & fibrosis Body attempts to repair the damage, & incr lung involvement reduces gas exchange & oxygenation MODS can occur Interventions focus on delivering adequate O2, preventing compl, & supporting the lungs

Fibroproliferative

___ phase Usually occurring after 14 days, end of inj can occur If not, pt either dies or has chronic dz; fibrosis may or may not occur

Resolution

___ phase Includes early changes of dyspnea & tachypnea resulting from the alveoli becoming fluid-filled & from pulm shunting & atelectasis Early int focus on supporting pt & providing O2

Exudative

Treatment ⭐ Prone position ⭐ Mechanical ventilation - PEEP ⭐ Treating the etiology ⭐ Fluid management ⭐ Prevent complications

Contraindications to prone positioning - ❌ spinal instability ❌ IICP ❌ abdominal compartment synd ❌ shock ❌ multiple trauma ❌ pregnancy ❌ abd surgery & extreme obesity

Disseminated Intravascular Coagulation (All Over / in Vessels / clotting) ❌ severe sepsis & septic shock; infections; solid cancers; hematologic malignancies; obstetric crises; trauma; aneurysm; liver diseases *DIC resulting from sepsis, hematologic malignancy or obstetric dz can be successfully treated for DIC, whereas DIC assoc w/solid cancers may not respond to standard treatments*

Manifestations ☞ Bleeding ☞ Renal dysfunction ☞ Hepatic dysfunction ☞ Resp dysfunction ☞ Shock ☞ CNS dysfunction

Selected Lab Tests ⬇ Platelet count Fibrinogen

⬆ PT PTT TT D-Dimer FDP Euglobin clot lysis ≤ 1 hr

Treatment for DIC ✧ Heparin ✧ Blood product replacement ✧ Treat underlying disorder ✧ Supportive therapy - Dialysis - Ventilator

Multiple Organ Dysfunction Syndrome (MODS) Systemic Inflammatory Response Syndrome / Multi-System Organ Failure ***Overwhelming infection which causes vasodilation & ⬇ perfusion***

Failure of 3 or more organs = 90-95% mortality rate High risk: shock, ruptured aneurysm, acute pancreatitis TREATMENT GOALS: arrest acute process, re-establish homeostasis, prevent re-occurrence