CVR scenario 1 (sepsis) Flashcards
Explain what sepsis is and how it results in decreased BP.
Include diagnosis and treatment
Sepsis is the body’s extreme response to an infection and is a life-threatening medical emergency.
Sepsis happens when an infection you already have —in your skin, lungs, urinary tract, or somewhere else—triggers a chain reaction throughout your body causing systemic inflammation.
It occurs when bacteria from the local infection spreads toxic substances into the bloodstream. The immune system can go into overdrive, causing inflammation throughout the entire body. In a typical infection, the cytokines will dilate the blood vessels at the site of the infection to allow more blood to pass through the area, carrying the cells and mediators needed to fight the bacteria. With the systemic response, all blood vessels dilate causing the blood pressure to drop. It slows down blood flow making our immune system less effective. The bacteria can damage vital organs and lack of blood flow can spark organ failure.
The immune system overreacts to an infection and starts to damage your body’s own tissues and organs. Also knows as blood poisoning.
It progresses in 3 stages:
- sepsis (high fever, high RR, high HR)
- severe sepsis (slurred speech, dizziness, confusion)
- septic shock (lung inflammation)
Diagnosis:
Bacteria in the blood or other body fluids.
Low blood pressure.
Altered kidney or liver function.
Treatment:
medications: IV antibiotics - Once a specific bacterium has been identified, a more focused antibiotic can be used. Ideally within 1 hour of hospital admission
IV fluids
O2 if levels are low
What questions could you ask for the subjective and why?
How did he feel prior to falling - did he feel dizzy?
How did he land and was his wife present - may have MSK problems such as fracture
Where does he live and does he have any adaptations?
What is his wife’s health like - will she be able to care for him or will she need help?
How progressed is his dementia - will it be useful to aim treatment at his wife
What type of diabetes and how does he manage it?
Any hobbies - used to make treatment saline
Goals and physio expectations?
Medications - doses, timings and side effects
THREADS
Red flags - unexplained weight loss, history of Ca, haemoptysis, infection, inflammation
Clinically reason treatment options for this pt giving indications, contraindications and cautions.
Focus on airway clearance and early mobilisations Positioning - 30-45 degrees of sitting is optimal to decrease aspiration pneumonia and ventilator associated pneumonia. Secretions - percussion = energy wave sent through the lungs to loosen the secretions so they can be mobilised up the airways - postural drainage = lower zone, lay left side so right lower zone is at the top - suctioning = removal of mobilised secretions from upper airway that are accessible by a catheter. ventilated pt is unable to expectorate secretions themselves so removal of airway secretions/foreign material by artificial means, using an applied negative pressure. Yanker suctioning removes mucus from the mouth. Contraindications: - facial trauma - thoracic surgery - haemoptysis - stridor - bronchospasm Cautions: - distress/aggression - CVR instability - intact gag reflex - raised intercranial pressure - trauma to trachea STERILE PROCEDURE - MHI = helps with lung re-expansion and aids secretion clearance when used in conjunction with suctioning. It not only increases the tidal volume but the quick release of the resuscitation bag increases the elastic recoil of the lung and therefore increases the expiratory flow rate. The expiratory flow rate is necessary to mobilise secretions Contraindications: - undrained pneumothorax - CV instability - raised intercranial pressure - acute head injury - extreme levels of ventilatory support Cautions: - bronchospasm - BP<80mmHg - distress/aggression - recent lung surgery - subcutaneous emphysmea (air under the skin) NON STERILE PROCEDURE.
Low pO2
- increase PEEP: improves oxygenation by ‘recruiting’ otherwise closed alveoli, thereby increasing the surface area for gas exchange. PEEP causes an increase in intrathoracic pressure.
Infection
- prescribe antiobiotics (ceftriaxone)
- intravenous fluids
How does PEEP affect pO2 and BP
PEEP ensures there is always pressure left in the lungs after expiration, so ‘splints’ open the airways.
Improves oxygenation by ‘recruiting’ otherwise closed alveoli, thereby increasing the surface area for gas exchange. Increases the functional residual capacity- the reserve in the patient’s lungs between breaths which will also help improve oxygenation.
Increased PEEP increases intrathoracic pressure which creates pressure on the heart and in the right atrium. This slows VR as the pressure gradient between RA and vena cava is reduced. This means cardiac output is also reduced, resulting in a reduced BP
When should you wean a pt, how would you do it and what difficulties can occur?
When to wean:
- condition of pt has improved
- normalised I:E ratio
- reduced FiO2 (<0.5)
- no requirements for high PEEP
- appropriate RR
Weaning is performed through a trial of spontaneous breathing through the ET tube and eventually extubation. It involves vastly reducing the PS and analysing the effects. Performed by connecting humidified O2 directly to the ET tube with a t-piece.
Can be endurance or interval.
Endurance: weaning down the settings gradually over a few days
Interval: periods of time with pt completely weaned off, rest breaks are needed
Weaning trials should happen every day as research has shown pts will remain on ventilators longer than they should be. Increases the risk of contracting pneumonia.
Difficulties in weaning:
- inspiratory muscle atrophy
- fatigue
- fear of suffocating
Explain what the mucociliary escalator is and the effects a ventilator has on it
The role of the mucociliary escalator is to trap inhaled particles before they reach the deeper, more vulnerable levels of the respiratory system (trachea, bronchi, bronchiole, and alveoli). It also stops the epithelial cells from coming into contact with any potentially toxic materials and microorganisms.
Goblet cells are modified epithelial cells that secrete mucus on the surface of mucous membranes of the airways. They produce approx 100ml of mucus/day.
Mucus has 2 layers:
- viscous (gel) layer, sits on the top. it is more sticky and acts like flypaper
- aqueous (sol) layer, sits below. is more fluid-like and bathes the cilia.
The cilia are small hair-like structures with hooks in the gel layer and they beat in a coordinated fashion to propel the mucus. 20 cycles/second
When on a ventilator, the air bypasses the mucociliary transport system and so is not humidified. This dehydrates the mucus and creates thick and immobile mucus which hinders ciliary motion. Secretions remain in the lungs which increases the chance of infections - as it is warm in the lungs and the mucus is moist. Overall the O2 saturation is decreased as airways are obstructed by secretions.
What other information about this pt would you want?
- Chest X-ray
- if pt has ventilator-acquired pneumonia it will show up as white spots in the lungs
- check for pacemaker etc
- consolidation in both lungs may be apparent if pt has ARDS
- ARDS can cause pneumothorax which is more dangerous when on mechanical ventilation
How does sepsis cause ARDS?
Sepsis is one the most common causes of acute respiratory distress syndrome (ARDS), in which the lungs are injured by circulating inflammatory mediators, A direct or indirect injury to the epithelial cells of the lung increases alveolar capillary permeability, causing ensuing alveolar edema (fluid leaks into the alveoli), resulting in severely impaired gas exchange
ARDS is a complication of severe sepsis.
Sepsis-induced ARDS is a form of severe organ failure,
ARDS is a life-threatening condition where the lungs cannot provide the body’s vital organs with enough oxygen.
Complete an A-E assessment for this pt
A = patent airway, artificial airway - ETT
B = Invasive PRVC with TV 500ml, RR 25, PEEP 6, FiO2 0.4, Sats 92%, PAP 30
ABGs
Observation - posture, hypoxic (blue fingers)
Auscultation - expecting crackles right lower zone
Percussion note - dull = abscence of air
Palpable fremitus - feel his auscultation sites
C = BP, HR, Temp, UO
pacemaker?
high HR and temp shows infection
dehydration causes viscous secretions
D = AVPU - voice (sedated)
E = pressure sores
Weight = 90kg, Height = 6”2 - BMI = slightly overweight
Any MSK problems
Finger clubbing, tremor
Peripheral oedema
Attachments
Urinary catheter with IV giving fluids.
