MODS, SIRS, Sepsis Flashcards
Shock continuum
hypoperfusion hypoxia cellular dysfunction cellular death organ dysfunction organ death
MODS
at least 2 organ systems severely deranged for at least 24 hours in the setting of sepsis, trauma, surgery, burns, severe inflammation
inflammatory response+hypotension+hypoxia
Poor prognosis
2 organ systems=40% mortality
3 organ systems >72=80% mortality
hypovolemic shock
acute blood loss, dehydration, third spacing
dry, tight
fluid resuscitation 3:1 (3mL isotonic crystalloid for every 1mL est blood loss)
cardiogenic shock
pump failure, MI (be aware PE and cardiac tamponade sometimes called obstructive shock)
wet, tight
distributive shock
aka vasogenic, tone issue
anaphylactic: antigen triggers mediators, vasodilation
Septic: infection triggers inflammatory response–>vasodilation
Neurogenic: massive vasodilation, SNS can’t respond
dry, loose, HR not increased
cardiac output
4-6L/min
PAWP/PAOP/Wedge: preload
8-12; if decreased, they have less blood. If elevated, then they have too much blood volume
CVP/RAP: RV preload-stretch:
2-6; speaks to blood volume
SVR: afterload-squeeze
900-1200; the pressure your LV is pumping against. How dilated/constricted is the aorta? Also, pressure will rise/fall depending on blood volume…
MAP
70-90 (at least 60 to perfuse organs)
Weight gain concerns:
3 lbs overnight, 5 lbs in a week
calculate MAP
Equation: MAP = [(2 x diastolic)+systolic] / 3
septic shock
dry, loose; tachycardic
6-10L of isotonic crystalloids and 2-4 L of colloids are needed in the first 6 hours to achive a target CVP of 8-12 mm Hg. add vasopressors such as Levophed or dopamine once CVP is 8mm Hg. Antibiotics should be started within the first hour of septic shock. **Obtain cultures first!!
needles decompression
14-16 gauge needle to 2nd or 3rd intercostal midclavicular line
remove a spleen
risk of infection for rest of life due to lack of platelets and macrophages that used to live in spleen
what is an early sign of hypoperfusion?
decreased urinary output
colloids
contain large molecules that don’t pass through semipermeable membranes. When infused, they remain in the intravascular compartment and expand intravascular volume by drawing fluid from extravscular space via their higher oncotic pressure.
crystalloids
contain small molecules that flow easily from bloodstream to cells and body tissues. This will increase fluid volume in both intravascular and interstitial spaces. Can be isotonic, hypotonic, or hypertonic.
isotonic solutions
250-375 mOsm/L; no fluid shift, cells do not shrink or swell. NS, LR, D5W, and Ringer’s
use this isotonic solution to replace GI tract fluid losses, fistula drainage, and fluid losses due to burns or trauma
LR: it is the most closely related to composition of body’s blood serum and plasma; LR is metabolized in the liver, which converts the lactate to bicarb. Often given to pts with metabolic acidosis. Don’t give LR to patients with liver disease!
Ringers Solution
like LR, contains sodium, potassium, calcium, and choloride in similar concentrations, but not the lactate, so no contraindications. WIll not correct metabolic acidosis bc no lactate.
D5W
unique bc it can be classified as isotonic or hypotonic. (hypotonic as dextrose is metabolized by the body, leaving a hypotonic solution behind); D5W provides free water, this aids the kidneys in excreting solutes; 170 cal/L
When should you avoid using D5W?
following surgery: body’s reaction to surgical stress may cause an increase in ADH
IICP: hypotonicity following dextrose metabolism will cause dangerous fluid shifts in the brain.
hypotonic IV solutions
osmolality less than 250 mOsm/L; hydrate the cells but may decrease blood volume in the process. helps kidneys excrete excess fluids and electrolytes. treat DKA, HHNA; watch for hypovolemia and cardiovascular collapse!
SIRS: Systematic Inflammatory Response Syndrome
overwhelming inflammation with no identifiable source of infection
SIRS + Documented culture or visualized infection
sepsis
SIRS+ documented culture or visualized infection+hypoperfusion or thrombocytopenia or DIC
severe sepsis
MAP 60
Septic Shock
hypertonic solutions
osmolarity >375mOsm/L. volume expanders. Watch for fluid overload and pulmonary edema! Watch for s/sx of hypernatremia (disorientation, convulsions) Central line preferred for infusing >3% NS as these solutions are caustic
CO ,4L/min
CI< 2.5
Increased PAWP, PVR
decreased renal blood flow leads to increased sodium and water retention and decreased urinary output
cardiogenic shock
a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism
shock
a systemic inflammatory response to a documented or suspected infection
sepsis
severe sepsis
sepsis complicated by organ dysfunction
Albumin, Hetastartch, and dextran
colloids=volume expanders
Hetastarch
colloid volume expander; may be 50% less costly than albumin, can exert osmotic effect for up to 36 hrs. has antiplatelet effect so use with caution if HF, Renal Failure, or bleeding d/o
Dextran
colloid volume expander; increases risk of bleeding; monitor pt for allergic rxn and A Renal Failure; limited use bc reduces platelet adhesion and dilutes clotting factors.
what is important to remember when infusing large quantities of PRBC’s?
they do not contain clotting factors, so replace those too
nitroprusside
arterial dilation’ protect from light and administer ONLY with D5W; monitor for cyanide toxicity (metabolic acidosis, tachycardia, altered LOC, seizures, coma, almond scented breath)
phenylephrine
neurogenic shock vasopressor; treat bradycardia with atropine; administer fluids cautiously bc hypotension is NOT the result of hypovolemia but instead a lack of SNS activity due to spinal injury above T5. monitor for hypothermia. Methylprednisolone (SOlu-Medrol) is used for patients with a spinal cord injury to prevent secondary spinal cord damage caused by the release of chemical mediators.
patients at increased risk for shock
older, debilitating illness, immunocompromised, surgical/trauma
Surviving Sepsis Bundle
first 3 hours:
- measure serum lactate
- obtain blood cultures PRIOR to admin abx
- admin broad spectrum abx
- crystalloids for hypotension or lactate >4
First 6 hours
- vasopressors for hypotension refractory to fluid resuscitation or lactate >4 to maintain MAP >65
- CVP target 8-12 but 12-15 if mechanically vented. SvO2 target 70%
dobutamine
raise cardiac output and improve lactate clearance
