Multi-System Concepts and Palliative Flashcards
What type of shock can result from low blood flow, low blood volume?
Hypovolemic Shock
What type of shock results from low blood flow, heart pump failure?
Cardiogenic Shock
What type of shock results from the vessels increased diameter (vasodilation) and maldistribution of blood flow?
Neurogenic shock, anaphylactic shock, septic shock
Hypovolemic shock, how is pre load, cardiac output and afterload affected? What is treatment?
Pre load: decreased
Cardiac Output: decreased
Afterload: increased
Treatment: IV fluids
Cardiogenic shock, how is pre load, cardiac output and afterload affected? What is treatment?
Pre load: increased
Cardiac Output: decreased
Afterload: increased
Treatment: Inotropes (increase myocardial contractility)
Distributive shock, how is pre load, cardiac output and afterload affected? What is treatment?
Pre load: decreased
Cardiac Output: decreased/increased
Afterload: decreased
Treatment: Iv fluids, vasopressors (increase vascular tone)
Who is at risk for septic shock?
Extremes of age, 70 Co-morbidities Immunosuppressed Major surgery invasive procedures
What is septic shock?
Distributive shock
systemic inflammatory response induced hypotension despite adequate fluid resuscitation and diffuse hypoperfusion
>50-60% mortality
What is the local inflammatory response?
Local response, induced by tissue damage, surrounds, destroys or sequesters foreign body/organism
Followed by reparation of the defect
What is SIRS (Systemic Inflammatory Response Syndrome) ?
2 or more of Fever, tachy, impaired 02, elevated wbc
Body’s response to an insult
activation of immune system
triggers are infection, trauma, burs, MI, pancreatitis
What is sepsis?
SIRS + presumed/confirmed infection
eg. surgical site infections, CVL infections, Ventilator associated pneumonia, catheter relater UTI
Can be urosepsis, bacteremia, septecemia
What is Severe Sepsis?
Severe sepsis + organ dysfunction
Labs, lactic acid, CBC-WBC, platelets, kidneys, ABG-acidosis
BP of
What is septic shock?
Severe sepsis + Hypotension
Unresponsiveness to fluid resuscitation
mortality 50-60%
Excessive activation of host defense mechanisms, rather than the direct effect of the microorganism
Inflammatory response, diffuse endothelium damage, vascular maldistribution (increased vascular permeability, vasodilation), coagulopathy (microvascular thrombi)
What is multi organ dysfunction syndrome? (MODS)
Failure of 3 or more organs
What will you see with sepsis VS, CNS, CVS
variable temperature, tachypnea, tachycardia, early will be warm, flushed, and late decreased cardiac output, pallor, grayish, mottled skin.
CNS: Altered confusion, to agitation. Late may be comatous.
CVS: Massive vasodilation, hypotension, tachycardia, cap refill normal (early) to delayed (late)
What will you see with sepsis? Respiratory and Hepatic
Resp: crackles, hyperventilation, hypoxia or hypercapnea, resp alkalosis or acidosis, resp failure
Hepatic: jaundice, high aPPT
What will you see with sepsis? GI, GU, Labs
GI bleeding, paralytic ileus, decreases urine output, high creatinine, variable WBC
What is the sepsis 6, for within 1 hour?
Give high flow oxygen take blood cultures Give IV antibiotics Start IV fluids Check Lactate Monitor ACCURATE hourly urine output
For a septic workup, how do you identify the source?
Swab everything!!
What are the 5 resuscitation efforts?
≥ 2 large bore lines Anticipate central line Bolus (30 mls/kg) NS Foley 0.5 mL/kg/hr Respiratory Support O² Anticipate early intubation Circulatory Support Crystalloids (litres) Colloids (Albumin)
What do we want to see, what is our early goal directed therapy?
MAP ≥ 65
Urine Output ≥ 0.5 ml/kg /hr
Normal serum lactate (2.2 mmol/L)
CVP 8-12
What are comfort measures we can apply in palliative care?
Play music or whatever the family thinks the patient would want for comfort
Reposition frequently
May need medication (Versed) to help with restlessness
How can we effectively and respectfully communicate in palliative care?
Continue to talk to the patient, not over them
Explain to the family what is going on
Family members will often only hear bits and pieces of a conversation so be clear/ confident
Family Meetings with the team
What should we NEVER say/do in palliative care?
Say “there’s nothing more we can do”.
Always ways to improve pain control, comfort, sedation etc
Set unrealistic goals
Give an expected time of death
What is a palliative care assessment?
Orientation, mentation Pain, restlessness, agitation Skin Break down – coccyx, heals, ears Incontinence vs Constipation Circulation – mottling, cool or warm? Asthenia (weakness, lack of energy) Respiratory distress (oxygen needed?) Nausea Mobility – still have PT / OT
What do we provide in palliative care?
No vital signs or medical assessments Thorough palliative care assessment Excellent personal care, turning and repositioning Comfort measures Pain Control ++ Bowel Care ++
When should a fentanyl patch not be used? when should it be changed?
With opioid naïve patients.
Patients that are on less that 100 mg PO morphine daily
For acute pain - takes 12-18 hours to reach effect and up to 18 hours to clear body after removal
Applied every 48 to 72 hours. CAN NOT BE CHANGED MORE OFTEN THAN THIS
Appears to cause less constipation and sedation by this route.
What is respiratory depression?
Respiratory arrest is the most serious adverse effect of overdose
Depressant effects begin in 7 minutes for IV, 60-90 minutes after PO/SC
Respiratory depression can persist for 4-5 hours
