Multi-System Concepts and Palliative

Question 1

What type of shock can result from low blood flow, low blood volume?

Answer 1

Hypovolemic Shock

Question 2

What type of shock results from low blood flow, heart pump failure?

Answer 2

Cardiogenic Shock

Question 3

What type of shock results from the vessels increased diameter (vasodilation) and maldistribution of blood flow?

Answer 3

Neurogenic shock, anaphylactic shock, septic shock

Question 4

Hypovolemic shock, how is pre load, cardiac output and afterload affected? What is treatment?

Answer 4

Pre load: decreased
Cardiac Output: decreased
Afterload: increased

Treatment: IV fluids

Question 5

Cardiogenic shock, how is pre load, cardiac output and afterload affected? What is treatment?

Answer 5

Pre load: increased
Cardiac Output: decreased
Afterload: increased

Treatment: Inotropes (increase myocardial contractility)

Question 6

Distributive shock, how is pre load, cardiac output and afterload affected? What is treatment?

Answer 6

Pre load: decreased
Cardiac Output: decreased/increased
Afterload: decreased

Treatment: Iv fluids, vasopressors (increase vascular tone)

Question 7

Who is at risk for septic shock?

Answer 7

Extremes of age, 70
Co-morbidities 
Immunosuppressed 
Major surgery
invasive procedures

Question 8

What is septic shock?

Answer 8

Distributive shock
systemic inflammatory response induced hypotension despite adequate fluid resuscitation and diffuse hypoperfusion
>50-60% mortality

Question 9

What is the local inflammatory response?

Answer 9

Local response, induced by tissue damage, surrounds, destroys or sequesters foreign body/organism
Followed by reparation of the defect

Question 10

What is SIRS (Systemic Inflammatory Response Syndrome) ?

Answer 10

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

Question 11

What is sepsis?

Answer 11

SIRS + presumed/confirmed infection
eg. surgical site infections, CVL infections, Ventilator associated pneumonia, catheter relater UTI
Can be urosepsis, bacteremia, septecemia

Question 12

What is Severe Sepsis?

Answer 12

Severe sepsis + organ dysfunction
Labs, lactic acid, CBC-WBC, platelets, kidneys, ABG-acidosis
BP of

Question 13

What is septic shock?

Answer 13

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)

Question 14

What is multi organ dysfunction syndrome? (MODS)

Answer 14

Failure of 3 or more organs

Question 15

What will you see with sepsis VS, CNS, CVS

Answer 15

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)

Question 16

What will you see with sepsis? Respiratory and Hepatic

Answer 16

Resp: crackles, hyperventilation, hypoxia or hypercapnea, resp alkalosis or acidosis, resp failure
Hepatic: jaundice, high aPPT

Question 17

What will you see with sepsis? GI, GU, Labs

Answer 17

GI bleeding, paralytic ileus, decreases urine output, high creatinine, variable WBC

Question 18

What is the sepsis 6, for within 1 hour?

Answer 18

Give high flow oxygen
take blood cultures
Give IV antibiotics
Start IV fluids
Check Lactate
Monitor ACCURATE hourly urine output

Question 19

For a septic workup, how do you identify the source?

Answer 19

Swab everything!!

Question 20

What are the 5 resuscitation efforts?

Answer 20

≥ 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)

Question 21

What do we want to see, what is our early goal directed therapy?

Answer 21

MAP ≥ 65
Urine Output ≥ 0.5 ml/kg /hr
Normal serum lactate (2.2 mmol/L)
CVP 8-12

Question 22

What are comfort measures we can apply in palliative care?

Answer 22

Play music or whatever the family thinks the patient would want for comfort
Reposition frequently
May need medication (Versed) to help with restlessness

Question 23

How can we effectively and respectfully communicate in palliative care?

Answer 23

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

Question 24

What should we NEVER say/do in palliative care?

Answer 24

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

Question 25

What is a palliative care assessment?

Answer 25

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

Question 26

What do we provide in palliative care?

Answer 26

No vital signs or medical assessments
Thorough palliative care assessment
Excellent personal care, turning and repositioning
Comfort measures
Pain Control ++
Bowel Care ++

Question 27

When should a fentanyl patch not be used? when should it be changed?

Answer 27

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.

Question 28

What is respiratory depression?

Answer 28

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