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Pharm Test 4 > Shock and Resuscitation 2 > Flashcards

Shock and Resuscitation 2 Flashcards

1
Q

The delivery of oxygen to the tissues is dependent on:

A

– Cardiac output of the animal
– Oxygen content of arterial blood

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2
Q

O2 Delivery (DO2) =

A

Cardiac output (CO) x Oxygen content of arterial blood (CaO2)

  • CO = Heart rate x Stroke volume
  • CaO2 = (Hemoglobin x 1.34 x SaO2) + (PaO2 x 0.003)
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3
Q

what do we require for proper tissue perfusion, ie for proper CO and CaO2

A

CO:
– Efficient cardiac pump
– Adequate intravascular volume
– Vasomotor tone

CaO2
– Adequate hemoglobin / red cell mass
– Good lung function

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4
Q

Resuscitation; To do list

A

-Ensure patent airway & patient ventilating
>Intubate & ventilate if necessary

-Supplement O2

-Provide intravascular volume support
>Crystalloids, colloids, blood products
>Not appropriate for cardiogenic shock

-Administer pain medication

-Treat primary problem
>Correct GDV, thoracocentesis for tension pneumothorax, address hemoabdomen, etc

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5
Q

goal of resuscitation:

A

– Normalization of vital parameters

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6
Q

O2 Supplementation methods

A
  • Flow by
  • Oxygen hood
  • Oxygen cage
  • Nasal oxygen
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7
Q

how do we monitor oxygenation while supplementing O2

A

– MM colour
– Pulse oximetry
* Measures amount of O2 bound to hemoglobin
* Max 100%
* Ideal > 97-100%
* Acceptable > 93%
– Arterial blood gases

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8
Q

what does pulse oximetry measure? what are ideal and acceptable values?

A
  • Measures amount of O2 bound to hemoglobin
  • Max 100%
  • Ideal > 97-100%
  • Acceptable > 93%
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9
Q

most common mismanagement for patients who die from trauma

A

– Inadequate fluid resuscitation
* Type?
* Volume?
* Rate?

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10
Q

when does the interstitial/intracellular compartment need resuscitation and how do we replace fluid deficits here?

A
  • Dehydration
  • Fluid deficits replaced with crystalloids
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11
Q

what fluids can we use to replace deficits in the intravascular compartment? How much?

A

– Crystalloids
* (2/3rd will leak into the other spaces)
OR
– Colloids
– Hypertonic saline – Blood components

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12
Q

what is our first line therapy for IV fluid selection?

A
  • Crystalloids
    – Examples of Balanced Electrolyte Solutions
  • Lactated Ringers Solution (LRS)
  • Plasmalyte A , Plasmalyte 148
  • Normosol R
  • 0.9% NaCl
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13
Q

Crystalloids composition

A

– Water, electrolytes (concentrations similar to blood)
– Solutions containing small molecules that may easily pass through blood vessels

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14
Q

what happens to crystalloids upon IV administration?

A

– ~ 1/3 remains in the intravascular space
– ~ 2/3 leaks out into the interstitium
* Volume of crystalloid administration to blood loss 3:1

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15
Q

Endpoint of fluid therapy for a patient in shock is:

A

the normalization of the vital signs rather than administration of a specific volume of fluids

  • Use math to come up with volumes needed
  • Recognize calculated amount is a rough estimate
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16
Q

how do we estimate a fluid volume for administration?

A
  • Based on percentage of volume lost
  • Hypovolemic shock noted when:
    – ≥30% blood loss
    – ≥10% dehydration
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17
Q

when do we note hypovolemic shock?

A

– ≥30% blood loss
– ≥10% dehydration

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18
Q

blood volume of dog, car, horse, and ruminant

A

– 80-90 ml/kg (Dog)
– 60ml/kg(Cat)
– 100 ml/kg (Horse)
– 60ml/kg(Ruminant)

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19
Q

how much blood loss for clinical signs or shock to be present?

A

Expect ≥ 30% blood loss for clinical signs of shock to be present

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20
Q

how much crystalloid volume required to replace blood loss?

A

Crystalloids - only 30% stays in the intravascular space
3x the crystalloid volume required to replace the blood loss

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21
Q

how do crystalloid solutions administered IV redistribute through the body?

A

IV > ECF > ICF

22
Q

shock rate for crystalloids fluids in dog, cat, horse, ruminant:

A

~ 1 x blood volume
– 80-90 ml/kg (Dog)
– 60ml/kg(Cat)
– 100 ml/kg (Horse)
– 60ml/kg(Ruminant)

23
Q

shock volume for 11kg dog

A
  • 11kg dog x 90ml/kg = 990ml ~ 1L
24
Q

Crystalloid Rate for shock

A
  • As fast as necessary
  • Conceptualize shock rate delivered over 1 hour
  • Administer 1⁄4 dose in 15-minute increments & reassess

eg.
30 kg Dog
Shock volume ~ 90 ml/kg
2700 ml » 3 L over 1 hour
= 750 ml / 15 minutes

25
5 kg Cat; shock volume and timing of admin
Shock volume ~ 60 ml/kg 300 ml over 1 hour = 75 ml / 15 minutes
26
is crystalloid rate for shock volume administration set in stone?
no, can increase or decrease as necessary to normalize vital signs
27
30kg Dog 10% dehydrated >what is the total fluid deficit?
* Total fluid deficit = % dehydration x BW(kg) = 10% x 30 = 10/100 x 30 = 0.1 x 30 = 3 L = 3000 ml
28
re-expansion of what fluid compartment critical of treating shock
intravascular
29
Fluid Replacement - Dehydration; what must we do? what if we have to anesthetize vs not?
* Address shock – Shock rate fluids in 15 min increments until vital signs normalize With Anesthesia * Replace 1⁄2 deficits prior to induction Without Anesthesia * Replace remaining deficits over next 12-24 hours * Rehydration of interstitial compartment to occur over longer time
30
Crystalloid Administration; Rapid intravenous fluid rates require (for dog and cat):
* Catheter: – Large – Short * Place the largest catheter possible – Large dog - 18g+ catheter – Cat - 20g catheter * Consider additional catheter placement
31
hypertonic saline; what is it for and how does it work?
* Hyperosmolar solution * Many Na+ molecules draw water into the intravascular space * Very rapid intravascular volume expansion * Short duration of action – As Na+ molecules are redistributed
32
what are colloids? what are they used for?
* Solutions containing large molecules that are trapped & stay within the blood vessels * Provide oncotic support * As they stay in the vessel, smaller volumes required for intravascular volume expansion
33
examples and properties of natural colloids
* Plasma,Blood * Remain in the vessel * Require collection * May need to be thawed
34
examples and properties of synthetic colloids
*Examples – Pentastarch (Canada) – Hetastarch (US) – Tetrastarch (Voluven) – Dextrans * Remain in the vessel+ draw fluid into the vessel * Readily available
35
MAX daily dose for synthetic colloids (dog and cat)? how should we administer?
– 20 ml/kg/day (dog) – 10 ml/kg/day (cat) * Administer in 1⁄4 aliquots over 5-10 minutes * Repeat up to 4X as necessary * Examples: Dog *5 ml/kg over 5-10 minutes *Repeat up to 4X if necessary Cat *2.5 ml/kg over 5-10 minutes *Repeat up to 4X if necessary
36
what volume of blood should we give for a transfusion?
* 10-20 ml/kg whole blood
37
Transfusion triggers – red cell indices: (dogs and cats)
– Acute anemia / blood loss * CLINICAL SIGNS * ~PCV <25% - dogs * ~PCV <15-20% - cats A drop in PCV may not be seen with acute hemorrhage
38
how do crystalloid requirements change when colloids, hypertonic saline or blood are used?
– Crystalloid requirements are reduced * Approximately 1⁄2 – Will note this once animal resuscitated
39
Over-aggressive fluid administration may:
1. Dislodge early clots 2. Aggravate fluid extravasation into damaged tissues – Lungs: pulmonary edema – Brain: increase intracranial pressures 3. Contribute to excessive hemodilution – General rule of thumb: aggressive fluid administration drops PCV and TS by 1/3 – Transfusion suggested if * PCV acutely<25%,TS<3.5-4.0g/L
40
how much does aggressive fluid admin drop PCV and TS by?
1/3
41
PCV and TS values where transfusion is recommended
* PCV acutely < 25%, TS < 3.5-4.0g/L
42
do we often need the full volume calculated to treat shock with shock rate?
no, rarely
43
analgesia recommendation for shock
– OPIOIDS * Mainstay of analgesia in shocky patient * Minimal cardiovascular & respiratory depression
44
corticosteroid recommendations for shocky patient, and possible adverse effects
* Examples: – Dexamethasone – Prednisolone sodium succinate (Solu-delta-cortef) – Methylprednisolone sodium succinate (Solu Medrol) * Pharmacological effects – Widespread cellular effect * Adverse effects: – Increased risk of infection – GI ulceration – No improvement in outcome!
45
when should we give antibiotics to a shocky patient?
* Administer if – Open wounds – Bacteremia /sepsis strong differential diagnosis – Immunocompromised patient * Otherwise, not used routinely
46
Delays in resuscitation of a previously healthy patient may have what result?
may render them unresponsive to aggressive therapy later on > decompensatory shock
47
what values should we monitor in a shocky patient
* Clinical Signs – Level of consciousness – Heart rate / rhythm – Changes in respiratory rate / rhythm – MM colour – CRT
48
how should we monitor a shocky patient?
* Monitor for Response to Therapy * Parameters should be re-evaluated frequently – Every 5 – 15 minutes * Parameters should be trended & should be improving if resuscitative efforts are appropriate.
49
most important values to monitor during shock/ best prognostic guides:
* Ideal – **Clinical signs** – pH – Blood lactate – CO – Oxygen delivery – Oxygen consumption >last two require invasive monitoring; impractical other values that are good to watch * BloodPressure – BP is an indirect assessment of cardiac output / tissue perfusion * Blood O2 content – Direct PaO2 – Indirect SpO2 * PCV/TS * Lactate * Blood Volume – Urinary output (palpate bladder) > Normal 1-2 ml/kg/hr
50
Possible Consequences of Shock
– GI hemorrhage / ulceration – Acute renal failure – Bacterial translocation – Endotoxemia / sepsis – Disseminated intravascular coagulation (DIC) (Blood clotting abnormalities) – Respiratory failure (ARDS) – Multiple organ failure

Pharm Test 4 (10 decks)

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