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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
Q

5 kg Cat; shock volume and timing of admin

A

Shock volume ~ 60 ml/kg
300 ml over 1 hour
= 75 ml / 15 minutes

26
Q

is crystalloid rate for shock volume administration set in stone?

A

no, can increase or decrease as necessary to normalize vital signs

27
Q

30kg Dog 10% dehydrated
>what is the total fluid deficit?

A
  • Total fluid deficit = % dehydration x BW(kg)
    = 10% x 30 = 10/100 x 30 = 0.1 x 30
    = 3 L = 3000 ml
28
Q

re-expansion of what fluid compartment critical of treating shock

A

intravascular

29
Q

Fluid Replacement - Dehydration; what must we do? what if we have to anesthetize vs not?

A
  • 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
Q

Crystalloid Administration; Rapid intravenous fluid rates require (for dog and cat):

A
  • Catheter:
    – Large
    – Short
  • Place the largest catheter possible
    – Large dog - 18g+ catheter
    – Cat - 20g catheter
  • Consider additional catheter placement
31
Q

hypertonic saline; what is it for and how does it work?

A
  • 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
Q

what are colloids? what are they used for?

A
  • 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
Q

examples and properties of natural colloids

A
  • Plasma,Blood
  • Remain in the vessel
  • Require collection
  • May need to be thawed
34
Q

examples and properties of synthetic colloids

A

*Examples
– Pentastarch (Canada)
– Hetastarch (US)
– Tetrastarch (Voluven)
– Dextrans
* Remain in the vessel+ draw fluid into the vessel
* Readily available

35
Q

MAX daily dose for synthetic colloids (dog and cat)? how should we administer?

A

– 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
Q

what volume of blood should we give for a transfusion?

A
  • 10-20 ml/kg whole blood
37
Q

Transfusion triggers – red cell indices:
(dogs and cats)

A

– 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
Q

how do crystalloid requirements change when colloids, hypertonic saline or blood are used?

A

– Crystalloid requirements are reduced
* Approximately 1⁄2
– Will note this once animal resuscitated

39
Q

Over-aggressive fluid administration may:

A
  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
Q

how much does aggressive fluid admin drop PCV and TS by?

A

1/3

41
Q

PCV and TS values where transfusion is recommended

A
  • PCV acutely < 25%, TS < 3.5-4.0g/L
42
Q

do we often need the full volume calculated to treat shock with shock rate?

A

no, rarely

43
Q

analgesia recommendation for shock

A

– OPIOIDS
* Mainstay of analgesia in shocky patient
* Minimal cardiovascular & respiratory depression

44
Q

corticosteroid recommendations for shocky patient, and possible adverse effects

A
  • 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
Q

when should we give antibiotics to a shocky patient?

A
  • Administer if
    – Open wounds
    – Bacteremia /sepsis strong differential diagnosis
    – Immunocompromised patient
  • Otherwise, not used routinely
46
Q

Delays in resuscitation of a previously healthy patient may have what result?

A

may render them unresponsive to aggressive therapy later on
> decompensatory shock

47
Q

what values should we monitor in a shocky patient

A
  • Clinical Signs
    – Level of consciousness
    – Heart rate / rhythm
    – Changes in respiratory rate / rhythm
    – MM colour
    – CRT
48
Q

how should we monitor a shocky patient?

A
  • 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
Q

most important values to monitor during shock/ best prognostic guides:

A
  • 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
Q

Possible Consequences of Shock

A

– 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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