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ICU > Shock + Nutrition > Flashcards

Shock + Nutrition Flashcards

1
Q

List the 4 main categories of shock.

A
  1. Hypovolemic
  2. Cardiogenic
  3. Obstructive
  4. Distributive

[Can always have mixed shock]

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2
Q

DDx - Hypovolemic shock

A

Hemorrhage (trauma, GI bleeding)
Third space loss of plasma volume (pancreatitis, bowel obstruction, infarction, anaphylaxis)
Diarrhea
Burns

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3
Q

DDx - Cardiogenic shock?

A 
Acute MI
Arrhythmia
Acute valvular dysfunction
Ventricular septal rupture
Dilated/end-stage cardiomyopathy
Ventricular aneurysm
LV outflow track obstruction
Myocarditis
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4
Q

DDx - Obstructive shock?

A 
Pericardial tamponade
IVC/SVC obstruction
Aortic dissection
Massive PE
Severe pulmonary HTN
Tension pneumothorax
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5
Q

DDx - distributive shock?

A 
Neurogenic
Septic
Toxic (OD)
Anaphylaxis
Endocrine (adrenal)
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6
Q

Pathophysiology of shock?

A

All involve circulatory failure leading to inadequate cellular oxygen utilization

Distributive - decreased SVR + altered O2 extraction

All others - low CO -> inadequate O2 transport

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7
Q

Calculate MAP

A

MAP = diastolic pressure + (1/3 pulse pressure) = [CO x SVR] + CVP

Pulse pressure = systolic - diastolic

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8
Q

Define each type of shock by warm/cold and wet/dry.

A

Warm: distributive (bounding pulses, high pulse pressure)
Cold: cardiogenic, hypovolemic, obstructive (weak, thready pulses)

Wet: cardiogenic
Dry: hypovolemic

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9
Q

What is the purpose of pulmonary artery catheter?

A

Measure CO

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10
Q

Indications for use of pulmonary artery catheter?

A

Dx and manage numerous CV illnesses (pHTN, cardiogenic shock, mixed shock, cardiac tamponade, mechanical complications of STEMI

Standard evaluation of patients being considered for heart and lung transplant

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11
Q

What is measured by a pulmonary artery cath and how is it used?

A

RA pressure ~ CVP ~ diastolic RV pressure

Pulmonary artery pressure ~ systolic RV pressure

Pulmonary capillary wedge pressure ~ LA pressure

Calculate CO, SVR, pulmonary vascular resistance

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12
Q

Normal range of RA, RV, PA, PCW pressures?

A

RA: 1-5
RV: 15-30/1-7
PA: 15-30/4-12
PCW: 4-12

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13
Q

Pulmonary artery cath findings in cardiogenic shock

A

Low CO
Increased filling pressures in LA –> elevated PCWP
Elevated SVR
Decreased MVO2

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14
Q

Pulmonary artery cath findings in early distributive shock

A

Increased CO
Decreased SVR
Increased MVO2

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15
Q

Pulmonary artery cath findings in hypovolemic shock

A

Low CO
Inadequate ventricular filling -> low PCWP
Compensatory changes in SVR and MvO2

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16
Q

CO = ?

Normal range?

A

Oxygen consumption (mL/min) divided by (Ca - Cv), where Ca is O2 content of arterial blood and Cv is O2 content of venous blood

4.8-7.3 L/min

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17
Q

CI = ?

Normal range?

A

CO/BSA

2.8-4.2 L/min/m^2

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18
Q

SVR = ?

Normal range?

A

80[(MAP - RA) / CO]

700-1600

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19
Q

PVR = ?

Normal range?

A

80[(PA - PCWP)/CO]

20-130

20
Q

SIRS?

A 
2+ of the following:
-Tachycardia (HR>90)
-Tachypnea (RR>20)
-Fever (T>38) or hypothermia (T<36)
Leukocytosis (WBC>12K), leukopenia (WBC<4K), or bandemia (>10%)
pCO2 32 or less
21
Q

Sepsis?

A

SIRS + suspected/confirmed infection

22
Q

Severe sepsis?

A

Sepsis complicated by organ dysfunction

  • Thrombocytopenia <100K, DIC, areas of mottled skin
  • Capillary refill 3+ seconds
  • UOP <0.5mL/kg
  • Lactate >2
  • Abrupt change in mental status or abnormal EEG findings
  • Acute lung injury/ARDS
  • Cardiac dysfunction
23
Q

Septic shock?

A

Sepsis-induced hypotension persisting despite adequate fluid resuscitation

24
Q

qSOFA?

A

2+ of the following:
RR 22+
Change in mental status
Systolic BP 100 or less

25
Q

What does mixed venous O2 saturation tell us?

A

End result of oxygen consumption and delivery; helpful in determining adequacy of balance between O2 demand and supply; helpful in interpreting CO

26
Q

Normal O2 delivery and extraction?

A

O2 delivery ~1 L/min
O2 extraction 250 mL/min
75% SvO2

27
Q

How can SvO2 be improved?

A

Increase delivery of O2 to the tissues (transfusion in theory; dobutamine increases contractility and CO)

Decrease O2 consumption (sedation, paralysis, treat fever)

28
Q

Rx shock?

A

Ventilate (O2) - decrease O2 demand of respiratory muscles, decrease LV afterload by increasing intrathoracic pressure
Infuse (fluid resuscitation - crystalloid at 300/30 min)
Pump (vasoactive agents)

29
Q

NS vs. LR fluids?

A

NS can worsen acidosis

LR can negate this due to presence of bicarb

30
Q

First line pressor in septic shock?

A

Norepinephrine

Predominant A1 + modest B1 (vasoconstriction, inotropy)
Improves MAP w/little change in HR or CO

31
Q

Second line pressor in septic shock?

A

Epinephrine

Predominant B1 at low doses
Predominant A1 at higher doses

32
Q

First line inotrope?

A

Dobutamine
Primarily B1, weak B2 -> increased HR, SV, CO; peripheral vasodilation

Preferred inotrope in patients w/myocardial depression associated with septic shock, IN COMBO w/vasoconstrictor

33
Q

Describe hemodynamic profile (CVP, PCWP, CO, SVR, SvO2) for distributive shock

A 
CVP: low
PCWP (preload): no change
CO (pump function): low/normal
SVR (afterload): low
SvO2 (tissue perfusion): high
34
Q

Describe hemodynamic profile (CVP, PCWP, CO, SVR, SvO2) for cardiogenic shock.

A 
CVP: high
PCWP (preload): high
CO (pump function): low
SVR (afterload): high
SvO2 (tissue perfusion): low
35
Q

Describe hemodynamic profile (CVP, PCWP, CO, SVR, SvO2) for hypovolemic shock.

A 
CVP: low
PCWP (preload): low
CO (pump function): low
SVR (afterload): high
SvO2 (tissue perfusion): low
36
Q

Describe hemodynamic profile (CVP, PCWP, CO, SVR, SvO2) for obstructive shock (think massive PE)

A 
CVP: high
PCWP (preload): normal/high
CO (pump function): low
SVR (afterload): high
SvO2 (tissue perfusion): low
37
Q

Basic methods of assessing nutrition status?

A

Hx: poor eating habits, alcohol abuse, social stressors
Exam: BMI, weight loss, thin appearance, temporal wasting

Labs

  • Best acute indicators: retinol binding protein, prealbumin, transferrin
  • Best overall indicator: albumin
38
Q

Prior to starting TPN, what should be done?

A

CBC, LFT, BMP, lipid w/triglycerides

Place CVC or PICC w/post-placement CXR

Nutrition consult

39
Q

Risks of TPN?

A

TPN metabolized by the liver, so can increase bilirubin, AST, ALT

Can cause profound hyperglycemia (insulin often added)

40
Q

Why is enteral nutrition preferred to TPN?

A

Better immunological function and overall better outcomes than those who are NPO or on TPN (disuse of intestines results in atrophy w/increased infection risk)

41
Q

Risks of enteral nutrition?

A

Pneumothorax if placed in lung, aspiration, can cause diarrhea + decreased GI motility

42
Q

What should be done if NG or DHT are placed following by acute SOB/hypoxia?

A 
CXR
Non-rebreather (hastens absorption of pneumo)
Pull tube
Serial CXRs
Chest tube if no improvement
43
Q

NG vs. DHT?

A

NG - easy to place, commonly dislodged, prolonged placement can result in nasal and esopahgeal erosion and sinusitis; can be used for both feedings and suction

DHT - dedicated feeding tube, weighted at end, somewhat easier to pass post-pyloric

44
Q

Define refeeding syndrome.

A

Hypophosphatemia (whole body depletion of phosphorus in the setting of insulin surge)
Hypokalemia (shift to anabolism -> increased potassium uptake)
Hypomagnesemia
Hyperglycemia (glucose intake after starvation suppresses gluconeogenesis through insulin release)

45
Q

Manage/prevent refeeding syndrome?

A

Slow nutrition intiation over several days

Decrease KCals by 50% until lytes are corrected.
Check lytes Q12 hours + aggressive repletion
Start thiamine and MV
Once clinically stable and normal lytes for 24 hours, increase nutrition by 10-20% caloric increments until final requirements are met

46
Q

What should be done if a patient has high residuals with tube feeds?

A

KUB - obstruction or ileus? (Note that ileus is not a contraindication to TF)
Do not immediately start TPN.

If ileus - promotility agents like erythromycin and Reglan

If aspiration pneumonia - ABX

If SBO - stop tube feeds, place NG to suction, initiate TPN.

ICU (6 decks)

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