Shock part 3 (sepsis) Flashcards
Primary sources of septic infection?
Central Lines
Picc Lines
Catheters
Anything invasive
Measures to help control sepsis from developing?
Abscess drainage
Tissue debridement
What are signs and symptoms of sepsis again?
LOC changes
Hypotension
Tachycardia
Fever
UO drops
If your patient is mechanically ventilated, what is your target CVP?
Mechanically ventilated patients target CVP should be greater than 12mmHg.
- this is due to intrathoracic pressure from the vent
Before we start using pressor for a shock patient , what will we try?
Fluid challenge
What is a fluid challenge?
Drop a 500 bolus over 30 minutes to see if it raises their blood pressure and stabilizes their heart rate.
What happens if we do a 30 min fluid challenge and they respond well?
We will try another fluid challenge over 30 minutes
What happens if we’ve done the 30 minute fluid challenges already and they’re just sort of on the fence with their blood pressure and heart rate?
We will probably start them on a low dose pressor.
What is the reasoning for why we try the fluid challenge before starting pressor?
Why the low dose of pressor as well if they’re on the fence?
We don’t want out patient to be pressor dependent in either case!
When using pressor what is the first measurement you want to look at for a baseline and what value do we want?
MAP greater than 65
- but also know we don’t use this as our only indicator
- the order will say it too
What two vasopressors/vasoactive drugs do we give through a central line?
Norepenephrine (levophed)
Dopamine
Why do we give Norepinephrine/Levo and Dopamine through a central line?
They are damaging to the vessels
What happens if we need to give Norepinephrine (Levo) and Dopamine but we don’t have a central line yet?
You can give it through a peripheral IV for a short period of time only. But, get your central lines in.
Your septic shock patient is on dopamine. After a 2 days, you’ve noticed their heart rate has climbed to 110-120. What do you do?
Call the doctor and suggest dobutamine so the HR isn’t affected.
Why would we use steroids for a septic shock patient?
Remember, they have a systemic inflammatory response occurring so they need to be on steroids..and especially if they respond poorly to fluids and pressor.
What is the complication that always happens though when you are giving steroids for sepsis?
Septic patients already have a high blood sugar because the infection… and adding steroids increases BS even more. We have to fix this.
How do you fix the blood sugar problem with septic patients in regards to steroids?
You have them on insulin drips - calculate it every hour.
What steroids can we use for septic chock?
Iv hydrocortisone
Dexamethesone
Prednisone
Cortisone
Solu Medrol
What is a significant decrease in hemoglobin?
1 gram decrease
What is the target hemoglobin?
If your hemoglobin is low, what other lab can indicate hypo-perfusion?
Hemoglobin = 7.9-9.0 g/dL
Lactate/lactic acid
What is ARDS?
Acute lung injury caused by sepsis treatment from ventilator damage
What PEEP do we want for the vent if we want to at least try to avoid the ARDS and what will the sats be?
Peep of 10-12 but they will have lower sats.
What is the bed angle we want for a ventilated patient?
30-45 degrees
Most common sedative + analgesic combo we will see for patients on the vent?
Propofol sedation
Fentanyl analgesic (which has some sedative properties to it)
T/F
We will ALWAYS give a ventilated patient a neuromuscular block/paralytic
False. We won’t use the paralytic if we don’t have to. It is just an option.
When do we use the train of four technique?
We use it on ventilated patients who are on a neuromuscular block only with continuous infusions.
- the whole point of it is to make sure they have enough paralytic in their system (2/4 twitches, temple & radial)
What is the target blood sugar for a septic shock patient on insulin and why?
150 mg/dL - this is high but due to their BS being in a hypermetbolic state, if we brought it any lower they would be having hypometabolic symptoms.
How does septic shock affect the kidneys?
Shock can make it hard for the kidneys to be perfused due to hypoperfusion
How do we help the kidneys when there’s a shock state?
CRRT or Continuous renal replacement therapy
What is CRRT for the kidneys?
A slow continuous dialysis that works like a short term fix for the kidneys so they can rest
Why do shock patients need DVT prophylaxis?
The patients aren’t moving XD
What drugs will shock patients be on for DVT prophylaxis? What else?
Heparin and Lovenox
SCD’s
Why do shock patients need to be on stress ulcer prophylaxis protocols?
What about for ventilated patients?
The body is in a hypermetabolic, stressed and there’s decreased peristalsis.
We don’t want vent patients aspiration as well
What drugs can we use for stress ulcer/aspiration prophylaxis?
Pepcids (H2 blocker)
Protonix or Prilosec (Proton Pump Inhibitor)
What is an Advance directive?
It means to discuss advance care planning, talk about reasonable outcomes, and expectations.
When can you give reasonable outcomes for family?
Only after a doctor has looked over it and signed off
