Shock part 3 (sepsis)

Question 1

Primary sources of septic infection?

Answer 1

Central Lines
Picc Lines
Catheters
Anything invasive

Question 2

Measures to help control sepsis from developing?

Answer 2

Abscess drainage
Tissue debridement

Question 3

What are signs and symptoms of sepsis again?

Answer 3

LOC changes
Hypotension
Tachycardia
Fever
UO drops

Question 4

If your patient is mechanically ventilated, what is your target CVP?

Answer 4

Mechanically ventilated patients target CVP should be greater than 12mmHg.

• this is due to intrathoracic pressure from the vent

Question 5

Before we start using pressor for a shock patient , what will we try?

Answer 5

Fluid challenge

Question 6

What is a fluid challenge?

Answer 6

Drop a 500 bolus over 30 minutes to see if it raises their blood pressure and stabilizes their heart rate.

Question 7

What happens if we do a 30 min fluid challenge and they respond well?

Answer 7

We will try another fluid challenge over 30 minutes

Question 8

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?

Answer 8

We will probably start them on a low dose pressor.

Question 9

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?

Answer 9

We don’t want out patient to be pressor dependent in either case!

Question 10

When using pressor what is the first measurement you want to look at for a baseline and what value do we want?

Answer 10

MAP greater than 65

• but also know we don’t use this as our only indicator
  
  • the order will say it too

Question 11

What two vasopressors/vasoactive drugs do we give through a central line?

Answer 11

Norepenephrine (levophed)

Dopamine

Question 12

Why do we give Norepinephrine/Levo and Dopamine through a central line?

Answer 12

They are damaging to the vessels

Question 13

What happens if we need to give Norepinephrine (Levo) and Dopamine but we don’t have a central line yet?

Answer 13

You can give it through a peripheral IV for a short period of time only. But, get your central lines in.

Question 14

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?

Answer 14

Call the doctor and suggest dobutamine so the HR isn’t affected.

Question 15

Why would we use steroids for a septic shock patient?

Answer 15

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.

Question 16

What is the complication that always happens though when you are giving steroids for sepsis?

Answer 16

Septic patients already have a high blood sugar because the infection… and adding steroids increases BS even more. We have to fix this.

Question 17

How do you fix the blood sugar problem with septic patients in regards to steroids?

Answer 17

You have them on insulin drips - calculate it every hour.

Question 18

What steroids can we use for septic chock?

Answer 18

Iv hydrocortisone

Dexamethesone

Prednisone

Cortisone

Solu Medrol

Question 19

What is a significant decrease in hemoglobin?

Answer 19

1 gram decrease

Question 20

What is the target hemoglobin?

If your hemoglobin is low, what other lab can indicate hypo-perfusion?

Answer 20

Hemoglobin = 7.9-9.0 g/dL

Lactate/lactic acid

Question 21

What is ARDS?

Answer 21

Acute lung injury caused by sepsis treatment from ventilator damage

Question 22

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?

Answer 22

Peep of 10-12 but they will have lower sats.

Question 23

What is the bed angle we want for a ventilated patient?

Answer 23

30-45 degrees

Question 24

Most common sedative + analgesic combo we will see for patients on the vent?

Answer 24

Propofol sedation

Fentanyl analgesic (which has some sedative properties to it)

Question 25

T/F

We will ALWAYS give a ventilated patient a neuromuscular block/paralytic

Answer 25

False. We won’t use the paralytic if we don’t have to. It is just an option.

Question 26

When do we use the train of four technique?

Answer 26

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)

Question 27

What is the target blood sugar for a septic shock patient on insulin and why?

Answer 27

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.

Question 28

How does septic shock affect the kidneys?

Answer 28

Shock can make it hard for the kidneys to be perfused due to hypoperfusion

Question 29

How do we help the kidneys when there’s a shock state?

Answer 29

CRRT or Continuous renal replacement therapy

Question 30

What is CRRT for the kidneys?

Answer 30

A slow continuous dialysis that works like a short term fix for the kidneys so they can rest

Question 31

Why do shock patients need DVT prophylaxis?

Answer 31

The patients aren’t moving XD

Question 32

What drugs will shock patients be on for DVT prophylaxis? What else?

Answer 32

Heparin and Lovenox

SCD’s

Question 33

Why do shock patients need to be on stress ulcer prophylaxis protocols?

What about for ventilated patients?

Answer 33

The body is in a hypermetabolic, stressed and there’s decreased peristalsis.

We don’t want vent patients aspiration as well

Question 34

What drugs can we use for stress ulcer/aspiration prophylaxis?

Answer 34

Pepcids (H2 blocker)

Protonix or Prilosec (Proton Pump Inhibitor)

Question 35

What is an Advance directive?

Answer 35

It means to discuss advance care planning, talk about reasonable outcomes, and expectations.

Question 36

When can you give reasonable outcomes for family?

Answer 36

Only after a doctor has looked over it and signed off