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High Acuity Ex. 2 Study Material > Shock States and Hemodynamic Management > Flashcards

Shock States and Hemodynamic Management Flashcards

1
Q

What can cause increased contractility?

A
  • Sympathetic Nervous System stimulation
  • Increased calcium release
    • Inotropic drugs
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2
Q

Describe the pathophysiology of shock

A
  1. Cells switch from aerobic to anaerobic metabolism
  2. Lactic acid production
  3. Cell function ceases and swells
  4. Membrane becomes more permeable
  5. Electrolytes and Fluids seep in and out of cells
  6. Na+/K+ pump impaired
  7. Mitochondria damage
  8. Cell death
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3
Q

What is the normal range for CVP?

A

2-6 mmHg

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3
Q

What does Nitroglycerine do and what are its effects on the heart?

A

Action: Venous vasodilator; Coronary artery vasodilator

**Effect: **Decrease preload (PAP, Wedge, CVP); May influence contractility in CAD

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4
Q

What are some indications for putting in a pulmonary artery catheter?

A
  • Following MI, Cardiogenic shock, Papillary muscle rupture, Mitral regurgitation, Cardiac rupture with Tamponade
  • Assess ventricular function in Heart failure
  • High-risk cardiac patients undergoing surgery
  • Evaluation of patients with major organ dysfunction
  • Shock States
  • Differentiate ARDS from Cardiogenic Pulmonary Edema
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4
Q

What can cause an increase in SVR?

A
  • Hypothermia
  • Hypovolemia
  • Cardiac failure
  • Vasoconstriction states
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5
Q

What does dobutamine do and what are its effects on the heart?

A

Action:

    • Inotrope, + Chronotrope, Mild vasodilatory action

Effect:

  • Increase CO, Decrease SVR increased myocardial O2 demand
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6
Q

Describe the hemodynamic values associated with cardiogenic shock

A

Preload: ↑

Afterload: ↑

Contractility: ↓

Oxygen Delivery: ↓

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7
Q

What are the effects of the RAAS on the heart?

A

–↑ Preload
–↑ BP
–↓ U/O

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7
Q

Describe the hemodynamic values associated with distributive shock

A

Preload: ↓

Afterload: ↓

Contractility: ↑

Oxygen Delivery: ↑

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8
Q

What are some interventions for increased preload?

A
  • Vasodilators (Nitroglycerin, Nitroprusside)
  • Diuretics, Fluid restriction
  • Continuous Renal Replacement Therapy, Dialysis
  • Low sodium diet
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9
Q

What is the normal mixed venous O2 sat range? (SVO2)

A

60-80%

reflects O2 extraction by tissues

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9
Q

What does Nitroprusside do and what are its effects on the heart?

A

Action: Arteriole vasodilation

Effects: Decrease afterload (SVR); Decrease preload (CVP, PAP, W)

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11
Q

What would we see on a physical assessment in a patient with increased preload?

A
  • Jugular venous distention
  • Peripheral edema
  • Ascites
  • Hepatic engorgement
  • Dyspnea, Cough, Crackles
  • S3 Heart sound
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11
Q

What does vasopressin do and what are its effects on the heart?

A

Action:

  • Moderate vasopressor

Effect:

  • Increase CO by ↑SVR and BP (afterload)
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12
Q

What would we see on a physical assessment in a patient with decreased preload?

A
  • Poor skin turgor
  • Dry mucous membranes
  • Orthostatic hypotension
  • Flat jugular veins
  • Tachycardia
  • Decreased urine output
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12
Q

What does dopamine do and what are its effects on the heart?

A

Action

    • Inotrope,
    • Chronotrope, Vasodilator (Low dose)
  • Vasopressor (High dose)

Effects:

  • Dose dependent:
  • < 5 mcg/kg/min= Renal/GI vasodilation
  • 5-10 mcg/kg/min= Beta stimulation
  • 10-20 mcg/kg/min= Alpha stimulation
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13
Q

What is a non-invasive technology used for hemodynamic monitoring?

A

Impedence Cardiography (ICG)

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15
Q

How does an increase or decrease in blood pressure affect changes in afterload?

A
  • Low BP= low afterload
  • High BP= increased afterload
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15
Q

What are some interventions for removing obstruction in obstructive shock?

A
  • Tension Pneumothorax:
    • Needle decompression
    • Chest Tube insertion
  • Pulmonary Embolism:
    • Emergency Embolectomy
    • Fibrinolytics: Streptokinase
    • Heparin
  • Cardiac Tamponade:
    • Pericardiocentesis
    • Thoracotomy Pericardial window
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16
Q

What is hemodynamic monitoring and when is it indicated?

A

Hemodynamic monitoring is a specialized method used to evaluate:

  • Cardiac Output and other parameters
  • Tissue perfusion
  • Tissue oxygenation
  • Vascular motor tone

Indications for Hemodynamic Monitoring:

  • Detect life-threatening conditions such as:
    • Myocardial infarction, Pulmonary Edema,
    • Shock states, Cardiac Tamponade
  • Evaluate patient’s immediate response to treatment such as:
    • Medications
    • Mechanical support (IABP, LVAD, ECMO)
  • Evaluate effectiveness of cardiovascular function
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17
Q

What occurs in the initial stage of shock?

A

–Body switches from aerobic to anaerobic metabolism
–Elevated Lactate level, lactic acidosis
–Subtle changes in clinical signs

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18
Q

What are causes of decreased CVP / Wedge pressure?

A
  • Hypovolemia
  • Sepsis, Anaphylaxis, Neuro- genic shock (vasodilation)
  • Dehydration states
    • Pancreatitits
    • Diabetes Insipidus
    • Hyperemeisis of Pregnancy
    • Multiple Trauma, Bleeding
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20
Q

What are causes of decreased afterload?

A
  • Hyperthermia
  • Septic shock
  • Spinal cord injury (because the smooth musle intervention by the SNS is disrupted)
  • Anaphylaxis
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21
Q

How would you prevent rupture of a pawp catheter?

A

–Balloon can NOT be inflated > 2-4 respiratory cycles and NOT > 15 sec
–Do NOT overinflate balloon
–Allow passive balloon deflation and Monitor for return to nl PAP
–Never inject > 1.25ml into balloon

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22
Q

What are some invasive types of hemodynamic monitoring?

A

–Arterial Line
–Central Venous Catheter
–Pulmonary Artery Catheter (Swan-Ganz Catheter)
–Left Atrial Line (L atria)

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24
Q

Describe contractility

A

The force of myocardial contraction upon ejecting blood from the heart

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25
Q

What occurs in the compensatory stage of shock?

A

–SNS stimulates Catecholamines –> contractility ↑
–Neurohormonal response –> vasoconstriction, blood to vital organs
–Aldosterone and ADH released –> u/o < 30ml/hr (body is trying to increase preload by holding on to the fluid)
–Cortisol released –> Increased glucose levels

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26
Q

What are some interventions for decreased contractility?

A
    • Inotropes (Digoxin, Dopamine, Dobutamine, Milrinone, Amrinone, Epinephrine) Electrolyte replacement (Mg++, Ca++, K+)
  • Anti-dysrhythmic meds
  • Left ventricular assist device
  • ECMO
27
Q

What are some indications for an arterial line?

A
  • Continuous reflection of BP
  • Useful in medication and fluid titration
  • Allows for ease of blood sampling
  • Common sites of insertion: Radial, Femoral
27
Q

What is the normal PAWP?

A

4-12mmHg

This is an indirect measure of left sided preload

28
Q

What 3 things must a nuse do to ensure accurate hemodynamic measurements?

A

1. Patient Positioning when taking Hemodynamic measures:

  • Acceptable Positions:
    • Supine
    • Head of Bed Angle (0-60 0)
    • Lateral (20,30,900)*
    • Prone*
  • Allow 5-15 min after a position change before taking measurement
  • Re-level w/ each change

2. “Level” Transducer at Phlebostatic Axis

  • Find “Phlebostatic Axis”
    • Represents catheter tip at ~ level of Right Atrium
    • Intersection of imaginary lines:
      • At 4th ICS space w/
      • Midpoint of Ant- Post diameter of chest wall

3. “Zeroing” the Transducer

  • Performed by opening Transducer system to air to establish atmosphere as zero
  • Corrects for any deviation from transducer baseline
  • Once Transducer leveled to Phlebostatic axis
    • open transducer to room air
    • by close stopcock to patient
    • and remove cap
  • Then press “0” on monitor to label room air a pressure of “0 mm Hg”
  • Replace w/ sterile cap on stopcock and Reopen stopcock to patient
29
Q

What occurs in the progressive stage of shock?

A

–Changes in LOC
–Lyte imbalance
–Metabolic acidosis, Respiratory acidosis
–Peripheral edema (3rd spacing)
–Irregular tachydysrhythmias, Hypotension
–Pallor, cool clammy skin

– MODS develops

30
Q

What are causes of cardiogenic shock?

A
  • Post Mi
  • Malignant dysrhythmia
30
Q

How would you calculate MAP?

A

MAP = (SBP + 2 (DBP)) / 3

31
Q

What are causes of increased afterload?

A
  • Hypertension and HTN Crisis
  • Stenotic Valves
  • Co-arctation of Aorta
  • Sympathetic Nervous System
33
Q

What is the normal PAP?

A

20-30 / 8-15

35
Q

What are causes of increased preload?

A
  • Fluid overload
  • Renal failure
  • Heart failure
  • Increased aldosterone secretion
  • Excess dietary sodium
  • End stage Liver failure
36
Q

What is the normal range for cardiac index?

A

2.4 - 4.0 L/min/m2

37
Q

What occurs in the refractory stage of shock?

A

–Irreversible cellular and organ damage, Impending death
–Resistant to therapies, Profound hypotension despite potent vasopressors

37
Q

What are some complications with arterial lines?

A

Bleeding:
–Check connections, ensure secure,
–Incorrect stopcock position, use dead-end caps
–Inadvertent line disconnection
Altered perfusion distal to site (Limb Ischemia):
–Check 6 P’s of Perfusion: Pain, Paralysis, Pallor, Polar, Paresthesia, Pulseless
nInfection
–Maintain sterile caps on ports
–Observe site for signs of infection
Air Embolism:
–Ensure all caps on ports and tubing openings

38
Q

What can cause a decrease in SVR?

A
  • Hyperthermia
  • Sepsis
  • Neurogenic shock
  • Anaphylaxis
  • Vasodilation states
39
Q

What are causes of distributive shock?

A
  • Septic shock
  • Anaphylaxis
  • Neurogenic shock
40
Q

What are some physical assessments that help determine cardiac contractility?

A
  • Pulse characteristics (weak, thready, bounding)
  • Pulse Pressure (same as afterload)
  • Split S2 heart sound (one ventricle empties before the other)
42
Q

What does Norepinephrine do and what are its effects on the heart?

A

**Action: **+ Inotrope; Vasopressor

**Effect: **Increase CO by Increasing LVSWI (contractility) and SVR (afterload)

44
Q

What is the normal range for MAP?

A

70-90mmHg

45
Q

What are causes of a increased SVO2

A

Increased Oxygen Supply

  • Increased CO
  • Increased Oxygen saturation
  • Increased hemoglobin

Decreased Oxygen Demand

  • Hypothermia
  • Fever reduction
  • Paralysis
  • Pain relief
  • Anesthesia
46
Q

What are some interventions for decreased preload?

A
  • Crystalloids
  • Colloids
  • Blood administration
47
Q

What are causes of increased CVP / Wedge pressure?

A
  • Hypervolemia
  • Pulmonic (R), Mitral Valve (L) Stenosis
  • Pulmonary Hypertension
    • –P Embolism
    • –Chronic Lung Disease
  • Chronic/Severe Left Heart Failure
  • Cardiac Tamponade
  • Myocardial Ischemia, Infarction, Heart Failure
48
Q

What does impedence cardiography measure?

A
  • Measured values:
    • HR, NIBP
    • Velocity and Accleration Index
    • Pre-ejection time
  • Calculated values:
    • Stroke volume, C.O., SVR
  • Limitation:
    • Vigorous studies still needed
49
Q

Describe the hemodynamic values associated with obstructive shock

A

Preload: Either ↑ or ↓

Afterload: ↑

Contractility: ↓

Oxygen Delivery: ↓

51
Q

In what order does the progression of shock occur? (list the progression of the staging)

A
  1. Initial stage
  2. Compensatory stage
  3. Progressive Stage
  4. Refractory Stage
52
Q

What are some interventions for decreased afterload?

A
  • Crystalloid Fluids
  • Vasoconstrictors ( Norepinephrine [Levophed], Dopamine, Epinephrine , Phenylephrine)
53
Q

What is shock?

A

Occurs when the O2 supply does NOT meet O2 demand

54
Q

What can cause decreased contractility?

A
  • Hypoxia (ran out of O2 for the heart to keep pumping)
  • Acidosis
  • Myocardial Disease
  • Low Ca, Mg, K states
55
Q

What are some interventions for increased afterload?

A
  • Vasodilators (Nitroglycerine, Nipride, Cardene, ACE Inhibitors)
  • Intra-aortic balloon pump
56
Q

What is the proximal infusion lumen hub used for in a pulmonary artery catheter?

A

Measure CVP, Give IV fluids, Vasoactive meds only if NOT using for CO

57
Q

What causes obstructive shock?

A
  • Tension pneumothorax
  • Cardiactamponade
  • PE
58
Q

What are causes of a decreased SVO2

A

Decreased oxygen supply

  • Decreased cardiac output
  • Decreased oxygen saturation
  • Decreased hemoglobin

Increased oxygen demand

  • Hyperthermia
  • Seizures
  • Shivering
  • Pain
  • Increased work of breathing
  • Increased metabolic rate
  • Exercise
  • Agitation
59
Q

Describe the hemodynamic values associated with hypovolemic shock

A

Preload: ↓

Afterload: ↑

Contractility: ↓

Oxygen Delivery: ↓

60
Q

What are causes of hypovolemic shock?

A
  • Hemorrhage
  • Burns
  • Pancreatitis
62
Q

What is the normal range for SVR?

A

800 - 1200 dynes/sec/cm-5

63
Q

What does Epinephrine do and what are its effects on the heart?

A

Action: + Inotrope, + Chronotrope, (

+ inotrope = contractility, + chronotrope = increased HR) Vasopressor

**Effects: **Increase CO by increasing HR, Increases LVSWI (contractility) and SVR (afterload)

64
Q

What does Milrinone do and what are its effects on the heart?

A
  • Action: +Inotrope (which means it increase the contractility of the heart) & has a Mild vasodilatory action
  • Effects: Increase CO, Decrease SVR
65
Q

What are some pulmonary artery line complications?

A

Pneumothorax

–Obtain CXR following placement

Damage to blood vessels / heart

Infection

–Insertion under sterile precautions

–Utilize sterile plastic sheath over catheter

–Maintain sterile caps on ports

–Observe site for signs of infection

–Use occlusive dressing

Bleeding, Exsanguination due to loose connections

Pulmonary infarction

–Continuously monitor PA waveform

Thromboembolism (clot at end of PA distal)

–Do not flush a port if resistance is met

Air embolus (occurs with balloon rupture or open ports w/out caps)
–Assure tight connections
–Check integrity of balloon prior to insertion
–Do not overinflate
–If a change in PA waveform does not occur following inflation of balloon with recommended volume of air, discontinue use, and label catheter “not to be used”

Ventricular Dysrhythmias (when PA cath travels through RV [on insertion] or migrates from PA into RV)
–Monitor cardiac rhythm during PA catheter insertion
–Monitor for RV catheter position

Catheter wedges permanently: “spontaneous wedge position”= EMERGENCY
–Occurs when balloon is left inflated or
–Occurs when catheter migrates too far into the pulmonary artery (flat PA waveform)
–Can result in PULMONARY INFARCTION in a few minutes
–Ask patient to cough and turn side to side, then Notify MD immediately (catheter needs repositioned)

66
Q

What are causes of decreased preload?

A
  • Hemorrhage
  • Dehydration
  • Diuretic Use
  • Third-spacing
  • Loss of venous tone
  • Rapid HR
  • Diabetic Insipidus
67
Q

What is the function of a PA catheter?

A
  • To determine Cardiac Output
  • To determine direct or indirect pressures (ex: PAP, Wedge) and calculated values (ex: SVR)
  • To sample and monitor mixed venous samples to test for oxygen saturation
  • To provide therapies (IV fluids, meds, transvenous pacing)
68
Q

What does Digoxin do and what are its effects on the heart?

A

Action: +Inotrope, Controls ventricular rate

Effects: Increases CO by Increasing LVSWI & rate control

69
Q

How is a PAWP obtained?

A
  • Obtained by inserting < 1.25 ml air into the distal balloon port
  • Let ballon deflate passively
70
Q

What is the RAAS stimulated by?

A

–Low Venous return
–Low Cardiac Output
–Low Renal Perfusion

71
Q

How would you ensure the accuracy of a PAWP measurement?

A

–Taken at end-expiration
–Re-level transducer w/ every change in backrest elevation (HOB)

72
Q

What does Lisinopril do and what are its effects on the heart?

A

**Action: **Arteriole vasodilation

Effect: Decrease afterload (SVR); Decrease preload (CVP, PAP, W)

High Acuity Ex. 2 Study Material (3 decks)

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