Therapeutics - Shock Part 2 Flashcards
effect of vasodilators in cardiogenic shock on PCWP and SVR
decreases both
this in turn reduces myocardial oxygen consumption and improves LV performance
cardiogenic patients can only be given vasodilators if…
their systolic BP must be over 90 bc vasodilators can decrease BP
how often should vasodilators for cardiogenic shock be titrated?
what is goal map?
titrate every 5 mins to the lowest effective dose that achieves goal map of over 70mmHg
2 signs to STOP TITRATING the vasodilator in cardiogenic shock
if the MAP decreases by 5-10mmHg or the patient gets worsening tachycardia (reflex)
the vasodilator that decreases arterial pressre (afterload)
which decreases venous return? (preload)
hydralazine
decreases venous return = nitroglycerin
which 3 vasodilators have mixed artery and vein decreased pressure
nitroprusside
nesiritide
ace inhibitors
milrinone class and use in shock
a vasodilator - PDE inhibitor - has inotropic and vasodilator activity
potentiall can be useful in heart failure patients with cardiogenic shock
increases CO and decreases SVR like dobutamine, BUT for milrinone, b blockers dont interfere
true or false
while the effects of dobutamine are mitigated by beta blockers, the effects of milrinone are not
true
2 AE of milrinone
hypotension, arrhythmia
duration of action of milrinone and is this good or bas
LONG duraiton - needs a loasing dose. concern bc cant quickly d/c if AE occurs
true or false
milrinone does not really improve the mortality outcome in cardiogenic shock patients
true
recombinant BNP that has potential role in cardiogenic shock
nesiritide
effect of nesiritide on SVR and PCWP
decreased both
AE nesiritide
hypotension
role of nesiritide in cardiogenic shock
for refractory use in select patients. potential role in heart failure
goal in treating septic shock
-eradicate infection
-support hemodynamincs
-mitigate the pathology of sepsis
maximize O2 deliver to reverse anaerobic cellular metabolism!
1 of the “pillars” for treating septic shock is to manage the infection
explain what antibiotics should be used and when
broad coverafe AS SOON AS POSSIBLE - DO NOT WAIT FOR CULTURES
can deescelate potentially when the cultures come back
length of antibiotic therapy for septic shock patients
what other antimicrobial therapy may they need?
7-10 days
may also need antifungal coverage
patient with septic shock is hypovolemic
how is this handled
increase the intravascular volume AGGRESSIVELY
crystalloids are preferred (30mL/kg. if not meeting goals - can add inotropes or vasopressor)
true or false
vasopressors decrease the SVR
false 0 increase
preferred vasopressor for hemodynamic control in septic chock [atients
norepinephrine
can add vasopressin
explain algorithm for hemodynamic control in septic shock patients
goal MAP?
-if hypovolemic - correct fluid AGGRESSIVELY (follow hypovolemic shock guidelines)
-add vasopressor
-then inotropes if needed (usually dobutamine)
-GOAL MAP is 65 and over
5 vasopressors that have the potential to be used in septic shock for hemodynamic control
norepinephrine
epinephrine
phenylephrine
dopamine
angiotensin II
which vasopressor should be avoided if the cardiac output is decreased bc it has no direct cardiac stimulating effects?
phenylephrine
role of corticosteroids in septic shock
potentially can be used to mitigate the pathology of sepsis.
may be useful bc many septic shock patients are though to be adrenally insufficnet – if we give, we may reduce the vasopressor duration
role of statins in septic shock
if patient is on - just continue it. some evidence that taking them off is detrimental
immunomodulatory and antiinflammatory effecrs
specific corticosteroids that may be used in septic shock
hydrocortisone + fludrocortisone
pt suffered an abdominal wound with significant blood loss. confused and skin is pale and cool
low BP, high HR, high RR
what is the type of shock
what is the MAP
proper management
what monitoring
HYPOVOLEMIC SHOCK
give blood transfusion
MAP = 53.67 - LOW need 60-65 to perfuse brain
get BMP to monitor electrolyte disturbances from the transfusion
however, if the blood cant get here quick enough - crystalloids may be reasonable
while the patient is (+) for SIRS, there isn’t suspicion of infection, so not septic shock
pt admitted to ICU following a CABG.
has hypertension and high cholesterol
taking aspirin, lisinopril, and metoprolol
low pH
low BP
high HR
low CO
high PCWP
high SVR
urine output down
type of shock?
monitoring?
CARDIOGENIC SHOCK
since SVR is high - it’s not distributive shock
wedge pressure is high, meaning the patient has a high preload and HAS ENOUGH FLUID
since BP and MAP are low, hold the antihypertensives. do NOT need a fluid challenge bc the wedge pressure (PCWP is high)
give inotrope like dobutamine - no vasodilator bc will decrease BP even more
also, keep in mind dobutamine may need to be titrated higher if the last dose of metoprolol was recent
monitor for kidney injury - oliguric!
pt is 5 days post abdominal surgery. has chills and a fever. low BP, high HR, high RR, low urine output
PCWP normal
SCV is low
type of shock?
monitoring?
initial management?
septic shock
LOW SVR is consistent with septic shock!!!!!!!!
SIRS criteria met + suspicion of infection (surgery)
infection control - broad spectrum AB
aggressive crystalloids - 30cc/kg (NS or LR) – measure vitals repeatedly
if MAP 70 after crystalloids - dont need vasopressors. if pressure goes down - sign of more organ dysfunction - VASOPRESSORS
