MODS, SIRS, Sepsis

Question 1

Shock continuum

Answer 1

hypoperfusion
hypoxia
cellular dysfunction
cellular death
organ dysfunction
organ death

Question 2

MODS

Answer 2

at least 2 organ systems severely deranged for at least 24 hours in the setting of sepsis, trauma, surgery, burns, severe inflammation

inflammatory response+hypotension+hypoxia

Poor prognosis
2 organ systems=40% mortality
3 organ systems >72=80% mortality

Question 3

hypovolemic shock

Answer 3

acute blood loss, dehydration, third spacing
dry, tight
fluid resuscitation 3:1 (3mL isotonic crystalloid for every 1mL est blood loss)

Question 4

cardiogenic shock

Answer 4

pump failure, MI (be aware PE and cardiac tamponade sometimes called obstructive shock)
wet, tight

Question 5

distributive shock

Answer 5

aka vasogenic, tone issue
anaphylactic: antigen triggers mediators, vasodilation
Septic: infection triggers inflammatory response–>vasodilation
Neurogenic: massive vasodilation, SNS can’t respond

dry, loose, HR not increased

Question 6

cardiac output

Answer 6

4-6L/min

Question 7

PAWP/PAOP/Wedge: preload

Answer 7

8-12; if decreased, they have less blood. If elevated, then they have too much blood volume

Question 8

CVP/RAP: RV preload-stretch:

Answer 8

2-6; speaks to blood volume

Question 9

SVR: afterload-squeeze

Answer 9

900-1200; the pressure your LV is pumping against. How dilated/constricted is the aorta? Also, pressure will rise/fall depending on blood volume…

Question 10

MAP

Answer 10

70-90 (at least 60 to perfuse organs)

Question 11

Weight gain concerns:

Answer 11

3 lbs overnight, 5 lbs in a week

Question 12

calculate MAP

Answer 12

Equation: MAP = [(2 x diastolic)+systolic] / 3

Question 13

septic shock

Answer 13

dry, loose; tachycardic
6-10L of isotonic crystalloids and 2-4 L of colloids are needed in the first 6 hours to achive a target CVP of 8-12 mm Hg. add vasopressors such as Levophed or dopamine once CVP is 8mm Hg. Antibiotics should be started within the first hour of septic shock. **Obtain cultures first!!

Question 14

needles decompression

Answer 14

14-16 gauge needle to 2nd or 3rd intercostal midclavicular line

Question 15

remove a spleen

Answer 15

risk of infection for rest of life due to lack of platelets and macrophages that used to live in spleen

Question 16

what is an early sign of hypoperfusion?

Answer 16

decreased urinary output

Question 17

colloids

Answer 17

contain large molecules that don’t pass through semipermeable membranes. When infused, they remain in the intravascular compartment and expand intravascular volume by drawing fluid from extravscular space via their higher oncotic pressure.

Question 18

crystalloids

Answer 18

contain small molecules that flow easily from bloodstream to cells and body tissues. This will increase fluid volume in both intravascular and interstitial spaces. Can be isotonic, hypotonic, or hypertonic.

Question 19

isotonic solutions

Answer 19

250-375 mOsm/L; no fluid shift, cells do not shrink or swell. NS, LR, D5W, and Ringer’s

Question 20

use this isotonic solution to replace GI tract fluid losses, fistula drainage, and fluid losses due to burns or trauma

Answer 20

LR: it is the most closely related to composition of body’s blood serum and plasma; LR is metabolized in the liver, which converts the lactate to bicarb. Often given to pts with metabolic acidosis. Don’t give LR to patients with liver disease!

Question 21

Ringers Solution

Answer 21

like LR, contains sodium, potassium, calcium, and choloride in similar concentrations, but not the lactate, so no contraindications. WIll not correct metabolic acidosis bc no lactate.

Question 22

D5W

Answer 22

unique bc it can be classified as isotonic or hypotonic. (hypotonic as dextrose is metabolized by the body, leaving a hypotonic solution behind); D5W provides free water, this aids the kidneys in excreting solutes; 170 cal/L

Question 23

When should you avoid using D5W?

Answer 23

following surgery: body’s reaction to surgical stress may cause an increase in ADH
IICP: hypotonicity following dextrose metabolism will cause dangerous fluid shifts in the brain.

Question 24

hypotonic IV solutions

Answer 24

osmolality less than 250 mOsm/L; hydrate the cells but may decrease blood volume in the process. helps kidneys excrete excess fluids and electrolytes. treat DKA, HHNA; watch for hypovolemia and cardiovascular collapse!

Question 25

SIRS: Systematic Inflammatory Response Syndrome

Answer 25

overwhelming inflammation with no identifiable source of infection

Question 26

SIRS + Documented culture or visualized infection

Answer 26

sepsis

Question 27

SIRS+ documented culture or visualized infection+hypoperfusion or thrombocytopenia or DIC

Answer 27

severe sepsis

Question 28

MAP 60

Answer 28

Septic Shock

Question 29

hypertonic solutions

Answer 29

osmolarity >375mOsm/L. volume expanders. Watch for fluid overload and pulmonary edema! Watch for s/sx of hypernatremia (disorientation, convulsions) Central line preferred for infusing >3% NS as these solutions are caustic

Question 30

CO ,4L/min
CI< 2.5
Increased PAWP, PVR
decreased renal blood flow leads to increased sodium and water retention and decreased urinary output

Answer 30

cardiogenic shock

Question 31

a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism

Answer 31

shock

Question 32

a systemic inflammatory response to a documented or suspected infection

Answer 32

sepsis

Question 33

severe sepsis

Answer 33

sepsis complicated by organ dysfunction

Question 34

Albumin, Hetastartch, and dextran

Answer 34

colloids=volume expanders

Question 35

Hetastarch

Answer 35

colloid volume expander; may be 50% less costly than albumin, can exert osmotic effect for up to 36 hrs. has antiplatelet effect so use with caution if HF, Renal Failure, or bleeding d/o

Question 36

Dextran

Answer 36

colloid volume expander; increases risk of bleeding; monitor pt for allergic rxn and A Renal Failure; limited use bc reduces platelet adhesion and dilutes clotting factors.

Question 37

what is important to remember when infusing large quantities of PRBC’s?

Answer 37

they do not contain clotting factors, so replace those too

Question 38

nitroprusside

Answer 38

arterial dilation’ protect from light and administer ONLY with D5W; monitor for cyanide toxicity (metabolic acidosis, tachycardia, altered LOC, seizures, coma, almond scented breath)

Question 39

phenylephrine

Answer 39

neurogenic shock vasopressor; treat bradycardia with atropine; administer fluids cautiously bc hypotension is NOT the result of hypovolemia but instead a lack of SNS activity due to spinal injury above T5. monitor for hypothermia. Methylprednisolone (SOlu-Medrol) is used for patients with a spinal cord injury to prevent secondary spinal cord damage caused by the release of chemical mediators.

Question 40

patients at increased risk for shock

Answer 40

older, debilitating illness, immunocompromised, surgical/trauma

Question 41

Surviving Sepsis Bundle

Answer 41

first 3 hours:

1. measure serum lactate
2. obtain blood cultures PRIOR to admin abx
3. admin broad spectrum abx
4. crystalloids for hypotension or lactate >4

First 6 hours

1. vasopressors for hypotension refractory to fluid resuscitation or lactate >4 to maintain MAP >65
2. CVP target 8-12 but 12-15 if mechanically vented. SvO2 target 70%

Question 42

dobutamine

Answer 42

raise cardiac output and improve lactate clearance