Hemodynamics and Shock Flashcards Preview

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Flashcards in Hemodynamics and Shock Deck (44):
1

Hemodynamic instability

hypotension, change in mental status, and signs of shock

2

Hypotension

mean arterial pressure (MAP)

3

Mean Arterial Pressure

MAP

80 – 100 mmHg

MAP =DBP + 1/3 (SBP-DBP)***

Better mesured for t
Need at least 65 in order for your organs to have adequate organ perfusiotn

4

Cardiac Output

4 – 7 L/min

CO

5

Cardiac Index (CI)

2.8 – 3.6 L/min/M2

CO/body surface area

-->corrected CO for weight

6

Pulmonary Artery Occlusion Pressure
a.k.a. Pulmonary capillary wedge pressure

12-15 mmHg

Measure the pressure of L ventricle at the end of diastole. The heart is filled with the maximum volume of blood. Learn patients volume status.

-indicates preload
-pressure in left ventricle

7

Systemic Vascular Resistance

SVR

1300 – 2100 dynes-s/cm5

SVR- constriction/dilation of blood vessels

8

SHOCK

An acute, generalized state of inadequate perfusion of critical organs

• Serious pathophysiological consequences, including death

• USUALLY but not always associated with hypotension (SBP

9

o Signs of poor/reduced perfusion:

Hypotension
• Increased HR and RR
• Cold extremities
• Mental status change or unconscious
• Reduced urine output (worsening renal function)-increase in ScR
• Lactic acidosis

10

Shock: hypovolemic

Low vascular volume

11

Shock: Distributive

Septic or anaphylactic: vasodilation

12

Shock: Cardiogenic

poor heart function

13

• Vasopressors (“vasoconstrictors”)

Route and titrating frequency?

Administered via continuous infusion

Frequent dosing adjustments may be necessary
(titration) every 5-15minutes

14

Can Vasopressors be used in Central line?

phentolamine (antidote)

YES or else

Tissue necrosis with extravastation:
o To avoid: administer through a central line

o Treat extravasation with intradermal administration of
10-15 ml of saline and** 5-10 mg of phentolamine**

• Phentolamine: blocks alpha-adrenergic receptors
causing vasodilation and minimizes necrosis

15

α1 - Vasoconstriction

α2- Vasoconstriction

β1 - inotropic (contractility) and chronotropic (HR)


β2- vaso-/Brocodilation

DA - Vasodialtion in the kidney, Heart, and GI

α1 - Vasoconstriction

α2- Vasoconstriction

β1 - inotropic (contractility) and chronotropic (HR)


β2- vaso-/Brocodilation

DA - Vasodialtion in the kidney, Heart, and GI

16

Dopamine

Central line line

DOC if low risk of arrhtymias
-Large DA and B1 activity

AE:
**Worst for Tachycardisa-->B1
peripheral vasoconstriction-->a1

Arrhythmias, tachycardia, peripheral and gut ischemia/ necrosis

17

Epinephrine
Catecholamines

Central line line

(Adrenaline®)

Large a1 and B activity (less B2)

AE:
hyperglycemia**
hypokalemia*

Agitation, tremor, headache, Arrhythmias, tachycardia hyperglycemia, peripheral and gut ischemia/ necrosis, "K+

18

Norepinephrine
Catecholamines
Central line line

(Levophed®)

often 1st line: a and b activity.

generally additive therapy to dopamine for septic shock

AE:
Hyperglycemia**

Agitation, headache, tremor-->B
peripheral/gut ischemia-->a

Hypokalemia**

19

Phenylephrine

Noncatecholamines

Central line line

Neosynephrine

Only alpha- a

indicated if hypotensive with tachyarrhthmia (no B1 effects)

20

Vasopression


Antidiuretic hormone

V1 Receptors – located in smooth muscle in blood vessels, hepatocytes, platelets, and on some cells in kidney

V2 Receptors: located in the renal collecting duct


Higher doses restricted in shock due to AEs

AE:

Decreased CO and circulation to skin and GI tract
peripheral ischemia
Hyponatremia**

May decrease CO and circulation to skin and GI tract (high doses > 0.04 units/min), decreased splanchnic circulation (high doses > 0.04 units/min), peripheral ischemia, hyponatremia

0.01-0.04 units/min (higher doses NOT recommended in shock-->Will cause auto amputee??? Vasopressors

21

Inotropes

Dobutamine

Milrinone

22

Dobutamine

2min half-life
hepatic metabolism
B and a1 activity
two isomers: (+) -> B-activity, (-) -->a

used in low CO states
--> CI Left Ventricular dysfunction
--> Shock

AE: Tachycardia, arrhythmias, hypotension (rarely), angina, premature ventricular beats

23

Milrinone

Half-life: 1-2hours
Renal (need lower in renal dysfunction)

PDE-3 inhibitor to enhance contractility


AE: Hypotension, arrhythmias

24

Hypovolemic Shock: Causes

Blood loss (shot wounds)

Fluid sequestered within a compartment of the body due to loss of oncotic pressure or increased capillary permeability

Fluid lost from urine, diarrhea/vomiting, skin (burns) o Hemodynamic effects

25

Hypovolemic Shock: Hemodynamic effects

Decreased: MAP, CVP, PCWP, CO, SVR

Increased: SVR

26

Hypovolemic Shock: Treatment

Plasma expanders - 1st line
--> NSS or Lactated ringer (isotonic crystalloid)
-->albumin (colloids)
-->Blood: if caused by blood loss

Vasopressor--Last line
-->vessel are already contracted to compensate for loss of BP

27

Hypovolemic Shock: Monitoring

HR, BP, lactate, and Scr

28

Distributive Shock: Septic Shock

Cause

Infection - Gram (+) most common

29

Distributive Shock: Septic Shock

Risk factors

Elderly

Immunosuppressed states (AIDS, cancer, transplant,
chronic immunosuppressing medications)

Malnutrition

Alcoholism

Chronic organ failure

30

Definition of Systemic inflammatory response syndrome (SIRS)

**Patient must have two or more of the following:**

WBC ≥ 12,000 or WBC ≤ 4,000 or bands > 10%

Hyperthermia (≥38°C or 100.4°F) or hypothermia (≤36°C or 96.8°F)

(PaCO2 ≤32 mmHg)

RR ≥20

Mechanical ventilation for an acute respiratory process

Heart rate ≥ 90 beats/min

31

Sepsis

SIRS + infection

32

Severe Sepsis

Sepsis + organ dysfunction

33

Septic Shock

1 or 2 or 3 + Fluid refractory hypotension

34

Distributive Shock: Septic Shock

Pathophysiology

(1) Bacteria toxins cause-->Macrophages recognize the infection and (over)react and
release inflammatory mediators.
--> TNF-α
--> IL-1
--> IL-6

1.Vasodilation

2.Vascular endothelial injury resulting in activation of the coagulation cascade

3.o Fluid to leak out of vasculature and into tissues

35

Distributive Shock: Septic Shock

Hemodynamic Effects

Decreased: MAP, CVP, PCWP, SVR

Increased: CO

36

S/S

Early sepsis

Fever or hypothermia
Rigors or chiles
Tachycardia
Tachypnea
Hypoxia
Hyperglycermia
Myalgias

37

S/S

Late sepsis (evidence of organ failure

Increase Lactate*
Increase LFTs*
Pulmonary failure*

Decrease urine output/increase Scr
Hypotension
Thrombocytopenia
COMA

38

Treatment (Surviving Sepsis Guidelines)

Prompt diagnosis and identification of pathogen causing infection

Early administration of antibiotics

Adequate organ perfusion (CVP > 8 and MAP > 65,
lactate

39

Distributive Shock: Septic Shock

Antimicrobial therapy

Blood cultures should be sent before antimicrobial therapy is initiated as well as cultures from any other site that is suspected as causing the infection

--Blood must be sent immediately; start antimicrobial empirically within 1 hour*** (IV therapy)

40

Distributive Shock: Septic Shock

(1) Fluids

Fluide challenge:
Administer 30 ml/kg of NNS or Lactated Ringers
-->Continue giving until goals met or signs of volume overload

Albumin - 2nd line

Blood due to loss

Monitoring: Sodium/chloride (crystalloids only), BP, HR, CVP, lactate, urine output, pulmonary edema, heart failure, edema

41

(2)Vasopressors/inotropes

Noreperienpherine: 1st line for hypotension in septic shock

Dopamine: alternative if at low risk of arrhythmias--> low dose not useful. “Renal-dose dopamine” not useful (

42

(2) Vasopressors/inotropes

Goals and Monitor

MAP>65

BP, HR, potassium, glucose,
peripheral/splanchnic vasoconstriction

43

(3) Steroids

Adminstration (period) And Monitoring and Goals

Recommended to administer intravenous hydrocortisone in septic shock patients refractory to (1) fluids and (2) vasopressors
--> (Hydrocortisone 50mg IV)** every 6 hours or as continuous at 8 mg/hr

Goals: MAP > 65, avoid adverse effects, discontinuation of vasopressors

Monitoring: BP, glucose, mental status, fluid retention, infection, GI ulceration

44

(4) Insulin

Goal and monitor

Glucose elevate by EPI--> (precaution)
*Continuous infusion with short-acting insulin
(regular or lispro)*

***Goal: blood glucose