Seminar Exam 3 Flashcards
(171 cards)
1
Q
define acute pancreatitis
A
pancreatic enzymes, which are normally inactive until reaching duodenum, are activated within pancreas
2
Q
GI/hepatic changes in sepsis
A
- bowel ischemia
- stress ulcer
- hepatic dysfunction
- increased LFTs, jaundice
- encephalopathy
- w/o gut perfusion, lose protective mucosa
- bacteria colonizes
- bacterial translocation to blood stream
- bacteremia
3
Q
ACS and pancreatitis
A
- ACS may be as high as 78% in acute pancreatitis
- d/t inflammatory response syndrome
- capillary fluid leak and edema in mesentary and bowel wall
- leads to IAP
- fluid resusc worsens
4
Q
activation of coagulation system in SIRS
A
- results in
- clot formation in microvasculature (microemboli)
- decreases cellular perfusion and causes cellular death
5
Q
risk factors for ACS
A
- diminished abd wall compliance
- increased abd contents 2/2 air, blood, fluid sequestration
- capillary leak from fluid resusc measures
6
Q
damage control procedure on airway and bladder pressures
A
- emergent laparotomy
- abdominal compartment open and left open so organs can swell
- decreaes airway and bladder pressures immediately
- goal is immediate restoration of perfusion, reverse ischemia, prevent necrosis, and close back up
7
Q
platelet aggregation and microclot formation in SIRS
A
- clots can’t pass through capillary beds
- clump
- blockage
- poor perfusion
- in all oragns, not just periphery
8
Q
ROSC
A
- return of spontaneous circulation (ROSC)
- pulse and blood pressure
- abrupt sustained increase in PETCO (>40 mmHg)
- spontaneous arterial pressure waves w/ intra-arterial monitoring
9
Q
end result of SIRS response
A
decreased tissue perfusion resulting in cellular death and organ dysfunction
10
Q
hyperventilation during resusc
A
- correct vent rate is 10 breaths/min (q6sec)
- tidal volume is: ideal body weight * 6-8 ml
- don’t need entire bag!
- risk of too much tidal volume = overdistention
- barotrauma
- rising lung bed pressures
- less venous filling of SVC to heart
- less room for heart expansion
- no stretch, no squeeze
- 30:2 w/ no artifical airway
11
Q
“the person” in aseptic technique
A
- perfection
- thoughtful process
- repetition
12
Q
pharmacy in code
A
code drugs
13
Q
systemic effects of intraabdominal hypertension (IAH)
A
14
Q
how to keep patients safe with great outcomes
A
- aseptic technique
- hand hygiene
- in & out of rooms
- thoughtful culture usage
- PPE use
- never out of rooms
15
Q
members of the code team
A
- primary nurse
- nurses on unit
- anesthesia
- CC/intensivist physician
- nursing supervisor
- resp therapist
- pharmacy
- transport
16
Q
kill time
A
how long it takes for chemical to kill organisms after application to skin
17
Q
characteristics of effective CPR
A
- adequate CC
- rate correlated w/ increased survival
- depth correlated w/ increased survival and successful defib
- CC 90-100/min (highest survival rate)
- shocks more successful with 2-2.4 in compression depth
- greater pre-shock pause = less successful shock
18
Q
PCI and cooling
A
- incidence of CAD in VF pts is high
- STEMI - minimize delay to cath lab and initiation of cooling
- can be used during angiography
- surface or catheter
- can be used during angiography
- NSTEMI - initial streategy
- early invasive approach with PCI (w/in 24-48 hrs) in patients with
- recurrent angina or ischemia at rest
- elevated biomarkers
- new ST seg depression
- other high-risk features
- early invasive approach with PCI (w/in 24-48 hrs) in patients with
19
Q
improving oxygenation in sepsis
A
- ventilator therapy
- oxygen conservation
- improve delivery (hemoglobin)
20
Q
anesthesia provider during code
A
- except in surgical critical care environment
- already there
- manage airway
21
Q
hemodynamic variables reflecting various shock mechanisms
A
22
Q
neuro implications in ACS
A
- decreased perfusion from poor outflow
- high intrathoracic pressure may
- compress jugular veins
- obstruct cerebral outflow
- increase ICP
- d/t poor venous return vai jugulars
23
Q
cardiac arrest epidemiology
A
24
Q
patho of acute pancreatitis
A
- autodigestion of pancreatic tissue
- leading to inflammation and necrosis
- amylase and lipase are really good at digesting protein, fat, and starch
- which is what we are made of
- interruprs normal endocrine and exocrine fxns of pancreas
25
chlorhexidine gluconate + alcohol
* antimicrobial (not antifungal) skin prep
* alcohol - 70% or higher isopropol
* not for neonates \< 32 weeks
26
calculate abdominal perfusion pressure (APP)
* MAP - IAP
* maintain APP \> 60 to decrease morbidity, mortality
27
rapid response team members
* critical care nurse
* respiratory therapist
* physicial (CC or hospitalist)
* nursing supervisor (coordinators)
* can get a pt a bed
28
three key points in SIRS
* increased capillary permeability
* 3rd spacing of fluids
* activation of immune response
* fever, tachycardia
* activation of clotting cascade
* microemboli
29
drug therapy for code
* epi IV/IO: 1 mg q3-5 min
* amiodarone IV/IO:
* first dose 300 mg
* second dose 150 mg
30
monitoring ACS
* abd girth
* bladder pressure - gold standard
* q2-4 hr until abd pressure returned to normal
* continu to monitor even during release of pressure via damage control procedure
* until fascia closed and IAP normal
* via specific manometer that utilizes needle or needle-free access to aspiration port of indwelling urinary cath
31
epidemiology of acute pancreatitis
* 18 per 100,000
* 3x more in AA than caucasian
* males \> females
* 10-15% mortality in uncomplicated acute
* 30% if mounting MODS reaction
32
stages of SIRS response
* release of pro-inflammatory mediators
* pro-inflammatory and anti-inflammatory mediators appear in systemic circulation
* massive systemic inflammation
* compensatory anti-inflammatory response occurs to try and suppress inflammation
33
severe sepsis
* sepsis associated with
* organ dysfxn
* hypoperfusion (shock)
* hypotension
* other symptoms include:
* lactic acidosis (lactate \>2)
* oliguria - poor renal perfusion, poor intravascular volume
* acute alteration in mental status - poor cerebral perfusion
34
hematologic side effects of therapeutic hypothermia
* coagulopathy, despite normal lab tests
* decreased platelet function @ 35 C
* decreased function of plasma proteins @ 34 C
35
prognosis of MODS
* depends on length and severity of SIRS
* unpredictable organ response
* 1 organ \<50% mortality
* 2 organs 50-60%
* 3 organs 60-100%
* 4 organs 100%
36
concept of antimicrobial stewardship
* provide support to healthcare workers
* decrease inappropriate antimicrobial use
* optimize selection, dose, and udration of antimicrobial therapy
* streamline costs associated with antimicrobial use
* decrease spread and emergence of antimicrobial resistance
* improve patient outcomes
37
renal changes in sepsis
* metabolic acidosis
* decreased renal perfusion
* acute renal failure (pre-renal)
* kidneys lose ability to help body compensate for this d/t decreased renal perfusion
* usually produce bicarb
38
not recommended during therapeutic hypothermia
* focus on preventing fever or maintaining normothermia will not have same outcomes
* not substantiated
* prehospital cooling not recommended
39
causes of infection
* central lines, foley, A-lines
* trauma, surgery
* translocation of gut bacteria
* ventilators
* diabetes
* cancer, immune compromised
* alcohol, malnourished
* epithelial barrier
40
what happens when you cut your finger? (normal response)
* bleeds - washes away bacteria and flow of blood brings WBCs
* hyperemia - red and puffy ("too much blood")
* d/t inflammation leading to local cap dilation b/c WBC much larger than other blood components
* clot - stops bleeding, forms foundation for regeneration of new tissue
* swelling reduces, area heals over
41
maintaining therapeutic hypothermia
* internal catheter or external cooling blanket
* from time until patient hits target temp until re-warming begins
* serial labs
* patient testing
* EEG monitor
42
neuro monitoring during therapeutic hypothermia
* 80% of caridac arrest survivors comatose
* seizures common - 44%
* EEG most reliable way to detect
* many are subclinical
* NMB agents suppress convulsions but not seizures
* rebound fevers common (41%) and can be associated with worse outcomes
43
renal implications in ACS
* acute failure 2/2 renal vein obstruction
* indirect failure 2/2 decreased intravascular volume
* prerenal AKI
44
measuring intraabdominal pressure
* directly via intra-abdominal catheter
* more commonly indirectly via bladder pressure (special device on Foley)
45
#1 way to prevent infection
hang hygiene
46
1st hit vs 2nd hit in SIRS
* 1st hit - initial injury followed by SIRS response
* 2nd hit - another injury on top results in increased SIRS response
47
antibiotics for sepsis
* gram +
* vanco, linezolid
* gram -
* gentamycin, levaquin, ticarcillin, cefepime
* broad spectrum
* imipenem
* zosyn
* augmentin
48
"helper" nurses during code
* assist with families
* maintain privacy
* make necessary phone calls to chaplain, OR, radiology
* obtains needed equipment/supplies for patient
* watches other pts during this time
49
why would MODS patient need to be in ICU?
* if failure of 1+ body system requiring support
* cardiopulmonary - pressors and vent
* neurologic - invasive ICT monitoring, frequent neuro checks
50
allowing chest recoil during CPR
* perfuse coronary arteries
* diastolic filling of heart
* without recoil:
* blood can't get back into heart effectively
51
MODS
* multiorgan dysfunction syndrome
* presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention
52
circulating nurse in code
* obtain & dispense supplies
* supplies meds
* access, prime IVs
* send labs
* set up equipment
* dispense supplies
53
S/Sx of ACS
* earlier
* decrease CO/BP
* change in mental status
* increase in peak airway pressure
* decrease in tidal volume
* later
* increase in abd girth
* oliguria
* systemic and dependent edema
54
secondary conditions causing IAH and ACS
* severe intra-abd infection
* large-volume fluid replacement
* ascites
* pancreatitis
* ileus
* sepsis
* major burns
* continuous ambulatory peritoneal dialysis
* morbid obesity
* pregnancy
55
integumentary side effects of therapeutic hypothermia
skin breakdown d/t decreased circulation
56
2010 therapeutic hypothermia guidelines
* with ROSC after out-of-hospital VF, should be cooled to 32 to 34 for 12-24 hrs
* with ROSC after in-hospital cardiac arrest of any initial rhythm or after out-of-hospital cardiac arrest with an initial rhythm of PEA or asystole
57
supportive measures for sepsis
* fluid resuscitation
* improve oxygenation
* coag support
* treat organ dysfxn/failure as needed
* nutritional support
58
define abdominal compartment syndrome
increased pressure in closed anatomic space threatening viability of surrounding tissue
59
hands-only CPR
* can work until rescue gets there
* capacity of hbg molecular to carry up to 4 oxygen molecules
* blood is oxygenated enough
60
cardiac implications in ACS
* diaphragmatic elevation and increased intrathoracic pressure
* compress heart
* decrease venous return and contractile effectiveness
* decrease in preload 2/2 IVC compression, inhibits venous return
* decreased CO, more hypoperfusion
* increased IAP inhibits venous emptying from abd viscera and organs (venous pooling)
* venous pooling in lower extremities, overcoming oncotic pressure and forcing fluid to interstitium
* afterload increased 2/2 abd aorta compression
* decrease flow to abd, liver, kidneys
* shock
61
increased cap permeability in SIRS
* fluid leaks out of blood vessels and into interstitial space
* loss of vessels' normal response to stress
* normal response - catecholamines release and vessels tighten up
* results in
* massive edema
* intravascular fluid volume deficit
* hypotension
* distributive shock
62
site of injury in SIRS
vascular endothelium
63
IAH impact on hemodynamics
64
renal side effects of therapeutic hypothermia
* diuresis
* electrolyte imbalances
65
re-warming in therapeutic hypothermia
* initiate 24 hr after target temp reached
* set point 37 C moderate mode
* increase set point 0.33 C q1h until tem reaches 37 C (~12 hr)
* hold fluids w/ K+
* maintain normothermia 48-72 hours post-rewarm
66
leaky capillary syndrome (SIRS)
* fenestrations (opening) in capillaries allow for exchange of nutrients and oxygen btwn blood and tissue
* inflammatory response causes dilation of capillaries and fenestrations enlarge
* normally a balance between
* oncotic pressure attracting fluid to intravascular space
* hydrostatic pressure, cap filtration pressure pushing exchange of oxygen and fluid with tissues
* when fenestrations enlarge, cap filtration pressure overwhelmes oncotic pressure, resulting in inappropriate fluid movement to interstitium (3rd spacing edema)
67
why are SIRS patients in metabolic acidosis?
* anaerobic metabolism to overcome poor perfusion
* results in high lactate (byproduct of anaerobic metabolism)
68
bactericidal vs bacteriostatic
* bactericidal - killing bacteria
* bacteriostatic - preventing further growth
69
integumentary implications in ACS
* massive edema --\> skin breakdown
* dermis may separate from basement membrane
* form large bolus lesions
* infection risk if ruptured
* risk for insensible fluid loss
70
cardiovascular side effects of therapeutic hypothermia
* bradycardia
* hypovolemia
* prolonged QT
71
direct tissue injury/necrosis r/t SIRS
* direct tissue injury
* trauma
* surgery
* abdominal, cardiac, vascular
* necrotic tissue
* ischemic gut (very pro inflammatory)
* ischemic extremity
72
simultaneous pro and anti-inflammatory response in SIRS
73
thoughtful bacterial culture usage
* when is ordering a culture appropriate?
* what are the implications for patient?
* what are the implications for hospital?
74
CNS side effects of therapeutic hypothermia
* confusion
* amnesia
75
bystander CPR
improves survival rates to discharge
76
invasion of microorganisms r/t SIRS
* SIRS + infection = sepsis
* gram +
* gram -
* fungus
* virus
* parasite
77
what does SIRS stand for?
* systemic
* inflammatory
* response
* syndrome
78
types of direct tissue injury leading to SIRS
* obstetrical emergencies
* abruptio placenta (tears away from uterine wall)
* blood pump dyscrasias
* cardio-pulm bypass
* ECMO (extracorporeal membrane oxygenation)
79
neuroprotective effects of therapeutic hypothermia
* decreased neuro injury - decreased:
* cerebral metabolism
* oxygen consumption
* inflammatory response
* free radical release
* cell damage, apoptosis
* cerebral edema
* cerebral metabolism decreases 6-10% every degree Celsius body temperature drops
80
nursing management of hematologic fxn during therapeutic hypothermia
* if bleeding, increase target temp to 34-35 C
* treat as needed
81
antibiotic stewardship
* bactericidal vs bacteriostatic
* effectiveness of drug
* location of infection
* ability for antibiotic to permeate area
* ability of bacteria to resist/inactivate antibiotic
* minimum inhibitory concentration (MIC)
* level of abx associated with effective tx
* lowest concentration to tx organism
* lower MIC = better antimicrobial agent (also more expensive)
82
pediatric SIRS criteria
at least 2 of the following, one of which is abnormal temp or leukocyte count
* HR \>2 st.dev above normal for age in absnece of stimuli
* or unexplained elevation for \> 30min - 4 hr
* in infants: HR \< 10th percentile for age in absence of stimuli OR unexplained depression for \> 30 min
* body temp \< 36 or \> 38.5
* RR \> 2 st.dev above normal for age or requiring methcanical ventilation not r/t neuromuscular disease or anesthesia
* WBC eleated or depressed for age not r/t chemo OR \>10% bands plus other immatuer forms
83
CPR Quality
* push hard (2-2.4 in) and fast (100-120/min)
* allow complete chest recoil
* minimize interruptions in compression
* avoid excessive ventilation
* rotate compressor q2 min
* if no advanced airway: 30:2 compression-ventilation
84
nursing management of infectious disease during therapeutic hypothermia
* watch for fevers 48-72 hrs post event
* treat with acetaminophen and/or cooling blanket
85
supportive care for patient with open abdomen
* tx causative process
* invasive hemodynamic monitoring
* careful I/O
* vasoactive meds to support BP
* ventilatory support
* paralystics to decreas pressure and prevent evisceration
* skin care
* analgesia/sedation with paralytic
* train of four (how many twitches of 4)
86
lipase
* most sensitive marker for pancreatitis
* stays elevated for 14 days
* amylase could be elvated for another reason
* stone blocking salivary glands
* also returns to normal w/in 72 hr
87
pulmonary changes in sepsis
* pulmonary edema - from third spacing
* hypoxemia / shunting
* atelectasis
* initial respiraotry alkalosis, eventual acidosis
* ARDS - acute respiratory distress syndrome
88
treating sepsis
* treat underlying cause
* repair injury
* remove necrotic tissue
* immunosuppression for organ rejection
89
fluid resuscitation in sepsis
* crystalloid
* blood products BP support
* vasoconstrictors
* levophed
* dopamine
* vasopressin
* neosynephrine
90
adult cardiac arrest - steps
91
when will leukopenic responses occur during SIRS?
* in elderly - can't mount leukocytotic response
* or fungal infections
92
primary conditions causing IAH and ACS
* blunt/penetrating trauma
* liver transplant
* ruptured abd aortic aneurysm
* post op bleeding
* retroperitoneal hemorrhage
* mechanical intestinal obstruction
* postop closure of abd under tension
* bleeding pelvic fractures
93
nursing management of musculoskeletal fxn during therapeutic hypothermia
* sedate and paralyze prior to cooling
* check skin under wraps
94
exclusion criteria for therapeutic hypothermia
* \> 12 hrs since return of spontaneous circulation
* glasgow motor score \> 5
* minimial premorbid cognitive status
* other reason for coma
* sepsis as cause of arrest (no longer exclusion)
* DNR
* significant trauma - d/t risk of bleeding
95
nursing management of renal function during therapeutic hypothermia
* follow electrolytes closely
* esp during rewarming
* stop all K+ fluids prior
96
primary nurse during code
* knows patient best - don't leave room
* communicate with code captain
* what's been happening during shift or recent days
* events and assessment
* coordinate care for pt
* administer meds
* assist with procedures
97
hematologic changes in sepsis
* leukocytosis
* activation of clotting cascade (microemboli)
* DIC
thrombocytopenia
98
define infection
host response to presence of microorganisms or tissue invasion by microorganisms
99
endotoxin
* substance found in cell walls of gram negative bacteria
* aka lipopolysaccharide (LPS)
* LPS activates cell mediator pathway
* activates tumor necrosis factor
100
pathophys of ACS
* vicious cycle
* rising abd pressures --\> bowel ischemia --\> tissue dysfxn/anaerobic metabolism
* release of inflammatory mediators --\> 3rd spacing 2/2 leaky capillary beds and decreased intravascular volume --\> worsening hypoperfusion
* increasing amounts of fluid in interstitial space
* resulting edema rapidly increases pressure on abd
101
musculoskeletal side effects of therapeutic hypothermia
* shivering
* increases metabolic demand and O2 consumption
102
lower survival rates re: CPR
* PEA and asystole
* b/c less useful electrical and mechanical activity
* can't defib
103
integumentary changes in sepsis
* massive edema
* skin breakdown
* separation of skin from basement membrane
104
ACLS secondary survey
* airway
* intubate if non-invasive breaths ineffective
* breathing
* confirm airway, ventilate
* circulation
* establish IV, administer meds
* defib or differential diagnosis
* find and treat cause
105
biliary system
pancreatic enzymes normally travel to duodenum via pancreatic duct
106
documentation in code
* person identifies self as documenter
* code form on code cart
* document
* time of meds
* procedures
* vital signs
* events
* obtain necessary signatures after code
107
hallmarks of CPR
* compress deep and fast
* stay on chest while defib charging
* 2 min CPR btwn each shock
* then pulse check
* minimize hands-free time
* compressed heart = happy heart
108
when the rapid response team arrives...
communication is key!
* S - what's happening now?
* B - what were preceding events?
* A - findings and what you think is happening
* R - what do you want to be done?
109
pulmonary implications in ACS
* rising abdominal pressures mechanically elevate diaphraghm
* (rising 2/2 compression from abd edema)
* increases peak airway pressures and decrease in lung capacity
* resulting atelectasis
* also ARDS and direct tissue injury d/t pancreatic enzymes
110
preventing sepsis
* identify high risk patients
* elderly
* immunosuppressed
* surgery, trauma, vents
* all ICU patients
* keep IV lines clean, dry, intact dressings
* prevention of nosocomial infections
* feed patient
* handwashing
111
nursing management of CNS during therapeutic hypothermia
* if patient is not following commands, no cooling
* GMS \< 6
* no neuroprognostication until 72 hrs after re-warming
112
why not cool patients less than 32?
* pro-arrhythmic properties
* vtach and vfib become more refractory to successful defib at colder temps
113
hand hygiene products
* hand sanitizer
* soap & water
* antimicrobial soap
* CHG
114
coagulation abnormalities in SIRS
* considered key to organ dysfunction / death
* clots decrease perfusion, oxygen delivery
* research to design therapies to combat this destruction
115
SIRS criteria - diagnosing
2+ of following = SIRS
* temp \> 38.3/100.9 or \<36/96.8
* HR \> 90
* RR \> 20 or PaCO2 \< 32mmHg
* WBC \> 12,000, \<4,000, or \>10% bands
116
inflammation/increased WBCs in SIRS
* increases immune response
* results in
* fever
* vasodilation
* tachycardia
* leukocytosis
117
body's response to SIRS
* tissue hypoperfusion
* = shock
* systemic response - every cell affected
* in response to 3 key points
* cap permeability
* immune response
* clotting cascade
118
CAB in BLS
* circulation
* feel for pulse - start compressions
* 2-2.4 in, 100-120 bpm, chest recoil
* airway
* position head - tilt chin-lift
* breathing
* if not breathing, flatten head of bed
* begin bag/valve mask
119
treatment for ACS
* improve abd wall compliance
* analgesia, anxiolysis, +/- paralytics
* proper body alignment
* avoid hip flexion, HOB \< 20 (increased ICP, aspiration)
* evacuate abd contents
* NGT/OGT, +/- drugs to increase gastric motility
* correct positive fluid balance
* restrict fluids, administer colloids
* diuretic therapy
* HD or CRRT to remove fluid
* surgical decompression, damage control abdomen with open fascia, sterile dressing
120
clinical parameters indicating need for rapid response
* cardiovascular
* HR \>140 or \<40
* CP unrelieved by nitro
* pulm
* oxygen sat \<90% w/ oxygen
* inability to protect airway
* neuro
* acute change in mental status
* seizure
* urine output
* \<50 ml in 4 hrs
* uncontrolled pain
* staff or family member concerned about patient's condition
121
early goal directed therapy in sepsis
* recognize patients via SIRS criteria
* appropriate labs, tests
* early abx targeted empirically
* fluid resuscitation
122
pediatric emergencies (re: code)
* usually airway issues
* pediatric bls
* clear obstructed airway
* resusc breathing
123
SIRS overview
* can affect any patient, especially acute care
* often associated with infection (sepsis)
* occurs in response to injury
* may be result of multitude of causes
* mostly d/t
* direct tissue injury/necrosis
* presence of foreign invaders
* invasion of microorganisms
124
cooling methods in therapeutic hypothermia
* surface ooling
* precooled surface cooling pad
* water-circulating surface cooling pad
* core cooling methods
* cold IV fluids
* catheter-based endosvascular device inserted in femoral vein
125
timeline for therapeutic hypothermia
* cool for 24 hours
* rewarm gradually over 12 hrs
* check neuro outcome 3 days later
126
define syndrome
* set of medical signs and symptoms that are correlated with each other and, often, with a specific disease
* derived from Greek word "concurrence"
127
bacterial sepsis
* bacteria invade and release endotoxins
* cell mediator pathway is initiated
128
as code team arrives
* documentation
* bring code cart (CPR board on back of cart)
* bring airway box
* situate at head of bed for anesthesia to arrive
* connect and test suction
* apply leads on patient and defib pads if indicated
* crowd control
129
how does hypothermia protect from ischemic injury?
* neuroexitatory processes slowed by stabilizing influx of calcium and glutamate
* cerebral metabolism slowed --\> decreased oxygen consumption
* inflammatory response hampered --\> decreased release of free radicals --\> decreased cell damage and apoptosis
* limits cell death, decreases disruptions in blood brain barrier, limits cerebral edema
130
characteristics of hemorrhagic vs nonhemorrhagic acute pancreatitis
131
cardiovascular changes in sepsis
* tachy
* increased CO in early phase
* decreased SVR
* hypotension
* fluid shifts
132
why is a SIRS patient tachypneic?
blowing off CO2 to combat metabolic acidosis through respiratory compensation
133
non-bacterial sepsis
* fungal
* aspergillus, coccidiomycosis, histoplasma
* yeast - candida
* parasites
134
endocrine side effects of therapeutic hypothermia
* hyperglycemia
* decreased insulin sensitivity and secretion
135
advanced airway in code
* supraglottic or ET
* waveform capnography to confirm/monitor ET placement
* 8-10 breaths/min with continuous chest compressions
136
what is a rapid response?
* when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to the bedside to immediately assess and treat the patient with the goal of preventing ICU transfer, cardiac arrest, or death
* used as a system to recognize clinical deterioration before we reach need for a code
137
nurses on unit during code
* sometimes might have too many
* may need to do crowd control
* don't forget about other patients
138
immune/inflammatory response to therapeutic hypothermia
* impaired
* increased risk of pneumonia and infectious disease
139
cell mediated activity r/t SIRS
* damage to vascular endothelium causes release of cell mediators
* cascade effect occurs resulting in:
* increased cap permeability
* 3rd spacing of fluids
* activation of immune response
* fever, tachycardia
* activation of clotting cascade
* microemboli
140
leading cause(s) of acute pancreatitis
* **alcohol abuse**
* gallstones
* ERCP
141
transport in code
may need emergent teting or emergent surgical intervention
142
shock energy in code
* biphasic
* initial 120-200 J
* if unknown, use maximum available
* second doses equivalent or higher
* monphasic 360 J
143
septic shock
* subset of severe sepsis
* severe tissue hypoperfusion, organ failure, hypotension, acidosis
* sepsis induced hypotension despite adequate fluid resuscitation
* post 30 ml/kg bolus
* SBP \<90, MAP \<65 or lactate \>4
144
betadine
* for mucosal areas
* b/c alcohol is very drying and betadine isn't
* betadine + alcohol = duraprep (in OR)
145
presence of anti-inflammatory mediators in SIRS response
* released in response to the release of pro-inflammatory mediators
* to protect areas not affected by SIRS response
* normally come in to chill the body out after healing is done
* presence of both pro and anti mediators confused body and creates negative result
146
induction phase of therapeutic hypothermia
* infuse 2L 0.9% NS over 30 min
* continuous temp monitoring
* goal temp 32-34 C asap (w/in 4 hrs)
* sedation, paralytics, neuromuscular blocking agents
* maintain goal temp for 24 hours from time target temp reached
147
purpose of targeted temperature management
optimize neurological outcomes for survivors of cardiac arrest
148
neurological changes in sepsis
* decreased level of consciousness
* decreased cerebral blood flow
149
types of foreign invaders leading to SIRS
* transplant organ rejection
* acute/chronic rejection breaks through immune suppression and has tremendous inflammatory response to that foreign tissue
* obstetrical
* retained placental fragments
* after vaginal delivery or spontaneous miscarriage
150
when inflammatory response is not normal
* inflammatory response to injury is usually normal, compensatory mechanism
* SIRS increases exponentially and overwhelms body's system
151
gram negative sepsis
* most common cause of sepsis/septic shock
* "classic" sepsis
* common organisms
* enterobacter - e.coli, salmonella, serratia, proteus
* pseudomonus, acinetobacter - tend to be HAI, require long-term care
* H influenza
152
mortality from cardiac arrest
153
define bacteremia
presence of viable bacteria in circulating blood
154
characteristics of ineffective CPR
* w/o effective CC
* oxygen to brain and heart stops
* excessive pauses associated with
* decreased survival, unsuccessful defib
* hyperventilation = decreased survival
155
gram positive bacteria
* more prevalent in surgical population
* also produce toxins (peptidoglycans) that activate cell mediator pathway
* organisms
* staph (skin flora), strep
* bacillus
156
what do we know about CPR?
* quality of CPR is poor
* time to defib is too long (goal is 2 min)
* hyperventilation is rampant
* pauses are long and frequent
157
"the equipment" in aseptic technique
* bundles
* skin prep
* sterile field
158
what is a code?
* pt requires immediate life-saving intervention
* cardiac or resp in nature
* if no intervention is performed, patient will not survive
159
link btwn acute pancreatitis and ACS
* IAH as early as day 1 of symptoms and up to 6 days
* ACS initiated by inflammatory process
* capillary leakage and fluid resusc worsens edema
* paralytic ileus and upper GI tract obstrution by pancreatic collections can aggravate ACS
* reduced abd wall compliance d/t edema
* arterial/venous bleeding from necrotic/inflammed tissue
* increase IAP
* pancreatic perfusion affected by disease process itself
* bacterial translocation
160
how does local infection become systemic SIRS response?
bacteria doesn't get into blood - toxins do
161
GI implications in ACS
* high abd pressure decreases perfusion of organ tissue
* via compression of vasculature
* resulting ischemia, acidosis, breakdown of intestinal epithelium
* bacterial translocation
* sepsis if not already occuring
162
coagulation support in sepsis
* blood products
* xigris
* synthetic protein C to control inflammation, coagulation and fibrinolysis
* pulled from markets Oct 2011
163
treating organ dysfunction/failure in sepsis
* dialysis
* ventilator (PEEP, PCV)
* inotropes
164
types of ACS
* primary
* disease process in abdomino-pelvic region
* most frequent
* secondary
* conditions not originating in abdomino-pelvic region
* most often after large volume resusc in burns, sepsis
* recurrent
* after treatment for prior ACS
165
nursing management of respiration during therapeutic hypothermia
* avoid hyperventilation
* avoid high FiO2
166
neuroprognostication re: therapeutic hypothermia
* neuro exam impaired for days
* associated w/ delay in recovery of motor response for 6+ days
* neuro exam (esp motor) at day 3 is less certain
* seizures may not have same implication on prognosis
* certain CT scans may not have same implication on prognosis
* should not neuroprognosticate until at least 72 hours after rewarming
* maybe longer
167
hypothermia mechanisms
168
SIRS epidemiology
* 10th leading cause of death
* 500 patients/day
* #1 cause of death in non-coronary ICUs
* 750,000 cases/year
* mortality
* gram negative 20-50% (like to share mechanisms for resistance)
* septic shock 40-60%
169
sepsis
* systemic inflammatory response to infection
* manifestations of sepsis are same as those for SIRS
170
nursing management of endocrine function during therapeutic hypothermia
* hyperglycemia - follow ICU protocol
* watch for drug accumulation
* train of four - paralytics
* BIS - sedation
171
IAP and ACS
* normal IAP \< 12 mmHg
* persistent IAP \> 12 mmHg = intra-abdominal hypertension (IAH)
* IAP \> 20 mmHg + new onset organ dysfxn = ACS
