Therapeutics - Shock Part 2

Question 1

effect of vasodilators in cardiogenic shock on PCWP and SVR

Answer 1

decreases both

this in turn reduces myocardial oxygen consumption and improves LV performance

Question 2

cardiogenic patients can only be given vasodilators if…

Answer 2

their systolic BP must be over 90 bc vasodilators can decrease BP

Question 3

how often should vasodilators for cardiogenic shock be titrated?
what is goal map?

Answer 3

titrate every 5 mins to the lowest effective dose that achieves goal map of over 70mmHg

Question 4

2 signs to STOP TITRATING the vasodilator in cardiogenic shock

Answer 4

if the MAP decreases by 5-10mmHg or the patient gets worsening tachycardia (reflex)

Question 5

the vasodilator that decreases arterial pressre (afterload)

which decreases venous return? (preload)

Answer 5

hydralazine

decreases venous return = nitroglycerin

Question 6

which 3 vasodilators have mixed artery and vein decreased pressure

Answer 6

nitroprusside
nesiritide
ace inhibitors

Question 7

milrinone class and use in shock

Answer 7

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

Question 8

true or false

while the effects of dobutamine are mitigated by beta blockers, the effects of milrinone are not

Answer 8

true

Question 9

2 AE of milrinone

Answer 9

hypotension, arrhythmia

Question 10

duration of action of milrinone and is this good or bas

Answer 10

LONG duraiton - needs a loasing dose. concern bc cant quickly d/c if AE occurs

Question 11

true or false

milrinone does not really improve the mortality outcome in cardiogenic shock patients

Answer 11

true

Question 12

recombinant BNP that has potential role in cardiogenic shock

Answer 12

nesiritide

Question 13

effect of nesiritide on SVR and PCWP

Answer 13

decreased both

Question 14

AE nesiritide

Answer 14

hypotension

Question 15

role of nesiritide in cardiogenic shock

Answer 15

for refractory use in select patients. potential role in heart failure

Question 16

goal in treating septic shock

Answer 16

-eradicate infection
-support hemodynamincs
-mitigate the pathology of sepsis

maximize O2 deliver to reverse anaerobic cellular metabolism!

Question 17

1 of the “pillars” for treating septic shock is to manage the infection
explain what antibiotics should be used and when

Answer 17

broad coverafe AS SOON AS POSSIBLE - DO NOT WAIT FOR CULTURES

can deescelate potentially when the cultures come back

Question 18

length of antibiotic therapy for septic shock patients

what other antimicrobial therapy may they need?

Answer 18

7-10 days

may also need antifungal coverage

Question 19

patient with septic shock is hypovolemic

how is this handled

Answer 19

increase the intravascular volume AGGRESSIVELY
crystalloids are preferred (30mL/kg. if not meeting goals - can add inotropes or vasopressor)

Question 20

true or false

vasopressors decrease the SVR

Answer 20

false 0 increase

Question 21

preferred vasopressor for hemodynamic control in septic chock [atients

Answer 21

norepinephrine

can add vasopressin

Question 22

explain algorithm for hemodynamic control in septic shock patients

goal MAP?

Answer 22

-if hypovolemic - correct fluid AGGRESSIVELY (follow hypovolemic shock guidelines)

-add vasopressor
-then inotropes if needed (usually dobutamine)

-GOAL MAP is 65 and over

Question 23

5 vasopressors that have the potential to be used in septic shock for hemodynamic control

Answer 23

norepinephrine
epinephrine
phenylephrine
dopamine
angiotensin II

Question 24

which vasopressor should be avoided if the cardiac output is decreased bc it has no direct cardiac stimulating effects?

Answer 24

phenylephrine

Question 25

role of corticosteroids in septic shock

Answer 25

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

Question 26

role of statins in septic shock

Answer 26

if patient is on - just continue it. some evidence that taking them off is detrimental immunomodulatory and antiinflammatory effecrs

Question 27

specific corticosteroids that may be used in septic shock

Answer 27

hydrocortisone + fludrocortisone

Question 28

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

Answer 28

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

Question 29

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?

Answer 29

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!

Question 30

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?

Answer 30

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