Pom Ii - Unit 3 - Rickelmann's Last 3 Lecs: Sepsis, Shock, Shock Tx & Hemodynamic Monitoring

Front 1

POM Lec 11: Sepsis

Back 1

POM Lec 11: Sepsis

Front 2

Typical Sepsis Case:

23 yo female presents with 2-3 days of feeling poorly. Recently
returned to Kirksville from Chicago for summer course work.
She noted a fever of 104 along with developing myalgias and
red raised rash on inner thighs and groin region. She has had
some increasing shortness of breath, but denies productive
cough. On initial evaluation in ER:
• SBP 80’s
• HR 107-120
• RR 25-30
• Sp02: 92% on room air
• Temp: 99.3 F

Back 2

Typical Sepsis Case:

23 yo female presents with 2-3 days of feeling poorly. Recently
returned to Kirksville from Chicago for summer course work.
She noted a fever of 104 along with developing myalgias and
red raised rash on inner thighs and groin region. She has had
some increasing shortness of breath, but denies productive
cough. On initial evaluation in ER:
• SBP 80’s
• HR 107-120
• RR 25-30
• Sp02: 92% on room air
• Temp: 99.3 F

Front 3

1st: Realize that sepsis is part of a continuum consisting of 4 stages, all resulting the body's response to something that is irritative to the body:

1. SIRS (Systemic Inflamm Response Syndrome)
2. Sepsis
3. Severe Sepsis
4. Septic Shock

Back 3

1st: Realize that sepsis is part of a continuum consisting of 4 stages, all resulting the body's response to something that is irritative to the body:

1. SIRS (Systemic Inflamm Response Syndrome)
2. Sepsis
3. Severe Sepsis
4. Septic Shock

Front 4

Let's Define the Stages on the Previous Card & Give their Criteria:

1) SIRS (Systemic Inflamm Response Syndrome)?

2) Sepsis?

3) Severe Sepsis?

4) Septic Shock?

Back 4

1) When an infectious or non-infectious "irritant" -->
Inflamm Response -->
Damage to the body
(Note: It's the actual inflammatory response that causes the damge, not the infxn!)

Criteria - Need 2 or More:
1. Temp: > 38 C or < 36 C
2. HR: > 90/min
3. RR: > 20 / min OR PaCO2 < 32 mmHg
4. WBC: > 12,000 OR < 4,000 OR > 10% bands

2) When criteia for dx of SIRS are met + evidence or Infxn in either the blood and tissues or just the tissues alone
**NOTE: Tachypnea and Tachycardia may be the only 2 SIRS criteria you have - and that's OK***

3) When the criteria for Sepsis are met + Organ Dysfnctn (Possible MODS)

4) Subset of severe sepsis.
Criteria:
1. Sepsis + SBP < 90 mmHg OR MAP < 65 OR SBP Decreases > 40 mmHg
+
DESPITE ADEQUATE FLUID RESUSCITATION

Front 5

In the previous slide, we said that the definition of sepsis was:

When criteia for dx of SIRS are met + evidence or Infxn.

1. What are the 3 MC locations that this infxn will come from?

2. In a later slide, we will mention how ppl in sepsis will develop dysfnctnl mitochondria. Dysfnctnl mitochondria will lead to what, which can be a clinical indicator that sepsis is occuring?

3. How people will respond to any infxn can be understood with the mnemonic PIRO. What does PIRO stand for and give details of them?

Back 5

1. Respiratory Infxn
GU Infxn
ABD Infxn

2. Dyscnftnl mitchondria -->
No more aerobic respiration -->
Anaerobic Respiration -->
INC LACTATE Levels

3.
P:Predisposition to infxn
A) Pts w/ TNF-beta2 and TLR 4 Asp299Gly are predisposed to what?


I: Infxn type
A) It is impt to determine whether the infxn is what?

R: Response of pt to that infxn
A) 3 Things you should give these pts?

O: Organ dysfnctn present?
A) Most important thingin organ dysfnctn?

Hint 5

P:
A) Septic Shock

I:
A) Viral, Bacterial, Fungal, etc...

R:
A) Corticosteroids, Fluids, Broad Spec ABX early bc longer they are HYPO-tnsive, the worse their survival rate

O:
A) Recognize it early

Front 6

It's the _______ @ the end of the sepsis progression that kills pts?

Back 6

MODS (Multiple Organ Dysfnctn Syndrome)

Front 7

A Few #s:
1) Sepsis is the # ____ cause of death?

2) 64.9% of Septic PTs were _____ old and had a 13.1 RR comp'd to younger pts?

Back 7

1) #10 Cause of Death

2) 65 y/o

Front 8

NOTE: page 5, slide 4 has a list of assoc s/s seen in sepsis. "The Update" - look @ if you think it may help

Back 8

NOTE: page 5, slide 4 has a list of assoc s/s seen in sepsis. "The Update" - look @ if you think it may help

Front 9

The Pathophys of Sepsis is complex: Here are some of the major players you should be familiar w/:

1. Gram Negs w/ Endotoxin / LPS
2. Gram Pos w/ Lipotechoic and Super-Ag (TSST)
3. IL-1, IL-6, IL-12, TNF, IFN-gamma
4. Toll Like Receptors
5. PRO C
6. NO
7. Mitochondrial Dysfnctn & PARPs (Poly-ADP-Ribosyl-Polymerase)
8.. GENETICS!!

Back 9

The Pathophys of Sepsis is complex: Here are some of the major players you should be familiar w/:

1. Gram Negs w/ Endotoxin / LPS
2. Gram Pos w/ Lipotechoic and Super-Ag (TSST)
3. IL-1, IL-6, IL-12, TNF, IFN-gamma
4. Toll Like Receptors
5. PRO C
6. NO
7. Mitochondrial Dysfnctn & PARPs (Poly-ADP-Ribosyl-Polymerase)
8.. GENETICS!!

Front 10

The previous slide mentioned Mitochondrial Dysfnctn and PARPS as part of the pathophysiology of sepsis.

Give the steps of mitochondrial dysfnctn, which is part of the pathophysiology of sepsis?

This is AKA what?

This may be responsible for what?

Back 10

Stim of PARPS -->
Dec NAD -->
Inability of Mitochondria to Use O2 -->
Dec TCA / Kreb's Cycle -->
Mitochondrial Dysfnctn

Cytopathic Hypoxia

Continued decline of pts even after restoration of nomrla PO2 tissue levels

Front 11

Can you list the 5 stages in the pathophysiology of sepsis?

Back 11

1. Infxous Insult to susceptible host
2. Preliminary systemic response
3. Overwhelming systemic response
4. Compensatory antiinflammatory rxn
5. Immunomodulatory failure

Front 12

The Following Gives the Actual Slides with all the details about Pathophys. Maybe Just Glance Through it to be familiar, but I def don't think you should memorize it.

Back 12

The Following Gives the Actual Slides with all the details about Pathophys. Maybe Just Glance Through it to be familiar, but I def don't think you should memorize it.

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Back 13

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Front 18

Slide 3 of the pathogenesis says that septic pts can develop a pro-thrombotic state.
Why does this happen?

Back 18

BC you will have consumption of coagulation inhibitors AND up-regulation of procoags

Front 19

Back 19

Front 20

Sepsis Case

Back 20

Front 21

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Front 22

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Front 23

Lec 12: Shock

Back 23

Lec 12: Shock

Front 24

1. What does the following define:
Profound and Widespread reduction of EFFECTIVE tissue perfusion that @ first causes reversible and eventually causes irreversible injury

2. What does the following define:

Back 24

1. Shock

2. Syndrome in which TISSUE PERFUSION is reduced & blood flow is INADEQUATE to meet cellular reqs.

Front 25

List 7 s/s that are common to all forms of shock (septic, hypovolemic, cardiogenic, extra-cardiac obstructive, distributive)?

Back 25

MAP < 60 in adults

Hypo-TN: Usually but NOT always

Tachy

Cool Extremities, but MAY be warmer in later stages

Oliguria from no kidney perfusion

Cloud sensorium

Elevated Lactate

Front 26

Give the 5 major variables that determine Oxygen Delivery (DO2)?

Back 26

CO (HR X SV)
HGB
SaO2

Front 27

What Do The Following Define:

1) A type of shock due to decreased circulating blood
volume in relation to the total vascular capacity and characterized
by a reduction of diastolic filling pressures

2) A type of shock due to cardiac pump failure related to loss
of myocardial contractility/functional myocardium or structural/
mechanical failure of the cardiac anatomy and characterized by
elevations of diastolic filling pressures and volumes

3) due to obstruction to
flow in the cardiovascular circuit and characterized by either
impairment of diastolic filling or excessive afterload

4) caused by loss of vasomotor control
resulting in arteriolar/venular dilatation and characterized (after
fluid resuscitation) by increased cardiac output and decreased SVR

Back 27

1) Hypovolemic shock

2) Cardiogenic shock

3) Extra-Cardiac Obstructive Shock

4) Distributive Shock

Front 28

Hypovolemic Shock:
What are 4 Causes of Hypovolemic Shock?

Back 28

1) Hemorrhagic Fluid Depletion
2) Non-Hemorrhagic Fluid Depletion (vomit, diarrhea,etc...)
3) Inc vasc capacitance (vasodilation from inc NOP or Dec Vasopressin and Cortisol)

Front 29

1) The most important cause of distributive shock is what?

2) Another common cause of distributvei shock is what?

Other causes of distributive shock listed:
Toxic Shock Syndrome
Anaphylactic, Anaphylactoid
Neurogenic
Toxic

Back 29

1) Septic shock (bacterial, fungal, viral, rickettsial) -->
Myocardial depression!!!!!!!

2) NO!

Front 30

1) 2 major causes of extracardiac obstructive shock?
A) 2 major causes of impaired diastolic filling?

Back 30

1) Impaired diastolic filling, impaired systolic contraction
A) Intra-ABD HTN; Tension Pneumothorax (see pics in notes)

Front 31

Back 31

Front 32

An endocrinoloogic shock is a combination of what 2 types of shock?

2 ets of endocrinological shock?

Back 32

Cardiogenic and Distributive

Adrenal Insuffic & Thyroid Disorder

Front 33

Lec 13: Shock Tx!

Back 33

Lec 13: Shock Tx!

Front 34

NOTE:
When you see that someone is in shock, you must do a PE and Tx simultaneously! - Get good IV access!

Back 34

NOTE:
When you see that someone is in shock, you must do a PE and Tx simultaneously! - Get good IV access!

Front 35

1) What are the 3 Tx goals for tx-ing shock?

2) What is the critical BP Equation you need to understand in order to Tx shock?

Back 35

1) Fluid Resuscitation: to inc SV
Vasopressor Therapy: to inc perfusion pressure and contractility
Inotropic Therapy: to increase contractility

2) BP = CO X SVR
CO = HR X SV
*SVR ( Systemic Vascular Resistence)
*SV = Stroke Volume

Front 36

Remember from last lecture,you want to tx the pt to a MAP of what?

Back 36

MAP > 60 mm Hg

Front 37

Fluid Resuscitation:
1) 2 Types agents for fluid resuscitation?

2) When a pt comes in and is in ANY kind of shock, what should your first tx be?

Back 37

1) Crystaloids and Colloids:
Saline and Albumin

2) Volume Replacement!!!!!!!

Front 38

Vasopressors:

1) Dopamine
A) @ low dose Dop binds what and does what?
B) @ Med - High Dose Dop Binds what and does what?
C) @ High Dose Dop binds what and does what?

2) Nor-Epi
A) MOA?
B) CU?
C) More potent than what?

3) Epi
A) MOA of epi?
B) Inc what 4 things?

4) Phenyl-ephrine
A) MOA of phenyl-ephrine?
B) Good if what else is present w/ shock?
C) 1 AE of phenylephrine?

5) Vasopressin (ADH)
A) 2 MOA of vasopressin?
B) AE?

6) Dobutamine
A) MOA of dobutamine?
B) AE of dobutamine?

7) Phosphodiesterase Inhib - Milrinone
A) MOA of PDI Inhib?
B) AEs?

Back 38

1)
A) DA1, DA2 --> Vasodilation
B) beta I --> Inc Contractility and HR
C) alpha --> Vasoconstriction

2)
A) alpha ag; moderate beta ag
B) Inc BO w/out adverse FX
C) Dopamine

3)
A) Alpha and beta ags
B) CI, SV, HR, SVR

4)
A) alpha-1 ag
B) Tachyarrhythmias
C) Inc O2 Consumption

5)
A) Stim ACTH --> better renal blood flow; Sensitizes catecholamine receptors
B) Coronary Ischemia

6)
A) beta-1 Agonist --> Inc CO and Contractility
B) Arrhythmias - esp tachyarrhythmias and vasodilation

7)
A) Inc cAMP -->
Inc IC Ca -->
Inc force of contraction
A) Hypo-TN; Tachyarhythmias, but less than dobutamine

Front 39

Back 39

Front 40

Rickelman's Review: HE gave away 1 test question.

1) PT w/ BP 70/40 back from elective surgery. CO = 2.4. SVR = 1400. What is your first step?

Back 40

1) VOLUME REPLACEMENT

NOTE:
1. Norm CO = 4
2. Norm SCR = 1,000
3. In this case CO was low and SVR was high, TF according to BP = CO X SVR & CO = SV X HR, if you Inc the Col -->
Inc SV -->
Inc CO -->
Inc BP

4. 1st step for ANY shock pt is fluid replacement!!!