Rc 246 Exam 1

Front 1

Def. Sepsis:

Back 1

"blood steam infection". the presence of bacteria or other infectious organisms or their toxins in the blood (septecemia) or in other tissues of the body.

Front 2

More than ______ cases annually of severe sepsis.

Back 2

750, 000

Front 3

Severe sepsis mortality rate

Back 3

28% to 50%

Front 4

Severe sepsis cost an average of $________ per patient.

Back 4

22,000

Front 5

Total cost to hospitals is _____ billion for sever sepsis.

Back 5

16.7

Front 6

____ x the cost of caring for a sepsis patient compared to a non-sepsis patietn in the ICU.

Back 6

6

Front 7

Goal of early tx for sepsis:

Back 7

will lessen the probability of spread to involve other organs and start a life threatenting cascade of evetns.
Goal: reduce mortality casued by sepsis

Front 8

Antigen

Back 8

enters the bloodstream and the immune system releases proinflammatory mediators including TNF, chemokines, postaglandins, and platelet activating factor to clear the antigen and promote recovery of affected tissue.

Front 9

Coagulation cascade

Back 9

initiated (fibrinogent to fibrin) which leads to developmetn of a clot to isolate the antigen.

Front 10

Plasminogen activator inhibitor and thrombin activatable fibrinolysis inhibitor

Back 10

released to suppress fibrinolysis to allow time needed to destroy the antigen before the body lyses the clot.

Front 11

Neutrophils

Back 11

engulf the antigetn

Front 12

Anti-inflammatory mediators

Back 12

create a balance with inflammatory mediators to restrict inflammatory response to local site of infection.

Front 13

Fibrin clots lead to:

Back 13

microvascular hypoperfusion, diminished O2 delivery, and tissue necrosis.

Front 14

Severe sepsis chain of events described results in:

Back 14

1. decreased blood flow to organ tissue
2. normal or increased C.O. with impeded tissue perfusion at the capillary level and impaired oxygenation

Front 15

Tissue oxygenation

Back 15

a critical indicator of sepsis that can be detected before organ failure occurs.

Front 16

What is an effective means of assesssing tissue oxygentation?

Back 16

SvO2, because this reflects the amount of oxygent left int he blood after completing circulation.

Front 17

Multiple organs involved

Back 17

severe sepsis

Front 18

Mortality Rate

Back 18

1 organ 20% mortality
2 organ 40% mortality
3 organ 65% mortality
4 or more organs 75% to 85% mortality

Front 19

Keys to identifying a patient with severe sepsis:

Back 19

1. infection or suspected infection
2. known infection and signs of inflammation
3. septic patients who fail to respond to fluid resuscitation, develop septic shock, during which releases chemical mediators that may cause cell damage.
4. sepsis combined with dysfucntion of one organ.

Front 20

Identifying acute organ dysfucntion as a marker of severe sepsis:

Back 20

-brain: altered consciousness, confusion, psychosis
-heart: tachycardia, hypotension, altered CVP and PAOP
-lungs: tachypnea, PaO2<70mmHg, SaO2<90%, PaO2/FiO2<300
-kidneys: oliguria, anuria, increased creatinine
-liver: decreased platelets, increased D-dimer, decreased protein C, increased PT/APTT

Front 21

Goals of sepsis tx:

Back 21

to manage the infection adn the body's response to the infection.

Front 22

Empiric antibiotic therapy

Back 22

should be instituted to control the origninal source of the infection.

Front 23

Optimize cardiac output by infusions of:

Back 23

colloid or crystalloid, vasoactive agents, and transfusions of red blood cells to increase oxygen delivery

Front 24

Recombinant human activated protein C:

Back 24

protein C is significant depleted this restores balance to the systemic irregularities that occur during sepsis and allows a return to homeostasis int he micorvasculature.

Front 25

Xigris

Back 25

indicated use for patients at high risk for death. Hospital slow to use due to high potential risk of bleeding and cost of the drug.
-3.5% chance of bleeding in recent study
-mortality rate decreases from 33% to 41%

Front 26

96 hour infusion of Xigris for 70kg patient cost approximately $________.

Back 26

6,800

Front 27

Recommended Tx for sepsis

Back 27

-fluid therapy:compensates for leaking of fluid from the capillaries.
- replacement dose steroids: assist dysfunctional adrenal glands.
-intensive insulin therapy: to maintain blood glucose levels at 80 to 110mg/dL
-vasopressor therapy: increases vascular constriction, leading to improved perfusion.

Front 28

Recommendation for subsequent organ dysfunction

Back 28

-rapid response (CVP 8 to 12mmHg)
-cultures drawn for rapid initiation of antibiotics
-fluid resusciation for shock management
-dobutamine to increase C.O.
-mechancial ventilation: low pressures, permissive hypercapnia, sedation with daily lightening of sedation, SBT, avoid neuromuscular blockers.

Front 29

Asthma/COPD management program goals:

Back 29

-improve quality of life
-highest quality of care
-empower pop. with confidence and skills necessary to self-manage their disease
-optimize medical management
-reduce disease progression
-increase exercise tolerance
-improve health
-prevent/tx exacerbations
-reduce mortality
-relieve symptoms

Front 30

Beclomethasone

Back 30

Ovar (corticosteroid)

Front 31

Mometasone

Back 31

Asmanex (corticosteroid)

Front 32

Omalizumab

Back 32

Zolair/Xolair (antiasthmatic) monoclonal antibody

Front 33

Formoterol

Back 33

Foradil (bronchodilator) B-adrenergic agonist

Front 34

Zafirlukast

Back 34

Accolate (bronchodilator) leukotriene receptor antagonist

Front 35

Salmeterol

Back 35

Serevent (bronchodilator) B2-adrenergic agonist

Front 36

Gold COPD Guidelines

Back 36

stage 1: mild COPD-mild airflow limitation (Fev1/FVC<70%, FEV1>80% predicted) and sometimes but not alwasy, chronic cough adn sputum production.
stage 2: mod. COPD-worsening airflow limitation (FEV1/FVC<70%, FEV1 50-80%predicted) with SOB typically developing on exertion.
stage 3: severe COPD-further worsening of airflow limitations(" ", FEV1 30-50%predicted), greater SOB, reduced exercise capacity adn repeated exacerabtions impacting quality of life.
state 4: very severe COPD-severe airflow limitation (" ", FEV1< 30%predicted) or FEV1 <50% predicted plus chronic respiratory failure.

Front 37

NAEPP

Back 37

national asthma education and prevention program

Front 38

GOLD

Back 38

global initiative for chronic obstructive lung disease

Front 39

NIH

Back 39

national insutute of health

Front 40

NHLB

Back 40

national heart, lung and blood institute

Front 41

NIAID

Back 41

national institute of allergy and infectious diseases

Front 42

CHF

Back 42

a weakening of the heart brought on by an underlying heart or blood vessel problme, often a combination of several different problems.

Front 43

Systolic heart failure:

Back 43

pumping action of the heart is reduced or weakened.
-measure EF
-EF = SV/Max vol. remaining in Lt ventricle at the end of diastole (relax phase)
EF <50%

Front 44

Normal EF

Back 44

>50%

Front 45

Diastolic heart failure:

Back 45

heart can contract normally but is stiff/less compliant when it is relaxing and filling with blood.
-impedes blood filling into the heart and produces backup in the lungs and CHF symptoms.
-EF is normal

Front 46

Causes of CHF

Back 46

-weakened heart muscle
-damaged heart valves
-blocked blood vessels
-toxic exposure (ETOH, Cocaine)
-infections
-high BP
-pericardial disease
-congenital heart disease
-prolonged, serious arryhythmias
-idopathic cardiomyopathy

Front 47

CHF the result of lifestyle habits

Back 47

-smoking
-excessive use of alcohol
-obesity (HTN, diabetes, CAD)
-high BP

Front 48

Statistics

Back 48

HF affects
-1% of people aged 50yrs
-5% of people aged >75yrs
-25% of people aged 85yrs

Front 49

In the US nearly ___ million people have heart failure

Back 49

5

Front 50

_________ new cases diagnosed/year for heart failure

Back 50

550,000

Front 51

___% mortality after a year of diagnosis of CHF

Back 51

10

Front 52

Early CHF symptoms

Back 52

-SOB
-Cough
-inability to take a deep breath
-difficult to distinguish from asthma, COPD, emphysema
-similar to cold, flu, or bronchitis

Front 53

Major symptoms of CHF

Back 53

1. exercise intolerance
2. SOB (dyspnea, orthopnea, paroxysmal nocturnal dyspnea)
3. fluid retention and swelling (legs and feet after prolonged sitting or standing. hips, scrotum, abdominal wall, abdominal cavity: ascites)

Front 54

Exams/Tests CHF

Back 54

chest xray
ECG
blood cell counts
ABG
electrolyte levels
kidney funciton test
B-type natriurteic peptide (BNP)
echocardiogram
stress test

Front 55

Tx/emergent CHF

Back 55

-O2
-NPPV (BiPAP, CPAP)
-intubation/ventilation management: (severe heart failure which leads to increased myocardial work, WOB, and hypoxemia)
-diuretics

Front 56

Initial ventilator settings for CHF patient

Back 56

select a mode that reduces WOB
-VC/PC-CMV (to avoid spont. breaths)
-Vt 8-10ml/kg
-peak flows > 60LPM
-descending/constant waveforms
-Ti 1-1.5 sec
-PEEP 5-10cmH2O (10-15 severe)
-FiO2 100% then titrate sat >90%

Front 57

Monitor the following for CHF

Back 57

ABG's
SpO2
hemodynamics
urine output
electrolytes
indication for weaning