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45 Cards in this Set

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What is the leading cause of death in the ICU's?
sepsis
What must be present to identify SIRS?
systemic inflammatory response syndrome
2 or more of the following:
-temp above 100.4 or below 96.8
-hr above 90 bpm
-RR above 20 or paCO@ less than 32 mmHg or mechanical ventilation
-WBC above 12,--- or less than 4,00 or 10% mature neutrophils
What are triggers of SIRS?
infection- commonly gram neg
injury- trauma, burn, surgery
hypoperfusion- thrombo-embolism/low hemoglobin etc.
When does a UTI become SIRS?
When the infection leaves the bladder and becomes systemic
What is present in severe sepsis?
hypoperfusion to any organ system
hypo tension
organ dysfunction
What causes septic shock?
severe sepsis with cardiovascular dysfunction. When body is no longer responsive to volume resuscitation you have septic shock
When there are still signs of hypoperfusion after volume resuscitation you have...
septic shock
What causes sepsis?
out of control systemic inflammatory response
The extent of the injury determines the extent of what?
Inflammatory response
What does vasodilation do during inflammation?
brings more WBC's to the area to perform phagocytosis.
What is the difference between physiologic inflammation and pathogenic inflammation?
physiologic is normal and healthy
pathogenic is not
Pathogenic inflammation consists of:
-exaggerated systemic response that is not localized
-loss of regulation mediators that would typically localize the response
Why does the inflammatory process not stay isolated to the injured area in pathologic inflammation?
Because of the rapid aggressive activation of inflammatory mediators (cytokines)
What causes the mal distribution of blood volume during SIRS?
as inflammatory mediators vasodilate, they become like soaker hoses.
Volume moves from vascular to extravascular space causing hypovolemia.
What are symptoms of a shift in blood volume?
Urine output drops, BUN increases.
Blood shunts to heart, lungs and brain
Does metabolism increase or decrease during sepsis?
Increase
What tissues are broken down during the increased metabolism of sepsis?
lean body mass and organs, this is why BUN increases.
What happens if the body continues to catabolize lean muscle and organ tissue?
MODS- multi organ dysfunction syndrome
What are symptoms of the body trying to compensate for decreased perfusion?
increased heart rate, increased respirations
What can trigger SIRS in an infection?
The release of endotoxins or exotoxins.
How do endotoxins escalate an infection to SIRS?
when gram negative bacteria die or multiply, endotoxins stored in the outer portion of the cell wall are released.
*Also, when we give antibiotics and cell walls are lysed, endotoxins are released and can cause endotoxin showers. This can manifest as a rapid escalation of the illness. Be prepared when giving antibiotics for symptoms to worsen.
How do endotoxins get from the GI tract to the blood?
The GI tract is not a priority system for perfusion. During times of stress, endotoxins can move from the tract to the blood stream because of hypoperfusion or injury.
How do exotoxins escalate an infection to SIRS?
Gram positive bacteria release exotoxins during cell death. This may come as the result of using antibiotics. A common culprit is group A strep.
Clinical presentation of early shock:
-Fever
-High cardiac output
-tachycardia
-bounding pulse due to increased preload
-peripheral vasodilation- warm skin, flushing
-non cardiogenic pulmonary edema
-hypoxia
-initial respiratory alkalosis due to breathing quickly
-SOB
-Crackles, wheezes
-SaO2 is WNL!
What is happening during early shock?
There is just enough of a decrease in systemic vascular resistance to facilitate an increase in CO. , The person commonly does not feel well. As fluid leaks out, Pulmonary edema develops. As hypoxia and damage to pulmonary capillaries occurs, the cardiac output starts to decrease.
What does BP do during early shock?
Intermittent drops in BP
hypotension (decrease in systemic vascular resistance).
What does late septic shock look like?
-decreased CO, decreased SVR
-Severe metabolic acidosis due to decreased oxygen transport and availability.
-hypoglycemia as all energy stores are used
-DIC
-myocardial failure, left ventricular
-CNA, coma
-Decreased SaO2 levels
-LATE sign: temperature falls
-confusion irritability- hypoxia
-cyanosis
-oliguria
what is a cardiovascular dysfunction that may occur during early shock?
Increased systemic vascular resistance so the blood has a hard time exiting left side of the heart, BUT BP doesn't go up because their volume is so low.
Where did all the volume go?
third space, but not usually tons of edema
What does increased serum lactate indicate?
late shock, lactic acid build up is causing metabolic acidosis. May also have respiratory acidosis because of a build up of CO2
How should antibiotic therapy be managed?
Give broad antibiotics as soon as possible. When C&S comes back, narrow spectrum of treatment.
What are common routes of infection leading to sepsis?
foleys
IV's
Central liens,
What are the treatment goals of sepsis and SIRS?
-maintain CO by providing adequate intravascular volume
-Maintain oxygenation
-determine septic focus
-treat with appropriate antibiotics
What is a problem with giving colloidal fluids?
While they will initiatlly pull fluid out of the third space, due to ongoing vasodilation, the fluid will go back into the third space within 24-48 hours.
Identifying septic shock:
Only 50% of patients will have a positive blood culture.
Where do endotoxins cause damage
to entothelial tissues
What guides fluid replacement therapy?
Wedge pressure. Measured by a swan ganz catheter. it is key in determining volume status.
How much crystaloid fluids should be given for volume resuscitation?
May need to give as much as 10 L in one hour.
What is a complication of giving vaso constrictors without giving fluids?
limp amputation- lawsuit!
What MAP is needed to maintain perfusion of the kidneys?
60 mmHg or above
What is the purpose of maintaining a Blood glucose of less than 150?
decreases morbidity and mortality. Often they become hyperglycemic because of the stress response, they need to be on an insulin drip to control WBG
Why do we need to keep bowels stimulated?
If gut is left empty, bacteria may move from the gut into systemic circulation. Even if they are on TPN, they need some kind of nutrition going into their GI tract.
What needs to be given with crystaloid fluid therapy to be effective?
Packed red blood cells, otherwise you are just diluting their blood
What does a nurse need to anticipate due to the client's non cardiogenic pulmonary edema?
mechanical ventilation
What does dobutamine do?
enhances cardiac output with contractility and increased systemic resistance