Sepsis And Shock

Front 1

What is hypotension?

Back 1

Drop in BP > 20% from baseline, or

sBP < 90, or

MAP < 60 mm Hg

Front 2

In what circumstances might lactate be elevated?

Back 2

Tissue hypoperfusion
Inadequate oxygen delivery (dehydration, anemia, hypovolemia)
Increased 02 demand
Inadequate oxygen utilization (SIRS, DM)

Front 3

What is shock?

Back 3

Inadequate delivery of oxygen and nutrients to the vital organs

Front 4

What are SSx shock?

Back 4

Hypotension
Altered mental status
Tachypnea
Pallor
Clammy, cool extremities
Decreased urine output

Front 5

Sites of end-organ dysfunction in shock?

Back 5

CNS: stroke, decreased LOC
CV: ischemia, hypotension, arrhythmia
Resp: ARDS
Liver: increased LFTs, coagulopathy
Kidneys: AKI

Front 6

What are indications for arterial line placement?

Back 6

Labile BP and need for close monitoring
End organ disease
Need for multiple ABG analysis

Front 7

Indications for a central venous line?

Back 7

- measurement of CVP (RA pressure) in shock resuscitation
- TPN, infusion of caustic drugs
- insertion of transvenous pacing leads

Front 8

What can a PA catheter tell you?

Back 8

Left-sided heart pressures

PCWP approximates LA pressure

Front 9

What is the shock index and what can it tell you?

Back 9

Shock index = HR/sBP

If > 1, sick patient!!

Front 10

What are positive orthostatic vitals?

Back 10

Drop in sBP > 20
OR Increase of HR > 30
OR severe postural dizziness, after standing > 1 minute from supine position

Front 11

Examination for volume depletion?

Back 11

- level of consciousness, confusion
- orthostatic vitals
- inspection: pallor, cyanosis, sunken eyes
- mucous membranes
- JVP flat
- loss of skin turgor
- weak cap refill
- axillary dryness

Front 12

What are the main categories of shock?

Back 12

Hypovolemic
Obstructive
Distributive
Cardiogenic

Front 13

Causes of hypovolemic shock?

Back 13

Hemorrhage
Inadequate intake
Excessive losses: N/V/D, diuretics, burns
Sequestration: CHF, effusion, bowel obstruction, nephrotic syndrome

Front 14

What are causes of cardiogenic shock?

Back 14

Ischemia
Arrhythmia
Cardiomyopathy
Valvular dysfunction

Front 15

Causes of obstructive shock?

Back 15

Tamponade
Tension pneumo
Massive PE
IVC compression (pregnancy, obesity)

Front 16

What are the major categories of distributive shock?

Back 16

Endocrine
Neurogenic
Septic
Anaphylactic

Front 17

What is the pathophys of septic shock?

Back 17

Vasodilation due to infection and toxins
Decreased cell utilization of 02

Front 18

What is a particular unique feature of neurogenic shock?

Back 18

Bradycardia (due to parasympathetic predominance)

Front 19

What are causes of distributive shock from an endocrinologic cause?

Back 19

Hypothyroidism
Thyrotoxicosis
Addisonian crisis

Front 20

How much blood loss is involved in Class I, II, III, and IV hemorrhagic shock?

Back 20

Class I: < 750 cc (<15% total blood volume)
II: 750-1500 cc (15-30%)
III: 1500-2000 cc (30-40%)
IV: > 2000 cc (>40%)

Front 21

In which class of shock do you see HR changes? BP?

Back 21

Class II: see beginning of tachycardia
Class III: BP drop

Front 22

How can you increase the rate of your fluid infusion in resuscitation?

Back 22

Use large bore, short IVs
Increase bag height
Use pressurized device

Front 23

What is the function of alpha-1 adrenergic receptors?

What is an example of an alpha-1 agonist?

Back 23

Vasoconstriction (vascular smooth muscle)

Phenylephrine

Front 24

What do alpha-2 agonists do?

Back 24

Mediate vasodilation of coronary arteries

Ex dexmedetomidine

Front 25

What do beta-1 receptors do?

Back 25

Mediate increased HR, cardiac contractility

Ex: dobutamine

Front 26

What do beta-2 receptors do?

Back 26

Bronchodilation
Dilate coronary arteries and visceral organ arteries

Front 27

What do the dopaminergic receptors do?

Back 27

Increase cardiac contractility (D4)
Increase renal diuresis and natriuresis

Front 28

What do vasopressin receptors mediate?

Back 28

Vasoconstriction in peripheral arterioles

Front 29

How does epinephrine work as a vasopressor?

Back 29

Acts on all alpha and beta receptors -->

Increases vasoconstriction
Increases cardiac output

Second line for shock

Front 30

How does phenylephrine work? What are its side effects?

Back 30

Pure alpha-1 agonist - vasoconstriction

Side effect: reflex bradycardia

Front 31

How does norepinephrine (Levophed) work?

Back 31

Alpha-1 and alpha-2 agonist at lower doses
Beta-1 agonist at high doses

Front 32

Which pressors are first line for septic shock?

Back 32

Norepinephrine
Dopamine

Front 33

How does dopamine work?

Back 33

Beta-1 and 2, alpha-1 agonist
Dopaminergic effects too

At 5-10 ug/kg/min, acts as beta agonist
At > 10 ug/kg/min, alpha effects predominate

Front 34

How does dobutamine work?

Back 34

Mainly beta-1 agonist - increases HR and CO

Front 35

How does ephedrine work?

Back 35

Mixed direct and indirect activity

Direct: alpha-1, beta-1 and 2 activity

Indirect: causes NE release from adrenal medulla

Front 36

What is the biggest downside of ephedrine?

Back 36

Cannot be used very often/as infusion - results in tachyphylaxis!

Front 37

What are SIRS criteria?

Back 37

At least 2 of:
- temp < 36 or > 38
- HR > 90
- RR > 20 or PC02 < 32
- WBC < 4 or > 12

Front 38

What is sepsis?

Back 38

SIRS + infection source

Front 39

What is severe sepsis?

Back 39

Sepsis plus at least one indicator of organ hypoperfusion/dysfunction:
- lactate > 4 mmol/L
- urine output < 0.5mL/kg/hr
- ARDS
- coagulopathy
- thrombocytopenia
- Bili > 34 (shocked liver)
- change in mental status

Front 40

Does severe sepsis improve with fluids?

Back 40

It should - whereas septic shock does not

Front 41

What is septic shock?

Back 41

Severe sepsis plus at least 1 of:
- sBP < 60 despite appropriate fluid resuscitation
- maintaining BP > 60 mm Hg requires vasopressors to do so

Front 42

What kind of shock is septic shock?

Back 42

Distributive

Front 43

What is multi-organ dysfunction syndrome?

Back 43

End-stage sepsis: dysfunction of 2+ organ systems

Front 44

What are your goals for EGDT in sepsis?

Back 44

CVP 8-12
MAP > 65
Scv02 > 70%

Front 45

How can you maintain CVP?

Back 45

Fluid boluses - up to 500 cc NS/Ringer's q15-30 min

Front 46

How do you maintain MAP if inadequate?

Back 46

First line vasopressors:

Norepinephrine

Dopamine

Front 47

How can you maintain central venous oxygen saturation in sepsis?

Back 47

- transfuse PRBC if Hct < 30%
- dobutamine infusion (inotrope)

Front 48

What are some of the potential complications of sepsis?

Back 48

ARDS
CHF
DIC
Liver failure (shock liver)
Renal failure (pre-renal, ATN)