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88 Cards in this Set

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What is the definition of shock?
Syndrome involving poor perfusion, normally presents as hypotension.
What is the end sequela of shock?
Multiple organ failure and DEATH
How is Tissue Perfusion clinically measured?
MAP
What two factors is MAP dependent on?
CO and SVR (remember the balance)
3 types of Shock
1.Hypovolemic
2.Cardiogenic
3.Septic(Distributive)
Which type of shock is characterized by intravascular volume loss?
Hypovolemic
How are some ways you could have intravascular volume loss?
Surgery, Trauma, bleeding
What type of shock is characterized by pump failure?
Cardiogenic
What is another name for septic shock?
Distributive
Which type of shock is characterized by severe peripheral vasodilation and increased vascular permeability?
Septic
Describe the clinical presentation of shock in terms of: Hypotension
SBP < 90
Or
MAP <65
Describe the clinical presentation of shock in terms of: Tachycardia
HR > 90
Describe the clinical presentation of shock in terms of: Tachypnea
RR > 20
Describe 6 forms of clinical presentation of shock
1.Hypotension
2.Tachycardia
3.Tachypnea
4.Altered mental status
5.Decreased organ perfusion (decreased urine output if kidneys)
6.Metabolic acidosis
MAP in hypovolemic? +/-
-
MAP in Cardiogenic +/- ?
-
MAP in Septic +/- ?
-
PCWP in Hypovolemic +/- ?
-
PCWP in Cardiogenic +/- ?
+
PCWP in Septic +/- ?
- or no change
CO in Hypovolemic +/- ?
-
CO in Cardiogenic +/- ?
-
CO in Septic +/- ?
- or no change
SVR in Hypovolemic +/- ?
+
SVR in Cardiogenic +/- ?
+
SVR in Septic +/- ?
-
Describe some hemorrhagic conditions of Hypovolemic shock
1.Trauma/Surgery
2.Internal bleeding
a.Aortic aneurysm rupture
b.Retroperitoneal bleed (GI bleed, fun)
Describe some non-hemorrhagic conditions of hypovolemic shock
1.Dehydration
2.Intravascular fluid shift (Ascites)
3.Fluid loss (Burns/Heat stroke)
Describe the hemodynamics associated with Hypovolemic shock
1.Decreased venous return--> decreased PCWP
2.Decrased venous return (SV) --> CO
3.In order to compensate for decreased MAP, an increase in SVR
1st line treatment of hypovolemic shock
Fluids
Increase that tissue perfusion.
What a possible sequela for hypovolemic shock?
Cardiogenic shock
Goal PCWP for Hypovolemic shock
6-15mmHg
Goal CVP for Hypovolemic shock
2-6
Goal CI for Hypovolemic shock
2.8-4.5 L/min/M2
Which type of fluids should always be used first for hypovolemic shock?
Crystalloids
Is there any convincing data supporting the concept of colloids being superior to crystalloids?
No
Describe the results of the SAFE study
It indicated that there is NO difference in mortality or mobidity in ICU patients resuscitated with Albumin vs Saline, thus NO advantage.
Describe use of Colloids in the treatment of Hypovolemic shock
They are to be used in conjunction with crystalloids PRIOR to blood products
ONLY IF YOU NEED THEM
In relation chronologically to Blood Products, when should colloids be administered?
Before, in conjunction with crystalloids
Which colloid type is preferred in hypovolemic shock?
Non-protein (Hetastarch)
When should Blood be used in hypovolemic shock and why?
It should be used in hemorrhagic hypovolemic shock to increase oxygen carrying capacity or need of clotting factors or platelets.
Describe some other treatment methods of hypovolemic shock
1.Oxygen
2.Packed Red blood cells (PRBC)
3.Other blood products
4.Inotropes
5.Vasopressors
Describe when platelets should be used in hypovolemic shock?
If <30K
or
an increase in INR
When should FFP (Fresh frozen plasma) be used?
Short term rectification of shock
What are cryoprecipitates?
Clotting factors
Describe Cardiogenic shock
1.Anadequate tissue perfusion due to cardiac dysfunction.
2.Decrased CO and evidence of tissue hypoxia in the presence of adequate intravascular volume.
Hemodynamic Criteria for Cardiogenic Shock
1. Sustained SBP <90 for at least 30 min
2. Reduced CI <2.2 in presence of PCWP above 15
Describe the Hemodynamic Mechanism for Cardiogenic shock
1. Decreased CO causes pulmonary congestion and +PCWP
2.In order to maintain MAP, SVR will shoot up
What are the most common causes of Cardiogenic Shock?
1.Acute MI
2.End stage cardiomyopathy
3.Hypertrophic obstructive cardiomyopathy
Cardiogenic Shock
Management Goals
1. CI > 2.5
2. PCWP <18
3. MAP > 65
4. Uout >0.5ml/kg/hr
Describe the initial hemodynamic support for Cardiogenic shock
1.Fluid coverage in those w/o pulmonary edema
2.Vasopressors for hypotension unresponsive to fluids.
After initial hemodynamic support cardiogenic shock, the patient still has insufficient Tissue perfusion, agents to use?
Medium dose atropine
Inotropic Agents (dobutamine, milrinone and DA (DA only if BP drops with Dobutamine))
For cardiogenic shock, if DA is to be used, what dose range would you use?
3-10, we don't want the vasoconstriction
The Inotropic agents used for cardiogenic shock all increase contractility, do they cause vasoconstriction or dilation elsewhere?
Vasodilation
After initial hemodynamic support cardiogenic shock, the patient has adequate perfusion but with pulmonary congestion, what agents do you use?
1.Diuretics
2.Vasodilators
Predominant Pressors used for cardiogenic shock?
NE
DA
What purpose do diuretics serve in the management of cardiogenic shock and which agents are used?
They reduce PCWP in patients that have adequate tissue perfusion after initial treatment but still have pulmonary congestion.
1.Furosemide
2.Bumetanide
What purpose do Vasodilators serve in the management of cardiogenic shock and which agents are used?
They are used to decrease SVR in patients who have undergone initial hemodynamic support and have adequate tissue perfusion but still have pulmonary edema.
Na Nitroprusside (Cyanide toxicity, caution in renal patients)
Nitroglycerine
Hydralazine
Causes of Sepsis
1. Infectiosn
2. Anaphylaxis
3. Neurogenic
4. Drug induced
5. Acute adrenal insufficiency
SIRS Criteria
Systemic Inflammatory Response Syndrome
Two or more of the following
1.Temp >38 or <36
2.HR >90
3.RR >20 paCO2 <32
4.WBC >12000 or <4000 or >10% immature bands
What is Sepsis?
SIRS + Presence of Infection
What is severe Sepsis?
Sepsis with organ dysfunction.
Define Septic Shock
Sepsis with hypotension despite adequate volume resuscitation.
SBP <90, MAP <60 or SBP >40 from baseline drop
Risk factors for Septic shock
1.AIDS
2.Immunosuppressant and cytotoxic agents3
3.Malnutrition
4.Alcoholism
5.Malignancy
6.DM
7.Elderly >65 yo
8.Increased number of resistant organisms
Describe clinical manifestations of Early Sepsis
1.Hyperthermia/Hypothermia
2.Hyperglycemia/Hypoglycemia
3.Myopathy
4.Tachycardia
5.Hypoxia/Mental status changes
6.Leukocytosis
7.Tachypnea
8.Rigor/Chills
9.Proteinuria
Clinical manifestations of late sepsis
1.Lactic Acidosis
2.Oliguria/anuria
3.Leukopenia
4.DIC
5.Myocardial depression
6.Pulmonary edema (Need intubation)
7.Hypotension (Shock)
8.Hypoglycemia
9.Azotemia
10.Thrombocytopenia
11.ARDS
12.Coma
Increased mortality with septic shock is usually likely with what two signs?
Decreased temperature and decreased WBC
Describe the Hemodynamics associated with Septic Shock
1.Decreased SVR to maintain MAP which increases CO.
2.Increased CO for a short term
3.CO will decrease and proceed to hypotension
Overall Sepsis management steps
1.Initial Resuscitation
2.Antibiotic therapy
3.Vasopressors
4.Inotropes
5.Steroids
6.Recombinant Activated Protein C
7.Blood Products
8.Glycemic Products
Describe the Resuscitation phase of sepsis management
Fluids and more fluids during 1st 6 hours.
Crystalloids in 500-1000ml boluses OR Colloids in 300-500ml boluses
Resuscitation goals for Septic shock
MAP >65
CVP 8-12
SCVO2 >70 or Hgb >7
Urine output >0.5ml/kg/min
Describe overall antibiotic CONCEPTS for septic shock
-Culture Suspected Sites
-Start appropriate antibiotics within 1 hour of Dx
-Appropriate antibiotics have activity against likely pathogens and have adequate penetration
-Epidemiological identification of pathogens and sources of infections.
-Reassess after 24-48 hours when cultures are available
Examples of Beta-lactams with adequate anti-pseudomonal coverage
Ticarcillin
Piperacillin
Describe Antibiotic choices with Septic shock
1.Betalactam (w/ pseudo coverage) + Aminoglycoside
2.Beta-lactam and FQ (careful in renal failure)
3.Vanco or linezolid for suspected resistant bugs
Describe the Vasopressor step for Septic shock
1.Only used if MAP is not achieved with the fluids alone.
2.NE or DA are 1st line agents (NE is 1st)
MAINTAIN MAP >65
What Cpp is necessary to perfuse the brain?
50-60
Describe the roll of vasopressin in the management of septic shock?
Used 0.01-0.04 U/min for refractory shock witha dequate fluid resuscitation and high dose vasopressors.
ALWAYS IN ADDITION TO NE/DA
May decrease pressor dose but will lower CO as well!
Describe the Inotrope phase of Septic shock management
Used with those with CI <2.2 despite adequate fluids.
At this point, a goal MAP is not recommended, instead we are trying to achieve adequate ScvO2
Describe length of Pressor treatment during Septic shock
As shorta s possible
Describe corticosteroid treatment in septic shock patients
Hydrocortisone 200-300mg divided TID or QID for 7 patients with vasopressors requirements.
-->Additional use of fludrocortisone 50mcg daily questionable
Describe the ACTH stimulation test
250mcg ACTH and measure cortisol change after 30-60 minutes.
>9 mg/dL increases-> No adrenal insufficiency
Decreased 28 mortality in relative adrenal insufficient patients
<9 mg/dL increase = Adrenal insufficiency present
Describe Recombinant human activated protein C MOA
Controls thrombin, anti-inflammatory and pro fibrinolytic, all 3 aspects of sepsis
Dose of Drotecogin alfa
24mcg/kg/hr continuous infusion for 96 hours
Adverse effects of Drotecogin alfa
Bleeding
Long list of relative contraindications
Disadvantages of Drotecogin alfa
High cost
Efficacy controversial
Inclusion criteria for use of Drotecogin alfa
Patients with >/= 3 SIRs criteria and >/= 1 organ dysfunction that has lasted longer than 24 hours
Describe Blood product management associated with septic shock
Use when Hgb < 7 and those with SevO2 <70% despite adequate fluids and pressors during 1st 6 hours.
Goals:
Hgb ~10
Hematocrit 30% during 1st six hours
Describe glycemic control associated with septic shock
Tight glycemic control is associated with improved survival, decreased length of stay and time on ventilator.
Glucose 70-110
Monitor q 30-60 min with initiation then q 4 h