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55 Cards in this Set

  • Front
  • Back
How is tissue perfusion clinically measured?
MAP
What are three classifications of shock?
1)hypovolemic
2)cardiogenic
3)septic
Hypovolemic shock
1)MAP 2)PCWP 3)CO 4)SVR
1)decrease
2)decrease
3)decrease
4)increase
Cardiogenic shock
1)MAP 2)PCWP 3)CO 4)SVR
1)decrease
2)increase
3)decrease
4)increase
Septic shock
1)MAP 2)PCWP 3)CO 4)SVR
1)decrease
2)decrease/no change
3)decrease/no change
4)decrease
What conditions are associated w/ hypovolemic shock?
1)hemorrhagic
-trauma/surgery, internal bleeding
2)non-hemorrhagic
-dehydration, intravscular fluid shift (ascites), fluid loss (burns, heat stroke)
What is the treatment of hypovolemic shock?
Fluids
-increase tissue perfusion (BP, HR, organ function)
What are the treatment goals for hypovolemic shock?
1)PCWP 2)CVP 3)CI
1)PCWP 6-15mmHg
2)CVP 2-6mmHg
3)CI 2.8-4.5L/min/m2
What is the definition of cardiogenic shock?
-inadequate tissue perfusion due to cardiac dysfunction
-decreased CO and evidence of tissue hypoxia in presence of adequate intravascular volume
What is the hemodynamic criteria of cardiogenic shock?
1)SBP 2)CI
1)sustained hypotension (SBP <90 for at least 30min)
2)reduced CI <2.2 in presence of elevated PCWP >15mmHg
What are three causes of cardiogenic shock?
1)AMI
2)end-stage cardiomyopathy
3)hypertrophic obstructive cardiomyopathy
What are the goals of the management of cardiogenic shock?
1)CI 2)PCWP 3)MAP 4)UO
1)CI >2.5
2)PCWP <18
3)MAP >65
4)UO >0.5mL/kg/hr
What is the treatment of cardiogenic shock?
1)fluid challenge, vasopressors for hypotension unresponsive to fluids
2)inotropes, IABP if tissue perfusion remains inadequate; diuretics, vasodilators for adequate tissue perfusion w/ pulmonary congestion
3)reperfusion
What are three inotropic agents?
1)dobutamine
2)milrinone
3)dopamine
What are the effects of dobutamine?
1)increase contractility, HR
2)peripheral vasodilation
What are the effects of milrinone?
1)increase contractility
2)peripheral vasodilation
What are the effects of dopamine?
1)increase contractility, HR (3-10)
2)peripheral vasoconstriction (doses >10)
What are two examples of vasopressors?
1)norepinephrine
2)dopamine
-increase MAP
What are two examples of diuretics?
1)furosemide
2)bumetanide
-decrease PCWP
What are three examples of vasodilators?
1)sodium nitroprusside
2)nitroglycerin
3)hydralazine
-decrease SVR
What are five causes of septic (distributive shock)?
1)infections
2)anaphylaxis
3)neurogenic
4)drug-induced
5)acute adrenal insufficiency
What is the definition of systemic inflammatory response syndrome (SIRS)?
2 or more of following
1)temp >38C or <36
2)HR >90
3)RR >20 or PaCO2 <32
4)WBC count >12000/mm3, <4000/m3, or >10% immature bands
What is the definition of sepsis?
SIRS with presence of infection (documented or suspected)
What is the definition of severe sepsis?
1)sepsis with organ dysfunction, hypoperfusion, or hypotension
2)organ dysfunction defined by MODS or SOFA
What is the definition of septic shock?
1)sepsis with hypotension despite adequate volume resuscitation
2)SBP <90 or MAP <60-65 or decrease SBP >40 from baseline
What are risk factors for sepsis?
1)AIDS 2)immunosuppressant and cytotoxic agents 3)malnutrition 4)alcoholism 5)malignancy 6)diabetes mellitus 7)elderly pts (>65yo) 8)increase number of resistant organisms
What are the three major pathophysiologic mechanisms in sepsis?
1)inflammation
-from inflammatory cytokines in response to infection
2)thrombosis
-activate coagulation cascade
3)suppressed fibrinolysis
-due to depletion of fibrinolytic pathway
What are the hemodynamics of sepsis?
1)SVR 2)CO
1)decrease SVR -> to maintain MAP -> increase CO
2)increase CO -> for short-term
3)CO can ultimately decrease -> hypotension
What are eight steps to sepsis manangement?
1)initial resuscitation
2)antibiotics
3)vasopressors
4)inotropes
5)steroids
6)recombinant activated protein C
7)blood products
8)glycemic products
Resuscitation management
-fluids during 1st 6hours
-cyrstalloids (500-1000mL) or colloid (300-500mL) boluses
What are the goals of resuscitation?
1)MAP 2)CVP 3)ScvO2 4)UO
1)MAP >65
2)CVP 8-12
3)ScvO2 >70% or Hgb >7
4)UO>0.5
Antibiotic management
-culture suspected sites
-start antibiotics w/in 1hr of diagnosis
-epidemiological identification of pathogens and sources of infections
-reassess after 24-48hr when cultures available
Antibiotic choices
1)double coverage for pseudomonas
-b-lactams AND aminoglycosides
-b-lactams AND FQs
-vanco or linezolid for suspected resistant pathogens
When should vasopressors be started?
if adequate MAP is not achieved w/ fluid resuscitation
What vasopressors are first-line agents for sepsis?
norepinephrine or dopamine
What are the goals for vasopressors in sepsis?
maintain MAP >65
What vasopressor is used for refractory shock?
vasopressin 0.01-0.04 units/min with adequate fluid resuscitation and high dose vasopressors
a)additive to NE or DA infusion
b)may decrease vasopressor dose but does lower CO
When are inotropes indicated in sepsis?
1)pts w/ low CI (<2.2) despite adequate fluid resuscitation
2)pts w/ ScvO2 <70% despite adequate blood transfusions during 1st 6hrs of resuscitation
What are the goals of the inotropes in sepsis?
1)goal CI not recommended
2)achieve adequate ScvO2
When are corticosteroids indicated?
1)in pts w/ vasopressors requirements
-hydrocortisone 200-300mg/day, tid-qid for 7d
-additional use of fludrocortisone 50mcg daily questionable
How is the ACTH stimulation test administered?
1)250mcg ACTH and measure cortisol change after 30-60mins
What do the results of the ACTH stimulation test mean?
1)>9mcg/dL increases = no adrenal insufficiency
2)<9mcg/dL increases = adrenal insufficiency present
What is the significance of the ACTH stimulation test results?
decreased 28 day mortality in relative adrenal insufficient patients
Indication for recombinant human activated protein C
sepsis due to inflammation and coagulation (low endogenous level of activated protein C)
What is the MOA of drotecogin alfa?
1)inhibits Va and VIIIa leading to decreased thrombin production
2)antiinflammatory and pro-fibrinolytic
What is the dose of drotecogin alfa?
24mcg/kg/hr continuous infusion for 96hrs
What are the adverse effects of drotecogin alfa?
1)bleeding
2)long list of relative contraindications
What are the disadvantages of drotecogin alfa?
1)high cost (8,000-10,000)
2)efficacy controversial in pts who do not fit into original study criteria
What were the inclusion requirements for the drotecogin alfa study?
1)pts w/ >= SIRS criteria and >=1 organ dysfunction that lasted no longer than 24hrs
2)therapy started w/in 24hrs
What was the primary endpoint of the study?
all cause mortality at day 28
What were the results of the study?
stat sig decrease in mortality and not stat sig increase in serious bleed
When is blood product management indicated?
1)hemoglobin <7g/dL
2)ScvO2<70% despite adequate fluid resuscitations and vasopressor therapy during 1st 6hrs of resuscitation
What are the goals of blood product management?
1)Hgb around 10g/dL
2)hematocrit 30% during 1st 6hrs of resuscitation
What is the significance of glycemic control?
tight glycemic control is associated w/ improved survival, decreased lenght of stay and time on ventilator
What are the goals of glycemic control?
1)glucose 70-110mg/dL
2)glucose monitoring q30-60mins w/ initiation then q4hr