Surgery Cf Ch 30 The Hypotensive Patient 1

Front 1

1. Best management for hypotensive patient with gram-negative bacteremia and fungemia (sepsis)?

Back 1

a. Play central venous pressure monitor and arterial catheter for continuous blood pressure monitoring
b. Consider Echo/pulmonary artery catheter placement to assess ventricular function or cardiac output
c. Consider uncontrolled ongoing surgical blood loss if the patient fails to respond to resuscitation.

Front 2

2. In general, to volume is found in each unit packed red blood cells?

Back 2

a. 250 to 300 mL of volume.

Front 3

3. Initial approach to hypotensive patient?

Back 3

a. Begin resuscitation w/crystalloid fluids and simultaneously begin close monitoring of response to resuscitative efforts.
b. The pt’s clinical picture, including mentation, urine output, peripheral circulation, should be assessed.

Front 4

4. Central venous catheter?

Back 4

a. An intravenous catheter of adequate length to measure pressures in the superior vena cava when placed via internal jugular vein or subclavian vein.

Front 5

5. Lactate?

Back 5

a. When this end-product of anaerobic metabolism is elevated, it suggests a global deficits and oxygen delivery.

Front 6

6. PA catheter?

Back 6

a. Catheter capable of measuring venous pressures that is placed in the pulmonary artery.
b. The pressure measured when inflow is blocked (by inflated balloon) is extrapolated to be equal to the right atrial pressure because normally pulmonary vascular resistance is very low.
c. This catheter can also measure cardiac output by the thermodilution method, thus permitting the clinician to track cardiac performance and response to intervention.
d. Not routinely used due to unproven nature of it.

Front 7

7. End effect of shock (persistent hypotension)?

Back 7

a. Resultant in lack of perfusion to organ systems and can lead to multiorgan system dysfunction and organ failure.

Front 8

8. Diagnosis of hypertension?

Back 8

a. Central venous monitoring or cardiac echocardiogram can provide valuable information concerning hypotension and help guide efforts at fluid resuscitation when the clinical picture is unclear.
b. However the diagnostic maneuvers should not be used to replace one's clinical judgment.

Front 9

9. What are the potential drawbacks of using urine output as the major endpoint of resuscitation?

Back 9

a. Doing so on a hyperglycemic patient with falsely high urine output caused by glucose spillage in the urine.
b. Also patients who may develop low urine output from acute renal insufficiency following severe or prolonged shock.

Front 10

10. Ways to monitor and measure resuscitation endpoints?

Back 10

a. Foley catheter
b. Central venous catheter for frequent CVP measurements
c. Arterial catheter for continuous blood pressure monitoring (preferred) or frequent noninvasive blood pressure measurements
d. Serial hemoglobin measurements
e. Serial ABGs for trends in lactate level or base deficit.

Front 11

11. Note: early hemoglobin levels may not reflect active hemorrhage prior to the delusional effect of crystalloid resuscitation.

Back 11

11. Note: early hemoglobin levels may not reflect active hemorrhage prior to the delusional effect of crystalloid resuscitation.

Front 12

12. Etiologies of hypovolemic shock (2)?

Back 12

1. Hemorrhage
2. Dehydration

Front 13

13. Four etiologies of distributive shock?

Back 13

1. Sepsis
2. Neurogenic
3. Anaphylaxis
4. Medications

Front 14

14. 2 etiologies of cardiac: intrinsic shock?

Back 14

a. Acute coronary syndrome
b. Cardiomyopathy

Front 15

15. 2 etiologies of cardiac: extrinsic shock?

Back 15

1. Cardiac tamponade
2. Tension pneumothorax
3. Massive pulmonary embolism

Front 16

16. Possible etiology in patients who respond initially crystalloid resuscitation but then have a subsequent drop in arterial blood pressure?!

Back 16

a. Ongoing surgical bleeding!!!

Front 17

17. In pts suspected of haemorrhage, what labs should be measured?

Back 17

1. INR
2. PTT
3. Platelets
b. To rule out nonsurgical sources of bleeding

Front 18

18. What is the treatment for distributive volume loss?

Back 18

a. Initial treatment involves fluid resuscitation to fill the increased volume of the vascular pool.
b. Once this has begun, application of vasoconstrictive agents may be necessary to maintain a balance of normal normovolemia and pharmacologic vascular tone.
c. If aetiology is sepsis treatment may also include broad-spectrum antibiotics and operative intervention.

Front 19

19. What drug classes may risk further increase vasodilation and cause profound hypotension?

Back 19

1. Sedatives
2. Drugs for analgesia
3. Drugs for induction of anesthesia

Front 20

20. What drug is often needed in acute anaphylactic shock?

Back 20

a. Epinephrine

Front 21

21. Hallmark of neurogenic shock (as from acute injury to the cervical or upper thoracic spinal cord)?

Back 21

a. A hallmark of this type of hypotension is a normal or low heart rate someone who's not on beta blockers!!!
b. Results from loss of autonomic tone.

Front 22

22. Goal of Therapy for shock!?!?!?!?!?

Back 22

a. Restore oxygen delivery!!!!
b. This can be approached from a basic pump, pipes, fluid algorithm

Front 23

23. Basic pump, pipes, fluid algorithm?

Back 23

a. 1st there has to be adequate fluid in the system for perfusion
b. If vasodilation is contributing to a perceived hypovolemia in the presence of adequate resuscitation then and only then should vasoconstrictive agents be considered.

Front 24

24. Vasoconstrictive agents for shock?

Back 24

a. Norepinephrine
b. Dopamine
c. Neo-Synephrine
d. Epinephrine
e. Vasopressin.

Front 25

25. Normal cardiac index?

Back 25

a. 2.4-3.0 L/min/M^2

Front 26

26. Normal pulmonary capillary wedge pressure?

Back 26

a. 8-12 mm Hg

Front 27

27. Cardiac index with distributive shock (sepsis, neurogenic, anaphylaxis)?

Back 27

a. Elevated

Front 28

28. Cardiac index with cardiogenic shock (myocardial infarction, cardiomyopathy)?

Back 28

a. Decreased

Front 29

29. Cardiac index with hypovolemic shock (hemorrhage, dehydration)?

Back 29

a. Decreased (because the decreased volume)

Front 30

30. Cardiac index with obstructive shock (tamponade, tension pneumothorax, pulmonary embolism)?

Back 30

a. Decreased

Front 31

31. Systemic vascular resistance with distributive shock (sepsis, neurogenic, anaphylaxis)?

Back 31

a. Decreased (because of decreased vascular tone)

Front 32

32. Systemic vascular resistance with cardiogenic shock (myocardial infarction, cardiomyopathy)?

Back 32

a. Increased

Front 33

33. Systemic vascular resistance with hypovolemic shock (hemorrhage, dehydration)?

Back 33

a. Increased (in attempt to maintain blood pressure)

Front 34

34. Systemic vascular resistance with obstructive shock (tamponade, tension pneumothorax, pulmonary embolism)?

Back 34

a. Increased

Front 35

35. Pulmonary capillary wedge pressure with distributive shock (sepsis, neurogenic, anaphylaxis)?

Back 35

a. Low to normal

Front 36

36. Pulmonary capillary wedge pressure with cardiogenic shock (myocardial infarction, cardiomyopathy)?

Back 36

a. Increased

Front 37

37. Pulmonary capillary wedge pressure with hypovolemic shock (hemorrhage, dehydration)?

Back 37

a. Decreased