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29 Cards in this Set

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How do you define septic shock
High CI (2.5-4 normal)
Low PCWP (8-12)
Low SVR (800-1400)

High CO but with vasodilation and low SVR with leaky capillaries causing intravascular fluid to move to interstitial space. This causes low PCWP (low blood volume pumping)
How do you define hypovolemic shock
Low CI
High SVR
How do you define cardiogenic shock
Low CI
High SVR

Heart failure, low CI. This causes increased volume (high PCWP) and high pressure.
How do you treat hypovolemic shock
Restore intravascular volume, use crystalloids and colloids

May need vasopressors if hypotension not controlled by fluid resuscitation

Use target CVP of 8-12 to guide fluid resuscitation
How do you define general sepsis
Temp greater than 38 or lower than 36

HR > 90

Altered mental status
WBC>12000 or<4000
How do you differentiate severe sepsis
Complicated by organ dysfunction or hypoperfusion
What constitutes organ dysfunction by system
CV: SBP >90 or MAP<70
Pulmonary: Need for mechanical ventilation
Kidney: UOP <30ml/hr
Hematologic: Decreased platelet or WBC or increase in INR
How do you initially treat sepsis
In 6 hours:

CVP 8-12
MAP > 65
SV02 > 70%
Protocol for achieving sepsis goals
1) Fluid resuscitation using 1000ml of crystalloids or 300-500ml of colloids
2) There is no evidence that colloids are superior to crystalloids
3) If SV02 target not met, consider fluid resuscitation, packed red blood cells and dobutamine
4) Vasopressors may be necessary to keep MAP > 65 if fluid challenge fails to restore BP
5) Norepi or dopamine are vasopressors of choice
6) Vasopressin efficacy similiar to norepi, but can be used together for vasopressor sparing effect
7) Inotropes (dobutamine, milrinone) may be needed to improve cardiac function with low CO
What are the features of vasopressin
Direct stimulation of smooth muscle receptors, peripheral vasoconstriction

Effective during acidosis and hypoxia because does not rely on adrenergic receptors

Not titrated
What are some of the features of dobutamine
Positive inotrope to increase CO

Can cause hypotension due to Beta 2 stimulation
What are the indications of using corticosteroids in sepsis
IV hydrocortisone can improve short term survival in adult patients who continue to have hypotension despite vasopressors or fluid resuscitation

Usually 50mg IV Q6hrs
How do you use drotrecogin alfa?
Can improve survival in adult patients with sepsis induced organ dysfuinction (at least 2 organs) who has APACHE score > 25

Do not use in internal bleeding, hemorrhagic stroke, recent intracranial or intraspinal surgery or head trauma, epidural catheter
What is the dose of drotrecogin alfa?
24mcg/kg/hr for 96 hours based on actual body weight

Started within 24 hours of onset of severe sepsis or septic shock.

Hold 2 hours before a procedure, resume 12 hours after surgery
What route is preferred in cardiac arrest? Intraosseus or endotracheal?
What drugs can be given endotracheal?

N - Naloxone
A - Atropine
V - Vasopressin
E - Epinephrine
L - Lidocaine
When do you consider hypothermia?

For patients who have been resuscitated after cardiac arrest but are still comatose
What complications can occur during hypothermia
Shivering - causes excess heat production, excess oxygen consumption

Treat with BZD, meperidine, fentanyl, buspirone, magnesium 2gm
What analgesic is not prolonged in hepatic or renal failure?
Remifentanil (Ultiva)
What abnalgesi has no effects on hypotension?
What are the characteristics of propofol in sedation
Avoid loading doses because of risk of hypotension

Use in intubated patients because of risk of respiratory depression

Propofol infusion syndrome is more likely to occur with prolonged infusions and is metabolic acidosis, cardiac failure, arrythmias
What are the characteristics of dexmedetomidine
Sedative and analgesic properties through alpha recept agonist activities

Does not cause respiratory depression or drug dependency

Rapid onset, short duration

Compared to BZD's, causes less ICU delirium
How do you treat delirium in the ICU
1) Haldol 1-10mg
Monitor for hypotension, QT interval, EPS effects, seizures
2) Atypical antipsychotics are potential alternatives
When do you use therapeutic paralysis
Only use for intubated patients with persistant hypoxia despite sedation and analgesia

Should be used with continuously infused sedative
What are the duration of effects of the paralytic agents
Atracurium - 0.25 to 0.5hrs
Vecuronium - 0.5 to 0.75 hrs
Cisatracurium - 0.5 to 1 hrs
Pancuronium - 0.75-1.5 hrs
What paralytics are not prolonged in renal or hepatic failure
Atracurium and cisatracurium
What paralytics do not cause tachycardia or hypotension
Vecuronium and cisatracurium
Which risk factors are present for stress ulcers
Respiratory failure requiring mechanical failure

Coagulopathy, platelets <50k, INR>1.5
What drugs are normally used for stress ulcer prophylaxis
Most evidence with H2 blockers, PPI also used