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55 Cards in this Set
- Front
- Back
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How is tissue perfusion clinically measured?
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MAP
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What are three classifications of shock?
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1)hypovolemic
2)cardiogenic 3)septic |
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Hypovolemic shock
1)MAP 2)PCWP 3)CO 4)SVR |
1)decrease
2)decrease 3)decrease 4)increase |
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Cardiogenic shock
1)MAP 2)PCWP 3)CO 4)SVR |
1)decrease
2)increase 3)decrease 4)increase |
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Septic shock
1)MAP 2)PCWP 3)CO 4)SVR |
1)decrease
2)decrease/no change 3)decrease/no change 4)decrease |
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What conditions are associated w/ hypovolemic shock?
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1)hemorrhagic
-trauma/surgery, internal bleeding 2)non-hemorrhagic -dehydration, intravscular fluid shift (ascites), fluid loss (burns, heat stroke) |
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What is the treatment of hypovolemic shock?
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Fluids
-increase tissue perfusion (BP, HR, organ function) |
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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 |
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What is the definition of cardiogenic shock?
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-inadequate tissue perfusion due to cardiac dysfunction
-decreased CO and evidence of tissue hypoxia in presence of adequate intravascular volume |
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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 |
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What are three causes of cardiogenic shock?
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1)AMI
2)end-stage cardiomyopathy 3)hypertrophic obstructive cardiomyopathy |
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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 |
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What is the treatment of cardiogenic shock?
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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 |
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What are three inotropic agents?
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1)dobutamine
2)milrinone 3)dopamine |
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What are the effects of dobutamine?
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1)increase contractility, HR
2)peripheral vasodilation |
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What are the effects of milrinone?
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1)increase contractility
2)peripheral vasodilation |
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What are the effects of dopamine?
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1)increase contractility, HR (3-10)
2)peripheral vasoconstriction (doses >10) |
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What are two examples of vasopressors?
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1)norepinephrine
2)dopamine -increase MAP |
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What are two examples of diuretics?
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1)furosemide
2)bumetanide -decrease PCWP |
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What are three examples of vasodilators?
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1)sodium nitroprusside
2)nitroglycerin 3)hydralazine -decrease SVR |
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What are five causes of septic (distributive shock)?
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1)infections
2)anaphylaxis 3)neurogenic 4)drug-induced 5)acute adrenal insufficiency |
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What is the definition of systemic inflammatory response syndrome (SIRS)?
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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 |
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What is the definition of sepsis?
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SIRS with presence of infection (documented or suspected)
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What is the definition of severe sepsis?
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1)sepsis with organ dysfunction, hypoperfusion, or hypotension
2)organ dysfunction defined by MODS or SOFA |
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What is the definition of septic shock?
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1)sepsis with hypotension despite adequate volume resuscitation
2)SBP <90 or MAP <60-65 or decrease SBP >40 from baseline |
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What are risk factors for sepsis?
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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
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What are the three major pathophysiologic mechanisms in sepsis?
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1)inflammation
-from inflammatory cytokines in response to infection 2)thrombosis -activate coagulation cascade 3)suppressed fibrinolysis -due to depletion of fibrinolytic pathway |
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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 |
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What are eight steps to sepsis manangement?
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1)initial resuscitation
2)antibiotics 3)vasopressors 4)inotropes 5)steroids 6)recombinant activated protein C 7)blood products 8)glycemic products |
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Resuscitation management
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-fluids during 1st 6hours
-cyrstalloids (500-1000mL) or colloid (300-500mL) boluses |
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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 |
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Antibiotic management
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-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 |
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Antibiotic choices
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1)double coverage for pseudomonas
-b-lactams AND aminoglycosides -b-lactams AND FQs -vanco or linezolid for suspected resistant pathogens |
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When should vasopressors be started?
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if adequate MAP is not achieved w/ fluid resuscitation
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What vasopressors are first-line agents for sepsis?
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norepinephrine or dopamine
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What are the goals for vasopressors in sepsis?
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maintain MAP >65
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What vasopressor is used for refractory shock?
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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 |
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When are inotropes indicated in sepsis?
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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 |
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What are the goals of the inotropes in sepsis?
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1)goal CI not recommended
2)achieve adequate ScvO2 |
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When are corticosteroids indicated?
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1)in pts w/ vasopressors requirements
-hydrocortisone 200-300mg/day, tid-qid for 7d -additional use of fludrocortisone 50mcg daily questionable |
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How is the ACTH stimulation test administered?
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1)250mcg ACTH and measure cortisol change after 30-60mins
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What do the results of the ACTH stimulation test mean?
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1)>9mcg/dL increases = no adrenal insufficiency
2)<9mcg/dL increases = adrenal insufficiency present |
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What is the significance of the ACTH stimulation test results?
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decreased 28 day mortality in relative adrenal insufficient patients
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Indication for recombinant human activated protein C
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sepsis due to inflammation and coagulation (low endogenous level of activated protein C)
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What is the MOA of drotecogin alfa?
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1)inhibits Va and VIIIa leading to decreased thrombin production
2)antiinflammatory and pro-fibrinolytic |
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What is the dose of drotecogin alfa?
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24mcg/kg/hr continuous infusion for 96hrs
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What are the adverse effects of drotecogin alfa?
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1)bleeding
2)long list of relative contraindications |
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What are the disadvantages of drotecogin alfa?
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1)high cost (8,000-10,000)
2)efficacy controversial in pts who do not fit into original study criteria |
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What were the inclusion requirements for the drotecogin alfa study?
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1)pts w/ >= SIRS criteria and >=1 organ dysfunction that lasted no longer than 24hrs
2)therapy started w/in 24hrs |
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What was the primary endpoint of the study?
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all cause mortality at day 28
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What were the results of the study?
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stat sig decrease in mortality and not stat sig increase in serious bleed
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When is blood product management indicated?
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1)hemoglobin <7g/dL
2)ScvO2<70% despite adequate fluid resuscitations and vasopressor therapy during 1st 6hrs of resuscitation |
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What are the goals of blood product management?
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1)Hgb around 10g/dL
2)hematocrit 30% during 1st 6hrs of resuscitation |
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What is the significance of glycemic control?
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tight glycemic control is associated w/ improved survival, decreased lenght of stay and time on ventilator
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What are the goals of glycemic control?
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1)glucose 70-110mg/dL
2)glucose monitoring q30-60mins w/ initiation then q4hr |
