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29 Cards in this Set
- Front
- Back
How do you define septic shock
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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) |
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How do you define hypovolemic shock
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Low CI
Low PCWP High SVR |
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How do you define cardiogenic shock
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Low CI
High PCWP High SVR Heart failure, low CI. This causes increased volume (high PCWP) and high pressure. |
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How do you treat hypovolemic shock
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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 |
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How do you define general sepsis
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Temp greater than 38 or lower than 36
HR > 90 Tachypnea Altered mental status Hyperglycemia WBC>12000 or<4000 |
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How do you differentiate severe sepsis
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Complicated by organ dysfunction or hypoperfusion
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What constitutes organ dysfunction by system
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CV: SBP >90 or MAP<70
Pulmonary: Need for mechanical ventilation Kidney: UOP <30ml/hr Hematologic: Decreased platelet or WBC or increase in INR |
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How do you initially treat sepsis
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In 6 hours:
CVP 8-12 MAP > 65 UOP>0.5ML/KG/HR SV02 > 70% |
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Protocol for achieving sepsis goals
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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 |
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What are the features of vasopressin
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Direct stimulation of smooth muscle receptors, peripheral vasoconstriction
Effective during acidosis and hypoxia because does not rely on adrenergic receptors Not titrated |
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What are some of the features of dobutamine
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Positive inotrope to increase CO
Can cause hypotension due to Beta 2 stimulation |
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What are the indications of using corticosteroids in sepsis
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IV hydrocortisone can improve short term survival in adult patients who continue to have hypotension despite vasopressors or fluid resuscitation
Usually 50mg IV Q6hrs |
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How do you use drotrecogin alfa?
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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 |
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What is the dose of drotrecogin alfa?
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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 |
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What route is preferred in cardiac arrest? Intraosseus or endotracheal?
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Intraosseous
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What drugs can be given endotracheal?
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NAVEL
N - Naloxone A - Atropine V - Vasopressin E - Epinephrine L - Lidocaine |
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When do you consider hypothermia?
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12-24 HOURS BEGINNING AS SOON AS POSSIBLE AFTER CARDIAC ARREST TO IMPROVE MORTALITY AND NEUROLOGIC RECOVERY
For patients who have been resuscitated after cardiac arrest but are still comatose |
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What complications can occur during hypothermia
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Shivering - causes excess heat production, excess oxygen consumption
Treat with BZD, meperidine, fentanyl, buspirone, magnesium 2gm |
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What analgesic is not prolonged in hepatic or renal failure?
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Remifentanil (Ultiva)
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What abnalgesi has no effects on hypotension?
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Fentanyl
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What are the characteristics of propofol in sedation
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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 |
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What are the characteristics of dexmedetomidine
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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 |
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How do you treat delirium in the ICU
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1) Haldol 1-10mg
Monitor for hypotension, QT interval, EPS effects, seizures 2) Atypical antipsychotics are potential alternatives |
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When do you use therapeutic paralysis
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Only use for intubated patients with persistant hypoxia despite sedation and analgesia
Should be used with continuously infused sedative |
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What are the duration of effects of the paralytic agents
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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 |
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What paralytics are not prolonged in renal or hepatic failure
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Atracurium and cisatracurium
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What paralytics do not cause tachycardia or hypotension
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Vecuronium and cisatracurium
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Which risk factors are present for stress ulcers
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Respiratory failure requiring mechanical failure
Coagulopathy, platelets <50k, INR>1.5 |
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What drugs are normally used for stress ulcer prophylaxis
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Most evidence with H2 blockers, PPI also used
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