Why is Mean Arterial Pressure (MAP) preferred over SBP as an indicator of perfusion pressure with a patient in shock?
A. It gives minimum pressure in which to perfuse major organs
What is the goal of urine output for a patient in shock? (in ml/kg/hr)
greater than or equal to 0.5ml/kg/hr
In the shock patient, this is elevated as a direct result of anaerobic tissue metabolism:
C. Lactate levels as evidence of sepsis
In describing CBC, a "shift to the left" means...
B. Indications of beginning infections
List infections most associated with sepsis (4)
PNA (top)
UTI
abdominal surgery
Bloodstream
List values for SIRS criteria:
Temp
Pulse
RR
LOC
WBC
Glucose
Temp: >38.5 or <36
Pulse: >90 (tachy)
RR: >20
Altered mental status
WBC: >12,000 or <4,000
Hyperglylcemic
How does a pt. meet SEVERE sepsis criteria?
List some of these conditions
Diagnostic creteria for SIRS/Sepsis present, PLUS at least one indicator of possible organ failure
Including:
Greatly reduced urine output
Abrupt change in mental status
Decreased platelet count
Abnormal HR or SOB
What is defined as septic shock? Sepsis induced tissue hypoperfusion?
Septic Shock: A sepsis-induced HYPOtension persisting despite adequate fluid resuscitation.
Sepsis induced tissue hypoperfusion: an infection-induced hypotension, elevate lactate or oliguria
What is normal lactate leel?
>2
How will betablockers contribute to septic shock?
It will prevent HR and BP from going up if they were bottoming down initially
If a patient is going to get a fluid bolus of NS at 30ml/kg (Pt is 68kg) for septic shock, how much total volume will they receive and over what period of time? What will you set pump to (if possible)?
2040mL over 15-20 minutes
2040 x 3 = +6000mL pump rate (cannot set pump that fast) so take it out of pump and use free flow.
What are normal Procalcitonin levels?
>0.15
This lab value can help determine when to stop abx.
Procalcitonin: returns to normal as patent is improving
T or F: Norepinephrine is used as a first line vasopressor in septic shock
True
List interventions within first 3 hours when patient screens positive shock (4)
1. Measure lactate levels
2. Get blood cultures BEFORE starting abx
3. Start broad-spectrum abx within 1 hour
4. Give 30ml/kg crystalloid bolus IF HYPOtensive or lactate >4 mEq/L
Fill in: When giving crystalloid bolus to someone with positive screening of sepsis, the dose is __a__ ml/kg. They must either be HYPOtensive or lactate at __b__ mEq/L.
a. 30ml/kg
b. 4
List interventions after positive sepsis screenings with a 6 hour bundle (4)
1. Vasopressors for HYPOtension that is not corrected by fluids
2. Central lines for persistent HYPOtension (measure CVP >8mmHg and ScVO2>70%)
3. Re-measure lactate if previously elevated
4. Documented re-assessment of volume status and tissue perfusion (MAP, cap refill, jugular veins)
When someone is positive for sepsis, what are the 6 hour goals of each:
1. CVP
2. Central venous SAT
3. MAP
4. UO
5. Lactate
1. CVP: 8-12mmHg
2. Central SAT: 65-70%
3. MAP: >65mmHg
4. UO > 0.5mL/kg/hr
5. Lactate: decreasing or normalizing
What are glucose controls for septic shock? (4)
1. Treat if glucose above 180
2. Keep it above 110
3. Check q1-2h until stabilized
4. Enteral nutrition when possible (start low calorie)
What is the max amount of days before you change c-line dressings?
Q7days for transparent, q2 for gauze
- Unless soiled or non-intact drsg, change immediately
How often do you change infusion set for continuous site? Intermittent? Caps?
Continuous = 72-96 hours
Intermittent = 24 hours
Cap = change q7days or after blood transfusion
A pt has these values:
Temp: 35.9
P: 107
RR: 25
SpO2 90% on 2L
BP: 92/53 (66)
List interventions needed for positive sepsis
Notify MD
Sepsis screen
Initiate 3 hour bundle:
- Blood cultures, serum lacate
- broad spectrum abx within 1 hour
- IV bolus for hypotension or lactate >3.9
What is CARS?
Compensatory Anti-inflammatory Response syndrome: this response can disregulate things and lead to higher death rate. Body can't respond to abx given
