Pharm Shock, Sepsis, MODS

4 different types of shock

Hypovolemic, Cariogenic:, Distributive, Obstructive:

Hypovolemic shock

fluid/blood loss (trauma, dehydration, burns)

Cardiogenic

heart pump failure (not enough squeeze)

Distributive:

excessive vasodilation → blood pooling (sepsis, anaphylaxis, spinal cord injury)

Obstructive:

blocked blood flow (clot, tumor)

Sepsis

systemic infection → dysregulated inflammatory response

Septic Shock

widespread vasodilation & inflammation from SIRS

MODS

 (Multiple Organ Dysfunction Syndrome): failure of ≥2 organ systems, often after shock

Regulation of Blood Pressure

Autonomic reflexes & neurohormones
Capillary fluid shifts
Baroreceptors (aortic arch)
Sympathetic nervous system (adrenergic receptors: alpha & beta)

Hemodynamic factors

CO = SV × HR (normal SV ≈ 60–90 mL)
Blood volume (hypovolemia vs hypervolemia)
Peripheral resistance

Adrenergic Drugs effects

1. Peripheral Artery Vasoconstriction (everywhere) → ↑ BP
   
   

2. Cardiac stimulation → ↑ MAP, HR, SV, SVR
   
   

3. Mimic/block natural hormones
   
   

4. Stimulate/block SNS

 Adrenergic common meds

1. Epinephrine, Norepinephrine (Levophed), Dopamine, Dobutamine, Albuterol, Beta-blockers
   
   

2. Phenylephrine (Neo-Synephrine) → ↑ BP, ↓ HR (not adrenergic)
   
   

Vasopressin

Pressor Infusion Order (typical)

1. Norepinephrine (levofed)
   
   

2. Epinephrine
   
   

3. Dobutamine
   
   

4. Dopamine
   
   

5. Phenylephrine
   
   

6. Vasopressin

Adrenergic Receptor Actions

Alpha 1, Beta 1, Beta 2:

Alpha 1:

vasoconstriction, ↑ BP, ↓ nasal congestion, sphincter contraction, ↑ glucose (cardiogenic patients only)

Beta 1:

 ↑ HR, ↑ contractility (heart stimulation)

Beta 2

• bronchodilation, vasodilation, ↑ blood flow to heart/brain/muscles, ↓ insulin, relax uterus/bladder, slows GI; increased risk for aspiration (NPO + NG/OG tube often needed)
  (a patient in DKA, DI or a burn victim. We have to replace fluids before we ever start a pressers)

• ( if a person has enough fluid then we give inotropes meds)

 Indications for Adrenergic Drugs

Cardiac emergencies:, Pulmonary:, Allergic reactions:, Obstetrics:Adjunct to anesthesia

Cardiac emergencies:

• Cardiac arrest → Epinephrine, Amiodarone
  
  

• Bradycardia → Atropine
  
  

• Hypotension → Norepinephrine (levofed)
  
  

• Hemorrhagic/hypovolemic shock → fluids + blood

Pulmonary:

asthma (Albuterol), nasal congestion (Neo-Synephrine)

Allergic reactions

anaphylaxis (Epinephrine)

Obstetrics:

preterm labor (inhibit contractions)

 Contraindications / Cautions

• Cardiac dysrhythmias, angina
  
  

• Hyperthyroidism, narrow-angle glaucoma
  
  

• Hypertension, CV disease, stroke risk
  
  

• Local anesthesia to fingers/toes/nose/ears (tissue necrosis risk)
  
  

• Older adults (poor peripheral circulation)
  
  

Anxiety, insomnia, psychiatric disorders

 Safety Points

• Give via central line (preferred)
  
  

• Peripheral IV only if necessary → monitor closely
  
  

• Infiltration risk: tissue necrosis (esp. norepinephrine → BLACK BOX WARNING)
  
  

If occurs → inject diluted phentolamine ASAP

Adrenergic Mechanisms of Action(direct, indirect, mixed)

1. Direct: bind receptors → stimulate target tissue
   
   

2. Indirect: increase norepinephrine, inhibit reuptake
   
   

Mixed: both direct & indirect

Nursing Implications

• Prevent drug interactions
  
  

• Monitor for therapeutic & adverse effects
  
  

• Patient teaching (risks, side effects)
  
  

• Adjust dosing to individual case

• Special population:

  • Children

  • Older adults 

  • Abnormal kidney function 

  • Critical illness 

• Do not let vasopressor bag run out, replace before

 IV Drug Calculations

• Use med-math formulas (from ATI dosage calc module)
  
  

• Doses individualized, no universal standard
  
  

• Emergency meds = IV route (cardiac arrest, shock, severe hypotension, anaphylaxis)