Exam 2 (Everything but Renal)

What is shock?

A life-threatening medical condition that results from inadequate tissue perfusion.

• It is not a disease itself, but rather the possible consequences of many diseases.

• It is a systemic response to an illness/injury that leads to a cascade of events with a potentially fatal outcome.

Regulatory Mechanisms in Shock (image)

Pathophysiology of Shock (image)

What are the Stages of Shock?

• Initial Insult

• Compensatory Stage—compensation

• Progressive Stage—decompensation

• Irreversible Stage—refractory (unresponsive to treatment)

Initial Insult: What are potential sources of shock?

• Infection

• Trauma

• Blood loss

• Dehydration

• Hyperthermia

• Allergic reaction

• Poisoning

• SCI

• MI

• Burns

Each of these can lead to decreased cardiac output of blood circulation and begin the cascade toward a shock state.

Compensatory Stage—Systemic Actions: What does the body do?

• Tries to increase supply to meet demand

• Sympathetic nervous system activated

• Renin-Angiotensin-Aldosterone (RAA) system activated

• Glucocorticoids released

• Blood flow decreases to non-vital organs

Compensatory Stage: Clinical Manifestations

• Relatively normal BP

• Tachycardia

• Tachypnea

• Decreased PaCO2

• Diaphoresis

• Cool or clammy skin (except in certain distributive shocks)

• Decreased UOP

• Hypoactive bowel sounds

• Increased serum glucose

What are the 3 ways compensation is measured?

1. Mentation

2. Blood Pressure

3. Pulse Oxygenation

Progressive Stage—Systemic Actions: What does the body do?

• Overworked heart can’t meet body’s requirements, becomes ischemic and fails.

• Microcirculation regulation fails, leading to widespread capillary permeability.

• Prolonged tissue hypoxia leads to acidosis and cellular dysfunction.

Progressive Stage: Clinical Manifestations

• Hypotension (this is a late sign!)*

• Tachycardia/tachypnea

• Pulmonary edema/crackles

• Multiple Organ Dysfunction Syndrome (MODS)**

• Altered mental status

• AKI (oliguria/anuria)

• GI ischemia (ulcers/bloody diarrhea)

• Abnormal hemostasis (increased clotting times, bruises/petechiae)

*Low B/P indicates prolonged tissue ischemia and poor prognosis. We must intervene before this develops.

Multiple Organ Dysfunction Syndrome (MODS)

Changes in other systems besides the initial area…

• Respiratory P/F ratio < 250 w/o pneumonia, or < 200 w/ pneumonia

• MAP < 65 mmHg, SBP < 90 mmHg, or SBP decrease > 40 from baseline

• Creatinine > 2 mg/Dl

• UOP < 0.5 mL/kg/hr in 6 hours or < 400 mL in 24 hours.

• Bilirubin > 2 mg/dL

• Platelets <100,000/mm3

• INR > 1.5 or aPTT > 60 secs

• Lactate > 2 mmol/L

Irreversible Stage—Systemic Actions: What does the body do?

• MODS progresses to total organ failure

• Liver and kidneys fail, leading to significant metabolic acidosis

• BP stays low despite treatment

• Survival is unlikely

Irreversible Stage: Clinical Manifestations

• Significantly diminished cardiac output

• Pale, cyanotic, or yellowish skin

• Anuria

• Disseminated Intravascular Coagulation (DIC)

• Coma

• Death

Disseminated Intravascular Coagulation (DIC)

Definition: 

• Inappropriate coagulation occurs within the blood vessels

• Endothelial damage triggers clotting cascade and widespread clot formation

• Systemic over-consumption of clotting factors

• Clotting factors get used up and patient develops uncontrollable bleeding

Causes:

• Not fully understood, but it’s most often associated with sepsis, severe infections, trauma, cancer, and obstetric complications.

• Never the primary issue/disease; occurs in response to another disease process or injury.

Some assessment findings on a patient with DIC

• Blood leaking from around their IV sites

• Bloody noses occurring often

• Gums bleeding very easily

• Pink tinges in their urine

• Dark tarry stools

• Petechiae, ecchymosis, bruising

Clinical Findings in Shock (image)

Shock in General: Initial S/Sx

• Tachycardia

• Tachypnea/shortness of breath

• Decreased blood pressure

• Delayed capillary refill

• Pale, cyanotic, cool, or clammy skin

• Decreased urine output

• Weakness/lethargy

• Dizziness/lightheadedness

• Altered level of consciousness

What are the 4 types of Shock?

1. Hypovolemic

2. Cardiogenic

3. Obstructive

4. Distributive

Hypovolemic Shock

Decreased intravascular volume due to fluid loss.

Hypovolemic Shock: Causes

• External bleeding (trauma)

• Internal bleeding (GI or bleeding disorders)

• Burns

• Diarrhea/vomiting

• Dehydration

• Diuresis (such as via hemodialysis)

• Diabetes insipidus

poor skin turgor; thirst

In addition to the common signs and symptoms of shock, a patient in hypovolemic shock may exhibit ____ ____ ______ and ______.

Hypovolemic Shock: Primary Treatment Goals

• Find the source and stop it! (#1)

• Replace lost intravascular volume.

• Redistribute fluid volume.

Cardiogenic Shock: Causes

• Myocardial infarction (#1)

• Heart failure

• Dysrhythmias

• Coronary artery disease

• Cardiomegaly

• Myocarditis

• Cardiac valve disorders

• Drug toxicity

Cardiogenic Shock

Impairment or failure of the myocardium

crackles in lungs; chest pain

In addition to the common signs and symptoms of shock, a patient in cardiogenic shock may exhibit _______ __ _____ and _____ ____.

Cardiogenic Shock: Primary Treatment Goals

• Restore tissue perfusion (including to the heart itself)

• Improve cardiac contractility

• Manage other organ dysfunction

Obstructive Shock

Inability of the heart to fill properly

Obstructive Shock: Causes

• Pneumothorax

• Cardiac Tamponade

• Pulmonary embolism

• Pulmonary hypertension

• Aortic dissection

• Restrictive cardiomyopathy

• Tumors

• Sickle Cell Disease

• Chest or abdominal pain

• Distended jugular veins

• Muffled heat sounds (in cardiac tamponade)

• Unequal peripheral pulses (in aortic dissection)

In addition to the common signs and symptoms of shock, a patient in obstructive shock may exhibit:

Obstructive Shock: Primary Treatment Goal

Remove the obstruction!

Distributive Shock

Loss of sympathetic vasomotor tone/ “maldistribution of blood flow”

• is marked by systemic vasodilation that leads to increased capillary permeability and decreased blood flow to the brain, heart, and kidneys, causing damage to vital organs.

Distributive Shock: Causes

• Sepsis (#1)

• Neurological dysfunction

• Spinal cord injury (SCI)

• Anaphylaxis

• Hypersensitivity reaction

• Effects of medication

• Warm or flushed skin

  • Blood sits/hangs out in vessels longer than normal due to the widespread vasodilation…

• Other symptoms depend on the type of distributive shock the patient is experiencing

In addition to the common signs and symptoms of shock, a patient in distributive shock may exhibit:

Distributive Shock: Primary Treatment Goals

• Restore sympathetic tone

• Reverse the cause

• Support BP, pulse, and respirations

Types of Distributive Shock

• Neurogenic Shock

• Anaphylactic Shock

• Septic Shock

Neurogenic Shock

Is a life-threatening condition in which the central nervous system becomes damaged, leading to loss of vascular tone, widespread vasodilation, and dangerously low blood pressure.

• Pathophysiology:

  • Damage to the sympathetic nervous system allows the parasympathetic system to take over unopposed, often leading to bradycardia and worsening cardiac output.

  • Intravascular volume remain the same, but vasodilation and bradycardia combine to create hypoxic state.

• Causes:

  • Spinal cord injury (SCI) is the most common cause, but other causes can include:

    • Spinal anesthesia

    • Autoimmune disorders, such as Guillain-Barre Syndrome or Transverse Myelitis

    • Severe stroke

    • Meningitis

Anaphylactic Shock

Is a life-threatening condition in which the body’s immune system overreacts to an allergen, causing rashes, hives, itching, edema, and if left untreated, severe hypotension and airway obstruction.

• Pathophysiology:

  • Allergens bind to IgE, which triggers a massive release of histamine from mast cells and basophils. Histamine then causes widespread vasodilation and capillary permeability, leading to hypotension and loss of intravascular fluid.

  • Histamines, along with prostaglandins and leukotrienes, cause smooth muscle contraction in the airways, limiting ventilation.

• Causes:

  • Can be caused by any numbers of potential allergens, differing from person to person.

    • Medications (antibiotics, NSAIDs, contrast dye, ACE inhibitors)

    • Foods (nuts, fruits, shellfish, milk)

    • Insect stings (bees, wasps, hornets)

    • Latex

General Treatment of Shock: Early Identification

• ABCs

• Assess and report subtle changes:

  • LOC, UOP, skin tone, cap refill

• Vital Signs:

  • HR, RR, BP, MAP, Temp, SpO2

• Note and report concerning lab trends

• Initiate timely treatment

• Correct precipitating event

General Treatment of Shock: Establish Adequate Tissue Perfusion

• Promote adequate cardiac output:

  • Restore intravascular volume (fluid replacement)

  • Restore vasomotor tone (vasoactive medications)

• Ensure adequate oxygenation

General Treatment of Shock: Restore Normal Cell Function

• Establish proper acid-base balance

• Provide nutritional support

• Use of antacids, PPIs, or H2 antagonists to prevent GI injury

• Short-term, mild hyperglycemia may be acceptable (140-180)—Permissive hyperglycemia

  • We don’t want them in a hypoglycemic state because their body needs enough glucose to recover from this shock state.

General Treatment of Shock: Monitor Labs

• Lactate levels

• Complete metabolic panel (CMP)—for electrolyte balances

• Complete blood count (CBC)—for blood cell counts, including WBCs and platelets

• Blood cultures (if an infection is suspected)

• Base deficit and anion gap

• ABGs

• Signs of MODs**

General Treatment of Shock: Monitor Hemodynamics

• Blood pressure:

  • MAP is generally the guiding factor (desired > 65 mmHg)

• Continuous monitoring (VS/ECG)

• Other measurements as warranted (PP, CVP, etc.)

General Treatment of Shock: Provide Psychosocial Support

• Provide emotional support and help reduce anxiety

• Communication with the patient and family members, including education about condition

• Care plan may include end-of-life issues and/or grief counseling

General Treatment of Shock: Provide Advanced Supportive Care as Needed

May include intubation, ventilation, dialysis, etc.

General: Fluid Replacement

• Fluid Challenge: 500 to 1,000 mL bolus of isotonic crystalloid

  • One-time bolus to see how the patient does…

• Aggressive Fluid Resuscitation: 30 mL/kg (using IDEAL body weight)

  • Long continuous bolus

• Crystalloids for IV treatment of shock: (they’re more acidic!)

  • 0.9% saline (Normal Saline Solution)—super cheap!

  • Lactated Ringer’s (closely mirrors regular blood plasma)—more $$

*Rule of Thumb: The best fluid is the fluid that’s readily available!

Why isn’t D5W included on the list for IV fluid treatment for shock?

• D5W sitting in the bag is isotonic. The second it enters your body it’s not isotonic anymore because your body grabs onto the dextrose and uses it → converts it into sugar, and you’re just left with water, which is hypotonic.

General: Fluid Replacement (Alternative or Adjunctive)

The following solutions can be use in special cases of shock, especially when isotonic crystalloids are not available or sufficient. However, they are NOT first-line therapies.

• Hypertonic solution for IV fluid treatment of shock:

  • 3% Sodium Chloride (HSS)

    • Can only be administered once or else you’re going to give them hypernatremia.

    • Good for patients who have edema, increased ICP

• Colloids for IV fluid treatment of shock:

  • Albumin—large protein molecule

  • Dextran—large sugar molecule

**essentially pulling more fluids back into the vasculature

Fluid Replacement in Shock (image)

Complications of Fluid Replacement

Fluid administration can be a double-edged sword, both helpful and harmful. Close monitoring is essential to patient safety!

• We need to avoid under resuscitating and over resuscitating.

• Insufficient fluid replacement = higher incidence of morbidity and mortality due to lack of tissue perfusion.

• Excessive fluid administration = higher incidence of morbidity and mortality due to multiple side effects:

  • Acute Lung Injury (ALI)

    • It’s basically pulmonary edema because a bunch of fluid is dumped into the patient and the fluid goes the wrong way (alveoli instead of blood vasculature)-this is why a fluid challenge is done!

  • Abdominal Compartment Syndrome (ACS) and/or Intra-abdominal hypertension (IAH)

    • similar to ascites

  • Multiple Organ Dysfunction Syndrome (MODS)

  • Hypothermia* (fluid = room temp 72F; patient = 98.6F)

  • Acidosis*

General: Vasoactive Medications

• These medications are used when fluid therapy alone does not maintain MAP.

• Dosages are often based on patient weight and titrated to patient response (mcg/min or mcg/kg/min)

• Continuous monitoring is a must!

• These medications should be administered in a central line to avoid extravasation and tissue necrosis.

  • The meds can be started in a peripheral, but eventually need to be moved to central asap.

Select Vasoactive Agents Used in Treating Shock (image)

General: Nutritional Therapy

Catabolic process body breaks down lean muscle, so nutritional support is key.

• Enteral nutrition (via the GI tract) is preferred, but parenteral nutrition (via central line) can be given if the patient has GI impairment.

  • Caloric intake may start off slowly due to fragile state of body (~12.5 kCal/kg), but as the body recovers, caloric intake is slowly increased to ~20-25 kCal/kg.

    • low → up

  • Protein intake is important—Shock patients should receive roughly 1.3 g/kg/day rather than the usual recommendation of 0.8 g/kg/day.

    • up → down

  • Nutrition includes carbohydrate (dextrose), amino acids, lipids, electrolytes, vitamins, trace elements (zinc, copper, manganese, selenium, etc.), and water. ← (TPN)

• Administration of protective meds (antacids, H2 blockers, PPIs) are also important to prevent peptic ulcer formation.

Hypovolemic Shock: Potential Treatment Strategies

• Surgical intervention to control bleeding (#1)

• IV fluid resuscitation with isotonic crystalloids

• Blood transfusion (generally if Hgb < 7 g/dL)*—varies by institution

Hypovolemic Shock Treatment: Blood Transfusions

• Indicated in episodes of significant blood loss (Hgb < 7 g/dL).

• Generally administered over 2 to 4 hours, unless its emergent, where it is given as rapidly as possible (use large gauge IV).

  • Time permitting, patient’s blood should be typed and crossmatched.

  • In an emergency, type O negative blood may be used.

• Blood products may include whole blood, PRBCs, FFP, and platelets:

  • Rule of thumb: 1 unit of PRBCs should raise Hgb by 1 g/dL.

  • Severity of blood loss dictates how much the patient receives.

  • Massive transfusion protocol (MTPs) utilize varying ratios of PRBCs, FFP, and platelets (ex. 4:2:1, 2:1:1, or 1:1:1)

• Monitor for transfusion reactions*:

  • Vital signs (including temperature)

  • SOB, increased WOB, adventitious lung sounds

  • Altered mental status

  • Hives/rash, flushing, back pain (wheezing)

**Should any undesirable symptoms occur, the first thing to do is stop the infusion!

Cardiogenic Shock: Potential Treatment Strategies

• Thrombolytics, PCI, Stents, or CABG (for coronary artery occlusion)

• Medications (for dysrhythmias or electrolyte imbalances)

• Mechanical assistive devices (IABP, Impella, LVAD, or ECMO)

• Use fluids with extreme caution.

Obstructive Shock: Potential Treatment Strategies

• Fibrinolytics and DOACs (for PE)

• Surgical intervention (for PE, tumors, aortic dissection, or splenic sequestration)

• Needle decompression/chest tube (for pneumothorax)

• Pericardiocentesis (for cardiac tamponade)

• Medications (HTN meds for restricted cardiomyopathy or PH)

• Use fluids with extreme caution

  • It’s not a volume problem. The fluids are being obstructed/backed up and adding more fluids can back it up even more, so be cautious!

Distributive Shock: Neurogenic Shock—Potential Treatment Strategies

• Spinal stabilization and surgery

• Atropine (for bradycardia)

• DVT or VTE prophylaxis (LMWH)

Distributive Shock: Anaphylactic Shock—Potential Treatment Strategies

• Remove causative agent

• Medications (IM epinephrine 1:1000, B2 agonists, antihistamines, corticosteroids)

Hemodynamic Monitoring

The use of technology to provide quantitative information about a patient’s vascular capacity, fluid volume, pump effectiveness, and tissue perfusion.

• Gives us insights into the patient’s preload, after load, and/or SVR.

• Used to guide their plan of care.

Volumes, Pressures, & Saturations: Cardiac Output

• CO = Stroke volume (SV) x heart rate (HR)

• Normal range = 4-8 L/min

• Stroke volume is determined via echocardiography

Volumes, Pressures, & Saturations: Blood Pressure (BP)

Systolic blood pressure (SBP):

• Normal range = 100-140 mmHg

Diastolic blood pressure (DBP):

• Normal range = 60-90 mmHg

Usually measured via NIBP cuff readings, but arterial lines are most accurate.

Pulse Pressure (PP)

• PP = SBP - DBP

• Normal range = 40-60 mmHg

• Wide pulse pressure (< 60 mmHg) usually indicates arteriosclerosis, atherosclerosis, or aortic regurgitation.

• *Narrow pulse pressure (< 40 mmHg) can be an indicator of shock from decreased CO or increased SVR.*

Mean Arterial Pressure (MAP)

• MAP = DBP + 1/3(SBP - DBP)***

• Normal range = 70-100 mmHg

• Most accurate estimate of organ perfusion

• MAP below 65 mmHg in adults is associated with multi-organ failure

Volumes, Pressures, & Saturations: Saturation of Peripheral Oxygen (SpO2) and Saturation of Arterial Oxygen (SaO2)

Normal range = 95-100%

Volumes, Pressures, & Saturations: Central Venous Oxygen Saturation (ScvO2)

Normal range = 70-80%

Volumes, Pressures, & Saturations: End-Tidal Carbon Dioxide (EtCO2) and Arterial Pressure of Carbon Dioxide (PaCO2)

Normal range = 35-45 mmHg

Volumes, Pressures, & Saturations: Urine Output (UOP)

Normal range = > 0.5 mL/kg/hr

Volumes, Pressures, & Saturations: Central Venus Pressure (CVP)

• Normal range = 8-12 mmHg

• Used to estimate right arterial pressure and overall fluid status

  • Less than = dehydration or decreased fluid volume; Higher than = fluid overload

• If used to evaluate fluid needs, also consider BP, UOP, and HR

Ex: if giving a lot of fluids and its at a 4, fluids might be elsewhere → should probably listen to the lungs! (ALI)

Volumes, Pressures, & Saturations: Pulmonary Artery Pressure (PAP)

• Normal range = mPAP of 12-20 mmHg

• Used to estimate right ventricular function and assess for pulmonary hypertension (PH)

  • right side of the heart → lungs

  • How well is the right side of the heart doing its job?

Volumes, Pressures, & Saturations: Pulmonary Artery Wedge Pressure (PAWP)

• Normal range = mPAWP of 6-12 mmHg

• Used to estimate left atrial pressure (left atrium)

• Decreased in hypovolemic and distributive shock**

  • The left side of the heart has less blood in it

• Elevated in cardiogenic shock***

  • The heart can’t pump it out (blood is pooling)

• Increased or decreased in obstructive shock depending on the cause**

Examples of Invasive Hemodynamic Monitoring Equipment

• Central Venous Pressure Monitoring

• Pulmonary Artery Pressure Monitoring (Swan-Ganz catheter)

Sepsis: Prevalence and Vulnerable Populations

Each year in the U.S.:

• 1.7 million Americans develop sepsis

• Roughly 350,000 die from sepsis

• 1 in 3 patients who die in the hospital has sepsis

The most vulnerable people are:

• Older adults

• Infants

• Pregnant women

• Those with chronic conditions

• Immunocompromised patients

A form of distributive shock that is caused by a cascade of events:

• Initiation of immune system

• Inflammatory products activated

• Vasodilation and blood vessel permeability (decreased SVR)

• Impaired oxygen exchange

• Trigged coagulation products

• Developments of organ failure, ARDS, DIC

Sepsis is …

What are the most common HAIs?

• Catheter Associated Urinary Tract Infection (CAUTI)

• Central Line Associated Blood Stream Infection (CLABSI)

• Ventilator Associated Pneumonia (VAP)

• Surgical Site Infection (SSI)

• Clostridium Difficile Infection (CDI)

Sepsis: Patient Assessment

• Septic patients can present in different ways.

• A thorough assessment is key.

• Make sure to pay attention to labs!

Systemic Inflammatory Response Syndrome (SIRS)

SIRS criteria consists of:

• Heart rate > 90 bpm

• Respiratory rate > 20 rpm

• Temperature > 38.8 C (100.9 F) or < 36.0 C (96.8 F)

• WBC > 12,000/mm3 or < 4,000/mm3 or > 10% bands

• Altered Mental Status

• Glucose > 140 mg/dL in absence of diabetes

**2 or more and you’re positive for SIRS, but not everyone who is positive for SIRS is septic.

SIRS: What are bands?

They are immature WBCs.

Ex: someone’s WBCs went from 5,000 to 9,000—which is WNL, but if their bands are 17%, that means that their body had to ramp up production of WBCs because they have an acute infection.

source of infection; 2

A patient needs to already have a ______ __ _________ along with _ or more of the SIRS Criteria to be considered to have sepsis.

Not everyone who is positive for SIRS is septic. What are some examples?

• A patient having an asthma exacerbation.

• A patient experiencing a panic attack.

• A patient suffering from heat exhaustion.

bacteremia

The biggest source of sepsis is __________.

Sepsis: Nursing Responsibilities

• Recognize early

• Treat promptly:

  • Follow the Sepsis Bundle**

  • Fluid Replacement

  • Pharmacologic

• Astute ongoing assessment

The Surviving Sepsis Campaign (SSC)

Was launched in 2002 as a collaborative initiative of the European Society of Intensive Care Medium (ESICM), the International Sepsis Forum (ISF), and the Society of Critical Care Medicine (SCCM). It is updated every 4 years.

~Sepsis Bundle

Sepsis Nursing Responsibilities Soap Box

• Monitor your patient for trends and report significant changes!

  • Do not just wait for a parameter to cross a predetermined threshold.

Nursing is about anticipation and preemptive action; addressing potential problems before they become actual problems.

• If a patient’s SBP was 130, but now is 95, that’s concerning. If their potassium was 3.8, but now it’s 5.0, that’s concerning. If a patient’s WBC was 5.2, but now it’s 10.2, that’s concerning.

Sepsis Progression

• Infection

• Sepsis (Compensatory)

• Severe Sepsis (Progressive)

• Septic Shock (Irreversible)

• Death or Recovery

Sepsis: Infection Stage

Initial Insult

Infectious Source

• Pneumonia

• UTI Wounds

• Gastrointestinal

• Cellulitis

Sepsis: Sepsis Stage

Compensatory Stage

2 SIRS Criteria

• Temperature

• Heart rate

• Respiratory rate

• WBC

• AMS

• Hyperglycemia

Sepsis: Severe Sepsis Stage

Progressive Stage

Organ Dysfunction

• Bilirubin

• Platelets

• Hypotension

• AKI

• Respiratory failure

• INR/PTT

• Lactic acidosis

Sepsis: Septic Shock Stage

Irreversible Stage

Presence of either:

• Lactic acidosis

• Persistent hypotension

*DIC most likely present

Severe Sepsis: Signs of Organ Dysfunction

• Respiratory P/F ratio < 250 w/o pneumonia, or < 200 w/ pneumonia

• MAP < 65 mmHg, SBP < 90 mmHg, or SBP decrease > 40 from baseline

• Creatinine > 2 mg/Dl

• UOP < 0.5 mL/kg/hr in 6 hours or < 400 mL in 24 hours.

• Bilirubin > 2 mg/dL

• Platelets <100,000/mm3

• INR > 1.5 or aPTT > 60 secs

• Lactate > 2 mmol/L

The Role of Lactate

• Lactate is an indicator of global tissue hypoxia.

• Increased lactate levels are associated with increased morbidity and mortality.

• Lactate levels are used to guide resuscitation efforts.

persistent hypotension; lactic acidosis

Septic shock is classified by __________ ___________ and/or ______ ________ (lactate > 4 mmol/L)

Sepsis 1-Hour Bundle

Our Priorities:

1. Obtain lactate level

2. Obtain blood cultures x2 (from two different sites, aerobic + anaerobic—so technically 4)

3. Administer fluids

4. Administer broad spectrum antibiotics

5. Administer vasopressors if needed

6. Constantly reassess

Sepsis: Broad Spectrum Antibiotics

• Multiple antibiotics can be used; check for compatibility.

• Delay in antibiotic administration is linked to increased mortality.

Administer IM, PO, or IO

If you can’t get IV access on your patient for broad spectrum antibiotics…

Broad Spectrum Antibiotics Compatibility

Incompatible medications can do many things when mixed:

• Antagonizing (nullifying) effects

• Precipitation (crystallization)

• Consistency changes

• Gas production, all of which are harmful to our patients!

Always check for compatibility within your documentation software. When in doubt, call the pharmacist!

Sepsis: Fluid Resuscitation

30 cc/kg of isotonic crystalloid solution

• Normal Saline

• Lactated Ringers

Calculation should be made using Ideal Body Weight (IBW)

FALSE! A history of heart failure does not exempt a patient from receiving a fluid bolus! Careful monitoring is required!

T/F: A history of heart failure exempts a patient from receiving a fluid bolus because it’s too dangerous.

Sepsis: Persistent Hypotension and Vasopressors

IF:

• BP is measured every 15 minutes post-fluids, so…

• Two consecutive low BP readings indicates persistent hypotension…

THEN:

• Vasopressors should be started without delay!

Norepinephrine (Levophed)

What is our first-line vasopressor in septic shock?

Persistent Hypotension and Vasopressors: Norepinephrine Dose + Receptor

Dose: 0.1-0.5 mcg/kg/min, titrate to effect

Receptor: a1 & b1