Sepsis, SIRS, Shock, MODS

The characteristic signs of neurogenic shock are

- Bradycardia - HYPOtension

Septic Shock manifests with

- DEC systemic vascular resistance (SVR) - INC CO

Hemodynamic monitoring in cariogenic shock will reveal

- INC PAWP - DEC CO

Hypovolemic shock is characterized by

- INC SVR - DEC CO - DEC PAWP

What are the jobs of the septic six in the prevention of Sepsis?

- blood cultures - measure lactate levels - urine output - fluid resuscitation - oxygenation - antibiotics - as long as they are called upon within one hour of symptoms.

What is the 2012 Recommendations for the Initial Resuscitation during the 1st 6 hours?

1. CVP: 8-12 mmHg 2. MAP: >/ 65 mmHg 3. UO: >/ 0.5 mL/ kg/ hr 4. ScVO: >/ 70%

SIRS

2 or more: - Temp <36 or > 38 c - HR: >90 - RR: > 20 - WBC: <>12,000 mmol/L or <4000 mmol/L

A patient on a med surg unit is suspected of having SIRS. What would be the identifying criteria for a diagnosis of SIRS? A. Heart Rate is 120 bpm with a respiratory rate of 34 B. Temperature is 35 C with a heart rate of 65 bpm C. Heart rate is 120 bpm with a respiratory rate of 12 D. WBC of 2300 with a PaCO2 of 34 mmHg

A. Heart Rate is 120 bpm with a respiratory rate of 34 Rationale: SIRS can be diagnosed when two or more of the following are present: 1. HR >90 bpm 2. Temperature of <36 C or >38 C 3. Hyperventilation (>20 breaths per minute) or a blood gas PaCO <32 mmHg 4. WBC <4000 or >12000 or the presence of >10% immature neutrophils

In addition to a positive SOFA score, you realize the following clinical findings indicate organ dysfunction caused by Sepsis: (SATA) A. Hypotension despite fluid resuscitation B. Fever C. Presence of UTI D. Serum Lactate level >2 mmol/L E. Positive SIRS score

A. Hypotension despite fluid resuscitation D. Serum Lactate Level >2 mmol/L Rationale: - Severe sepsis = sepsis + organ dysfunction - Septic shock = severe sepsis + hypotension ( despite fluid resuscitation) + hypo perfusion. - Elevated lactate indicates anaerobic metabolism at the cellular level as a result of organ dysfunction. - Fever (B), UTI (C), and + SIRS (E) score can all be present without organ dysfunction

In the compensatory stage of hypovolemic shock, to what organs does blood flow decrease after the sympathetic nervous system activates the alpha adrenergic stimulation (select all that apply ) A. skin B. Brain C. Heart D. Kidneys E, Gastrointestinal tract

A. Skin D. Kidneys E. Gastrointestinal tract Rationale: After SNS activation of vasoconstriction, blood flow to nonmetal organs, such as skin, kidneys, and the gastrointestinal (GI) tract is diverted or shunted to the most essential organs of the heart and brain. The patient will feel cool and clammy , the renin-angiotensin - aldosterone system will be activated, and the patient may develop a paralytic ileum.

Sepsis

SIRS + a culture- documented infection

Severe Sepsis

Sepsis + organ dysfunction

Septic Shock

Severe sepsis + hypotension (despite fluid resuscitation) + hypo perfusion

Your PT is transferred from the med surg floor to the ICU due to refractory hypotension. When she arrives to the ICU, she is placed on a Vasopressor. Which vasopressor is indicated as the first choice in the "surviving Sepsis campaign?" A. vasopressin B. norepinephrine C. Phenylephrine D. Epinephrine

B. Norepinephrine Rationale: - Norepinephrine is the first choice vasopressor as recommended by the surviving sepsis campaign - Vasopressin or epinephrine may be added to norepinephrine to raise the MAP to target (65 mmHg). - phenylephrine is often started initially because it can be administered peripherally, however it is NOT the first choice vasopressor as recommended by protocol.

A patient with massive trauma and possible spinal cord injury is admitted to the ED. Which findings by the nurse will help confirm a diagnosis of neurogenic shock? A. Cool, clammy skin B. Inspiratory Crackles C. Apical heart rate 48 Beats/ Min Temperature 101.2 ( 38.4C)

C. Apical Heart Rate of 48beats/min. Rationale: Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock. Inspiratory crackles would be ID of cariogenic shock Cool, clammy skin would be more indicative of cariogenic or obstructive shock Temperature of 101.2 would be a sign of septic shock or distributive shock

Your 41 yo, female PT presents to the ER with C/O Acute onset N/V and Right Flank Pain VS: Lab Values: 1. Temp: 39 C 1. pH: 7.35 2. HR: 103 bpm 2. PaCO2: 30 3. RR: 21 BPM. 3. PaO2: 109 on RA 4. SpO2: 95% on RA 4. Na: 138 5. BP: 110/78. 5. K+: 4.6 6. WBC: 11000 cells/mm3 Based on this information, you determine your patient has: A. Septic Shock B. Sepsis C. SIRS D. Severe Sepsis E. MODS

C. SIRS Rationale: SIRS can be diagnosed when two or more of the following are present: 1) HR > 90 BPM 2) Body Temp <36 c or > 38 c 3) Hyperventilation (high resp rate) >20 breaths per minute, OR on blood gas, a PaCO2 < 32 mmHg 4) WBC count <4000 cells/mm3 or > 12000 cells/mm3, or the presence of greater than 10% immatures neutrophils (bands) A. Septic shock = severe sepsis + hypotension (despite fluid resuscitation) + hypo perfusion B. Sepsis= SIRS + a culture- documented infection D. Severe Sepsis = sepsis + organ dysfunction E. MODS = Failure of 2 or more organ systems.

As the body continues to try to compensate for hypovolemic shock, there is increased angiotensin II from the activation of the renin- angiotensin - aldosterone system. What physiologic change occurs related to the increased angiotensin II? A. vasodilation B. dec BP and CO C. Aldosterone release results in sodium and water excretion D. Antidiuretic hormone (ADH) release increases water absorption

D. Antidiuretic hormone (ADH release increases water reabsorption. Rationale; angiotensin II vasoconstrictor both arteries and veins, which increase BP. It stimulates aldosterone release from the adrenal cortex, which results in sodium and water reabsorption and potassium excretion by the kidneys. The increased sodium raises serum osmolality and stimulates the pituitary gland to release ADH, which increases water reabsorption, which further increases blood volume, leading to an increase in BP and CO

Your PT is admitted to the hospital and transferred to a med surg floor for further evaluation. Vs: 1. Temp: 39 C 2. HR 115 bpm 3. RR: 24 BPM 4. SpO2: 95% on RA 5. BP: 95/56 Neuro Assess: - PT appears lethargic, opens eyes to verbal stimulation - PT is oriented to person and place only - PT is able to follow commands Based on this info, you determine your PT has developed A. SIRS B. Septic Shock C. Sepsis D. Severe sepsis

D. Severe Sepsis -> Glasgow Coma Score 13 According to your assessment, your PT has developed severe sepsis (sepsis + markers of organ dysfunction) determined by a SOFA score >/ 2 of the following clinical criteria: 1. Hypotension: SBP /< 100 mmHg 2. Altered mental status (GCS <15) 3. Tachypnea: RR >/ 22

A PT can NOT have SIRS withOUT Sepsis 1. True 2. False

FALSE Rationale: SIRS is a systemic inflammatory response to a variety of insults. A patient may have SIRS withOUT sepsis. Examples include: - mechanical tissue trauma (burns, crash injuries) - abscess formation (diverticulitis) - Ischemic or necrotic tissue (pancreatitis, vascular dz, MI)

MODS

Failure of 2 or more organ systems