case study #2 pp

Septic shock on pressor support

Megan Malek

BHS Dietetic Intern

Case Study #2

Overview

•  Stages of Sepsis

•  Pressor Support

•  Nutrition & Septic Shock

•  Associated Research Articles

•  Introduce Patient

•  Review Patient Care

•  Summary & Conclusion

Stages of Sepsis

Sepsis Severe Sepsis

Septic Shock

Sepsis1

Immune response to a severe infection that has spread via the bloodstream

•  Fever >101.3°F •  Hypothermia <96.8°F •  Heart rate > 90 beats/min •  Tachypnea (rapid breathing) •  Altered mental status •  Edema •  Hyperglycemia

•  Inflammatory variables •  Hemodynamic variables •  Hypotension

•  Organ dysfunction variables •  Tissue-perfusion variables

Symptoms: (+infection plus ≥ 1 of the following)

Definition:

Severe Sepsis1

Definition:

Sepsis complicated by tissue hypoperfusion or acute organ dysfunction

Symptoms:

•  Sepsis-induced hypotension •  Elevated lactate (>0.5-1

mmol/L) •  Low urine output (<0.5mL/

kg/hr for >2hrs depsite fluid replacement)

•  Acute lung injury

•  Creatinine >2.0 mg/dL •  Bilirubin >2 mg/dL •  Platelet Count <100,000 •  Coagulopathy

Septic Shock1,2

Definition:

Severe sepsis complicated by either hypotension that is resistant to fluid replacement or by hyperlactatemia

Symptoms:

•  Any symptom of severe sepsis

•  Hypotension

•  Cold skin

Etiology3

Sepsis can be caused by any type of infection-bacterial, fungal, or viral

Most Common:

•  Pneumonia*

•  Kidney infection

•  Abdominal infection

•  Bacteremia

Risk Factors3

Risk Factors

•  Age- Infants & Elderly

•  Compromised immune system

•  Preexisting illness, injury, or wound

•  Presence of invasive device (intravenous catheter or intubation)

Prevalence & Prognosis

Prevalence3

Incidence of sepsis appears to be increasing in the US, possibly due to:

•  Aging population

•  Drug-resistant bacteria

•  Weakened immune systems

Prognosis4

•  Mortality for septic shock is ~50%

•  Higher risk for future infections

Treatments1

What are vasopressors?1

•  Vasopressors: Compounds that raise reduced blood pressure via vasoconstriction

•  Inotropes: Compounds that increase cardiac contractility.

•  Many drugs have both vasopressor & inotropic effects

Nutrition & pressors5

•  ASPEN & SCCM suggest withholding EN in hemodynamically unstable patients on “high-dose” catecholamine therapy until stable, while advocating for the cautious use of EN in patients on “low-dose” catecholamines. •  However, the definition of “low-dose” is not well defined.

•  BHS guidelines: •  Start feeds when pressors are ≤0.1 mcg/kg/min

Terminology6

•  Splanchnic circulation- Celiac artery (liver, stomach, spleen, pancreas); Superior mesenteric artery (pancreas, SI, colon); Inferior mesenteric artery (colon)

Nutrition & pressors5

•  In hemodynamically unstable patients, enteral nutrition will increase splanchnic oxygen demand, rather than increase cardiac output

•  If the body is not able to meet this demandà splanchnic ischemia ensues

•  Other complications include: small bowel necrosis (abdominal pain, distention, high NG output, ileus)à mortality

Vasoactive agents4,5 Drug Recep

tor Typical Dosing mcg/kg/min

Pathophysiology Clinical Uses GI Effects

Epinephrine α β1 β2

Dose: 0.05 - 0.5 Max: 1

Arterial vasoconstriction, contracts heart, peripheral vasodilation

Shock, cardiac arrest, anaphylaxis, heart block, bradycardia

ê splanchnic blood flow

Norepinephrine (Levophed)

α* β1

Dose: 0.05 - 1.5 Max: 3

Arterial vasoconstriction, contract heart

Septic shock é gastric pH, é splanchnic blood flow, êmucosal blood flow

Dopamine Dopa α β1

Dose: 5 – 20 Max: 50

Vasodilation in renal & mesenteric beds, arterial vasoconstriction, contracts heart

Septic shock, bradycatdia

ê pH, éoxygen delivery, precapillary vasoconstriction, êmucosal blood flow

Phenylephrine α Dose: 0.4 – 9.1 Arterial vasoconstriction Septic shock, hypotension

Dobutamine β1 Dose: 2.5 Max: 40

Contracts heart Heart failure êGI mucosal blood flow, égastric intramucosal pH

Vasopressin (ADH)

V1 Dose: 0.01 – 0.04 U/min

Constricts vascular smooth muscle & increases uptake of catecholamines

Hypotension, septic shock, GI bleed, esophageal varices, diabetes insipidus, ê pressor needs

éintestinal vasoconstriction

Tolerability & Safety of Enteral Nutrition in Critically patients receiving Intravenous Vasopressor therapy7 (Mancl & Muzevich, 2013)

Obj:

Evaluate the tolerability & safety of EN in critically ill patients receiving IV vasopressor therapy

Methods:

Retrospective medical record review was conducted in an urban academic medical center 259 adult ICU patients who received concomitant EN & IV vasopressor

therapy for ≥1 hr.

(EN tolerance was defined as an absence of gastric residuals ≥300 mL, emesis, positive finding on abdominal imaging, and evidence of bowel ischemia/

perforation.)

Vasopressor dosage was converted to norepinephrine equivalents using this formula: norepinephrine equivalents= [norepinephrine (mcg/min)] + dopamine

(mcg/kg/min) ÷ 2] + [epinephrine (mcg/min)] + phenylephrine (mcg/min) ÷ 10] + [vasopressin (units/h x 8.33]

Tolerability & Safety of Enteral Nutrition in Critically patients receiving Intravenous

Vasopressor therapy7 (Mancl & Muzevich, 2013)

Results:

259 patients received 346 episodes of concomitant EN & IV vasopressor therapy with a 74.9% overall tolerability. Adverse events included:

•  Rising serum lactate (30.6%)

•  Elevated gastric residuals (14.5%)

•  Emesis (9%)

•  + findings on kidney/ureter/bladder imaging (4.3%)

•  Bowel ischemia/perforation (0.9%)

Tolerability & Safety of Enteral Nutrition in Critically patients receiving Intravenous

Vasopressor therapy7 (Mancl & Muzevich, 2013)

Results cont’d:

Patients who tolerated EN received a lower max norepinephrine equivalent dose compared with those who

did not tolerate EN (12.5 vs 19.4 mcg/min, P=.0009)

Patients who never prescribed vasopressin during the overlap periods were more likely to tolerate EN compared to those who received vasopressin (77.9% vs 58.9%,P=.0027) and

likewise for dopamine (77.6% vs 63.8%, P=.018)

Application to patient

Patient Overview

•  Pseudo-name: Ms. A

•  62 y.o. female

•  Caucasian

•  Single

•  Admit c/o: generalized weakness

•  Initial Dx: Septic shock 2/2 PNA and/or + UTI, ARF

•  LOS: 16 days

Patient history

•  Adolescence-onset paranoid schizophreniaà placed in state hospital at age 20 for most of lifeà moved around to numerous LTACs, shelters, and sister’s home

•  All information obtained from current boarding home director

•  Pt is “difficult to manage, must be watched very closely, poor boundaries, continuously tried to escape, will eat out trash cans, very aggressive at times, not suicidal, however quite paranoid”

•  Pmh: CAD, CHF, HTN, hypothyroidism, DMT2, CKD, smoker

•  Previous diet: Regular

Anthropometrics

•  Ht: 5’10 (70 in)

•  Wt: 268 lb (122kg)

•  IBW: 150 lb (68 kg)

•  %IBW: 180

•  ABW: 180lb (82kg)

•  BMI: 38.4 - Obese

Review of events prior to visit

•  1/27-PCU:+ UTI, hypotension (86/40) •  Started on Rocephin antibiotic

•  Fluids: NS @ 100ml/hr

•  Chest X-rayà RLL infiltrate PNAà 2L n/c

•  Choked on burger at dinner à NPO

•  1/28-2:20am: vomited à aspirated à developed bradycardia àasystolic àV-tach à 9 min code à CPR started & epinephrine given à 2 DC countershocks & bolus of Amiodarone à returned to a perfusing heart rhythm & given atropineà placed a central line & started Dopamine (2mcg/kg/min) à intubated & placed on a vent

Early nutrition & outcomes of critically patients treated with vasopressors and

mechanical ventilation8 (Khalid et al, 2010)

Obj:

Determine the effect of early EN on the outcome of critically ill patients who are hemodynamically unstable.

Method:

1174 patients were identified who required mechanical ventilation for more than 2 days and were treated with

vasopressors. Patients were divided into 2 groups: those who received EN within 48 hrs of starting mechanical ventilation (n=707) & those who received EN after 48 hrs (n=467). End

points were ICU & hospital mortality.

Results:

ICU mortality was lower in the early EN group compared to the late group (22.5% vs 28.3%, P=.03), and likewise for overall

hospital mortality (33.8% vs 43.9%, P=<.001).

However, there was no effect on vent-free days, days in ICU, or vent-associated PNA.

Early nutrition & outcomes of critically patients treated with vasopressors and

mechanical ventilation8 (Khalid et al, 2010)

NCP Overview

•  4 total visits

•  Initial assessment (1/30)

•  2 F/U (2/4, 2/6)

•  End of NEB Rotation

•  Last RD F/U (2/11)

Initial Visit Assessment (1/30) s/p cardiac arrest, septic shock 2/2 PNA-on low pressors tappering off, ARF,

Acute Resp fail 2/2 asp PNA-on vent support, sev schiczo-mild sedation

Current Diet/Appetite

NPO-OGT for suction-d/c soon, placing dbhf. Failed bedside SS 1/28.

Hydration NS @ 50; generalized edema 2+/3+; I/O: 2,635/3,450

Estimated needs (VENT SUPPORT)

2123 kcals (PENN st) 82-98g protein (1-1.2g/kg ABW) 2050 ml fluid (25 ml/kg ABW)

Regimen provides 1200 ml fluid

Nutrition Status Severe

Nutrition Dx Inadequate energy intake

Etiology Respiratory failure

Symptoms NPO, vent support

Rec Nepro @ goal rate 50 ml/hr-initiate at 30 ml/hr & titrate as tolerated. Regimen will provide 2160 kcals, 97g pro, 870ml. When IVF d/c flush 200ml q 4hrs (2070ml total). If K+ <4.5, will switch to less concentrated formula.

Outcomes Pt to meet >75% of ENN within 24-48 hours, Maintain LBM, promote gradual wt loss toward IBW

F/U 5 days

Initial Visit- Labs & Meds

Significant labs

1/30

Glucose 134 (H)

BUN 29 (H)

Na+2 134 (L)

K+ 6.1 & 5.2 (HH, 1/29); 4.9 (1/30)

CO2 20 (L)

Ca+2 8 (L)

Albumin 1.9 (L)

GFR 49 (L)

Mag 2.0

Lactate 2.4 (H)

TSH 5.56 (H)

Significant Meds 1/30

Usage Dosage

Norepinephrine

Pressor .02 mcg/kg/min

Fentanyl Narcotic 5 mcg/kg/hr

Klonopin Lorazepam Trazodone

Panic disorders 1mg 2mg 100mg

Colace Senna

Laxative 100mg 34.4mg

Pepcid Reflux 20mg

Arixtra Anti-thrombotic

2.5mg

Lasix Diuretic 40mg

Zosyn Antibiotic 2.25g

2nd Visit Assessment (2/4) F/U. Pt extubated-on Cipap, off pressors, not following commands but able

to communicate somewhat, yells out, restrained. Last BM 2/3

Current Diet/Appetite Continues on Nepro @ 50 (goal rate). RN gave trial sips of water today-pt tolerated.

Hydration NS @ 50; generalized edema 2+; I/O: 2,730/2,750

Estimated needs 1850-2100 kcals (23-26 kcals/kg ABW) 82-98g protein (1-1.2g/kg ABW) 2050 ml fluid (25 ml/kg ABW)

Regimen provides 2160 kcals 97g pro 2070 ml (870ml TF, 1200ml IVF)


Nutrition Dx Inadequate PO food intake

Etiology Swallowing difficulty, confused/disoriented

Symptoms Enteral intake

Rec Continuing current TF regimen. Rec swallow eval when appropriate.

Outcomes Pt to continue meeting >75% of ENN from EN.

F/U 5 days

2nd Visit- Labs & Meds

Significant labs

2/4

Glucose 175 (H)

K+ 4

Phos 4.8 (H)

Albumin 1.8 (L)

Mag 1.5 (L)

WBC 11.4 (H)


Usage Dosage

Klonopin Trazodone Trileptal Valporic acid

Panic disorders 0.5mg 50mg 300mg 500mg

Ambien Sedative 5mg

Pepcid Reflux 20mg


2.5mg

Lasix Diuretic 40mg


Mag sulf 1% Fluid balance 2g

3rd Visit Assessment (2/6) F/U- On Bipap, restrained d/t aggressive behavior overnight. 10-day zosyn d/c’d

today for asp PNA. DNR.

Current Diet/Appetite

TF changed per MD to Glucerna 1.0 @ 50 (2/5). No consult sent. Pt tolerating TF-no residuals. Last BM 2/6. R heel intact blister & R sole skin tear

Hydration NS @ 50; generalized edema 2+; I/O: 2,250/2,100

Estimated needs 1850-2100 kcals (23-26 kcals/kg ABW) 120-125g protein (1.5g/kg ABW) 2050 ml fluid (25 ml/kg ABW)

Current regimen provides

1200 kcals 50g pro 2224ml (1024 ml TF, 1200ml IVF)


Nutrition Dx Inadequate EN nutrition

Etiology Current regimen

Symptoms Estimated energy needs

Rec Glucerna 1.2 @ goal rate of 70 ml/hr + 1 pk Prostat daily to provide 2116 kcals, 116g pro, 1352 ml. When IVF d/c, flush 175ml q 6hrs (2050ml total). Rec ordering PAB w/ AM labs.

Outcomes Pt to meet >75% of ENN from EN

F/U 5 days

3rd Visit- Labs & Meds

Significant labs

2/6

Glucose 93, 138, 133, 115, 123, 161, 110, 169

K+ 4.1

Phos 3.3

Albumin 1.8 (L)

CO2 39 (H)

WBC 11.78 (H)


Usage Dosage

Klonopin Trileptal Valporic acid Geodon

Panic disorders 0.5mg 300mg 500mg 10mg

Colace Laxative 100mg

Pepcid Reflux 20mg


2.5mg

Lasix Diuretic 20mg

Mag sulf 1% Fluid balance 1g


4th RD Visit & Endpoint

•  2/11: Moved to PCUà passed MBSS à tolerating regular diet w/ >70% intake

•  2/12: Passed away •  Cause of death: septic shock, acute hypercapnic respiratory

failure, atelectasis of the lung

Summary

•  Is one vasopressor better than another? •  While some researchers argue one is better than another;

the decision should be situational based on the therapeutic strategy chosen.4

•  When is it safe to feed patients on vasopressors? •  When pressors are ≤0.1 mcg/kg/min •  Optimally within 48 hours post intubation8

•  More research needs to be done on timing, duration, and amount of enteral vs parental nutrition with vasopressor therapy in critically ill patients.

Thank you!!

REferences 1. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39(2):165-228.

2. Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med. 2013;369(9):840-851.

3. Disease and Conditions: Sepsis. Mayo Clinic Website. http://www.mayoclinic.org/diseases-conditions/sepsis/basics/symptoms/con-20031900. Published July 23, 2014. Accessed April 4, 2015.

4. Hollenberg SM. Vasopressor support in septic shock. CHEST Journal. 2007;132(5):1678-1687.

5. Allen JM. Vasoactive substances and their effects on nutrition in the critically ill patient. Nutr Clin Pract. 2012;27(3):335-339.

6. Gelman S, Mushlin PS. Catecholamine-induced changes in the splanchnic circulation affecting systemic hemodynamics. Anesthesiology. 2004;100(2):434-439.

7. Mancl EE, Muzevich KM. Tolerability and safety of enteral nutrition in critically ill patients receiving intravenous vasopressor therapy. JPEN J Parenter Enteral Nutr. 2013;37(5):641-651.

8. Khalid I, Doshi P, DiGiovine B. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care. 2010;19(3):261-268.

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