shock. shock, sepsis, and mods complex disorders affect body in multifaceted dimensions involve...
TRANSCRIPT
![Page 1: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/1.jpg)
Shock
![Page 2: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/2.jpg)
Shock, Sepsis, and MODS
• Complex disorders • Affect body in multifaceted dimensions• Involve breakdown in oxygen supply and demand• Begin with localized tissue damage, may progress to
organ failure and death
![Page 3: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/3.jpg)
Cellular Respiration (1 of 3)
• Produces ATP• Involves three parts
– Glycolysis (occurs in both aerobic and anaerobic environments)
– Citric acid cycle (aerobic environment)– Electron transport chain (aerobic environment)
![Page 4: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/4.jpg)
Cellular Respiration (2 of 3)
![Page 5: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/5.jpg)
Cellular Respiration (3 of 3)
![Page 6: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/6.jpg)
Aerobic Metabolism
• Mitochondria utilize glucose, amino acids, and fatty acids combined with oxygen and ADP to produce:– ATP– Carbon dioxide– Water– Heat
![Page 7: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/7.jpg)
Anaerobic Metabolism
• Alternative pathway converts glucose to pyruvic acid and produces ATP
• Less ATP results
![Page 8: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/8.jpg)
Microcirculation and the Cell (1 of 3)
• Understanding the imbalance between oxygen supply and demand is critical.
• Microcirculation– Nexus between arterioles and venules consisting of the
capillaries– “Crash site” hidden deep at cellular level
![Page 9: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/9.jpg)
Microcirculation and the Cell (2 of 3)
• Oxygen transport and utilization– Homeostatis requires supply of oxygen sufficient to meet
the body’s cellular demands– Cardiovascular system delivers oxygen-rich blood to the
tissues– When the oxygen-bound hemoglobin reaches the
capillaries, oxygen is released from the hemoglobin to the cells in exchange for cellular waste.
![Page 10: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/10.jpg)
Microcirculation and the Cell (3 of 3)
![Page 11: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/11.jpg)
Four Stages of Shock (1 of 5)
• Initial stage– Blood flow to microcirculatory beds decreases.– Hypoxia develops.– Cells cannot maintain homeostasis.
• Compensatory stage– Body uses physiologic mechanisms to maintain cellular
homeostasis
![Page 12: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/12.jpg)
Four Stages of Shock (2 of 5)
![Page 13: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/13.jpg)
Four Stages of Shock (3 of 5)
![Page 14: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/14.jpg)
Four Stages of Shock (4 of 5)
![Page 15: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/15.jpg)
Four Stages of Shock (5 of 5)
• Progressive (decompensatory) stage– Occurs when underlying cause untreated– Life-threatening emergency– Requires early fluid resuscitation and vasopressor
support
• Refractory or irreversible stage– Failure of compensatory mechanisms – Tissues and organs die– Highest mortality rate
![Page 16: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/16.jpg)
Effects of Shock on the Body
![Page 17: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/17.jpg)
Two Types of MODS
• Primary– Results from direct insult (trauma)
• Secondary– More progressive insult to organs– More common– Earliest affected organs: brain, kidneys, liver, adrenal
glands, heart
![Page 18: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/18.jpg)
Organs Affected by Hypoperfusion
![Page 19: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/19.jpg)
Classification of Shock (1 of 6)
• Cardiogenic shock– Failure of heart to pump blood effectively– Numerous intrinsic causes; left ventricular failure due to
MI most common– Numerous extrinsic causes (examples: pericardial
tamponade, pneumothorax)– Manifestations vary depending on underlying cause
![Page 20: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/20.jpg)
Classification of Shock (2 of 6)
![Page 21: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/21.jpg)
Classification of Shock (3 of 6)
• Hypovolemic shock– Low circulating blood volume results in hypotension
with blood or fluid lost or displaced internally or externally.
– Various associated conditions (examples: fever, vomiting, diarrhea, burns)
– Signs and symptoms include tachycardia, hypotension, confusion
![Page 22: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/22.jpg)
Classification of Shock (4 of 6)
![Page 23: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/23.jpg)
Classification of Shock (5 of 6)
• Distributive shock includes:– Neurogenic shock: Loss of sympathetic tone caused by
trauma, drugs– Anaphylactic shock: Life-threatening allergic reaction
caused by numerous antigens; includes true anaphylaxis and anaphylactoid reaction
– SIRS, sepsis, and septic shock: Progressive disease caused by infection
![Page 24: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/24.jpg)
Classification of Shock (6 of 6)
![Page 25: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/25.jpg)
SIRS
![Page 26: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/26.jpg)
Sepsis Definitions (1 of 2)
• Sepsis – Mild systemic response to (bacterial) infection or
suspected infection
• Severe sepsis – Sepsis with diagnosis of infection and dysfunction of
one organ minimum
• Septic shock– Hemodynamic instability with SIRS
![Page 27: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/27.jpg)
Sepsis Definitions (2 of 2)
![Page 28: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/28.jpg)
Sepsis Epidemiology (1 of 2)
• Prevalence increasing– 1.1 million new cases by 2020 anticipated by CDC
• All populations and age groups affected• Mortality rates for severe sepsis
– Leading cause of death in non-coronary ICUs– 10th leading cause of death in United States
![Page 29: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/29.jpg)
Sepsis Epidemiology (2 of 2)
![Page 30: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/30.jpg)
Sepsis Pathophysiology (1 of 5)
• Pathogens (usually bacteria)– Identified as non-self– Activate immune system response
• Infection– Invasion of host by pathogen(s)– Innate immune system stimulates inflammatory process
![Page 31: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/31.jpg)
Sepsis Pathophysiology (2 of 5)
![Page 32: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/32.jpg)
Sepsis Pathophysiology (3 of 5)
• Systemic infection– Activates widespread inflammatory response throughout
body, overwhelming immune system– Involves: proinflammation, procoagulation, decreased
fibrinolysis
![Page 33: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/33.jpg)
Sepsis Pathophysiology (4 of 5)
![Page 34: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/34.jpg)
Sepsis Pathophysiology (5 of 5)
![Page 35: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/35.jpg)
Sepsis Assessment
• Maintain high index of suspicion by considering:– Thorough patient history correlated with patient
presentation– Infection not necessarily required– Fever may not present in all populations
• Review signs and symptoms– Distributive shock, infection, cardiovascular changes,
tachycardia
![Page 36: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/36.jpg)
Sepsis Management (1 of 2)
• Early recognition and management are vital• Fluid resuscitation
– Volume expansion to optimize CO
• Vasopressor and inotropic support:– Dobutamine, phenylephrine, epinephrine, vasopressin
• Infection control• Immune-specific therapy
![Page 37: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/37.jpg)
Sepsis Management (2 of 2)
Reproduced from Rivers, E., Nguyen, B., Havstad, S., et al. Early goal directed therapy in the treatment of severe sepsis and septic shock. N Engl Med 2001; 234(19):1371. Copyright © 2001 Massachusetts Medical Society. All rights reserved.
![Page 38: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/38.jpg)
Blood Administration Considerations
• Results of risk-benefit analysis to weigh: – Urgency, “out-of-hospital” time, availability, type-and-
crossmatch information
• Possible complications• State regulations• Care, storage, transport of blood products• Skill of health care provider
![Page 39: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/39.jpg)
ABO System
• Identifies antigens A and B to determine following blood types:– Type A, type B, type AB, type O
• Identifies universal recipients– People who are type AB
• Identifies universal donors– People who are type O; can only receive this type
themselves
![Page 40: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/40.jpg)
Blood Administration Complications
• ABO-incompatible transfusion reactions– Patient receives blood type for which they have antibodies
• Rh-negative exposure to Rh-positive blood– Patient may have fatal hemolytic reaction on second
exposure
• Human leukocyte antigen (HLA)– Patients receiving blood from multiple donors may develop
fever
![Page 41: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/41.jpg)
Blood Products
• Blood components and derivatives include:– Whole blood: Contains all blood components, degrades
quickly– Packed red blood cells (PRBCs): Retain characteristics of
whole blood except 250 mL of platelet-rich plasma
![Page 42: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/42.jpg)
Platelet Products (1 of 2)
• Fresh-frozen plasma (FFP)– Uncoagulated plasma separated from RBCs; used for blood
loss, coagulation deficiencies, warfarin reversal, thrombotic thrombocytopenic purpura
• Cryoprecipitate– Frozen blood product created from donor’s plasma; used
for hemophilia A, fibrinogen deficiency, von Willebrand’s disease
![Page 43: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/43.jpg)
Platelet Products (2 of 2)
• Albumin– Fractionation of pooled plasma
• Plasma protein fraction– Contains 83% albumin, 17% globulins
• Synthetic blood substitutes– Research and development ongoing– PolyHeme
![Page 44: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/44.jpg)
Indications for Blood Administration
• Significant hypovolemia as the result of acute blood loss• Symptomatic anemia• Decreasing hemoglobin level• Decreasing hematocrit value • To increase oxygen-carrying ability• Decreased clotting factors• Presurgical care in select cases
![Page 45: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/45.jpg)
Skill Drill 9-1: Administering Blood Products (1 of 3)
Confirm the order or protocol.
Check the patient for the following: right patient, right blood product, and right type. Have a second provider confirm steps 1 and 2 with you.
Assess baseline vital signs and temperature.
![Page 46: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/46.jpg)
Skill Drill 9-1: Administering Blood Products (2 of 3)
Ensure suitable venous access. Check the blood again. Assess the patient for the possibility of a transfusion reaction, and consider prophylactic administration of medications. Maintain the temperature of the blood product.
Flush the tubing with normal saline. Cover the administration filter with blood.
Connect the blood to the tubing.
![Page 47: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/47.jpg)
Skill Drill 9-1: Administering Blood Products (3 of 3)
Piggyback into the IV line of normal saline.
Start the transfusion slowly. Monitor for adverse reactions.
![Page 48: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/48.jpg)
Transfusion Reactions (1 of 3)
• Allergic reaction– Caused by allergens in donated blood– Treatment: Antihistamines, patient monitoring
• Bacterial contamination– Occurs during phlebotomy, component preparation, blood
thawing– Treatment: Stop transfusion, begin protocol for transfusion
reactions
![Page 49: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/49.jpg)
Transfusion Reactions (2 of 3)
• Febrile transfusion reactions– Bacterial lipopolysaccharides or antileukocyte recipient
antibodies – Treatment: Antipyretics, antihistamines
• Hemolytic transfusion reactions– Immediate or delayed– Various causes related to incompatibility or error
![Page 50: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/50.jpg)
Transfusion Reactions (3 of 3)
• Plasma protein incompatibility– Immunoglobulin A incompatibility
• Other causes– Bleeding tendencies– Circulatory overload– Hypocalcemia– Hypothermia– Potassium intoxication
![Page 51: Shock. Shock, Sepsis, and MODS Complex disorders Affect body in multifaceted dimensions Involve breakdown in oxygen supply and demand Begin with localized](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfa71a28abf838c98da5/html5/thumbnails/51.jpg)