Topic 7-8 D

Q-1

Cardiogenic shock occurs when there is circulatory collapse due to pump failure of the heart resulting in poor perfusion, hypotension, low cardiac output. Management requires interventions to improve cardiac function with conservative boluses to restore volume, inotropic medications, revascularization, and/or mechanical support devices. If a patient has high right-sided pressures, right-sided heart failure, and hepatomegaly, increasing preload with IVF will worsen the clinical picture. Vasopressors such as norepinephrine increase preload and cause vasoconstriction leading to increased SVR, increasing MAP, and ultimately perfusion to organs. Inotropes such as dobutamine and milrinone help with contractility/inotropy, reducing afterload and preload and increasing cardiac output. Inotropes are useful when the shock is worsened by IV fluids, and work by improving cardiac output by decreasing afterload and increasing contractility or lusitropy, which is diastolic relaxation that allows the ventricle to fill. Milrinone has been shown in several comparisons, to improved preload, afterload, and cardiac output more than dobutamine, without significantly increased myocardial oxygen consumption (Nativi-Nicolau, Selzman, Fang, & Stehlik, 2018).

Factors to keep in mind when managing patients with shock include maintaining aseptic techniques during procedures, monitoring catheters for infection, and removing those that are not needed. The type of nutritional supplementation initiated varies according to the cause of shock, and it should be tailored to the individual patient’s needs, as indicated by the underlying condition, laboratory data, and treatment. Current guidelines recommend not starting enteral nutritional feedings before the hemodynamic status is stabilized and infusing EN at a low rate within 72 hours. If EN could not be increased because of gastrointestinal intolerance, supplemental PN should be considered, preferably one week after hospitalization (Heidegger, Darmon, & Pichard, 2016). For those with potentially irreversible myocardial injury or with profound shock or multisystem organ failure, revascularization alone may not improve outcomes, and hemodynamic support with mechanical circulatory support may also need to be considered. (Nativi-Nicolau et al., 2019)

 

 

Heidegger, C. P., Darmon, P., & Pichard, C. (2016). Enteral vs. parenteral nutrition for the critically ill patient: a combined support should be preferred. Current opinion in critical care, 14(4), 408–414. https://doi.org/10.1097/MCC.0b013e3283052cdd

Nativi-Nicolau, J., Selzman, C. H., Fang, J. C., & Stehlik, J. (2018). Pharmacologic therapies for acute cardiogenic shock. Current opinion in cardiology, 29(3), 250–257. https://doi.org/10.1097/HCO.0000000000000057

Q-2

The physical examination should first involve assessment of the patient’s general condition, including an assessment of airway, breathing, and circulation, as well as mental status. An acutely ill, flushed, and toxic appearance is observed universally in patients with serious infections. Altered mental status is another common feature of sepsis. It is considered a sign of organ dysfunction and is associated with increased mortality. No single diagnostic test is currently available that establishes the diagnosis of sepsis or septic shock. Sepsis and septic shock are clinical syndromes defined by a constellation of signs, symptoms, laboratory abnormalities and characteristic pathophysiological derangements. The term ‘septic shock’ remains current and is defined as a state in which sepsis is associated with cardiovascular dysfunction manifested by persistent hypotension despite an adequate fluid (volume) resuscitation to exclude the possibility of volume depletion as a cause of hypotension. The first priority in treatment is early adequate antimicrobial administration and source control (Font, Thyagarajan, & Khanna, 2020).

The hemodynamic management of patients with sepsis and septic shock can be considered in four phases: salvage, optimization, stabilization, and de-escalation. The overall goal of these four phases is to provide immediate hemodynamic support to prevent organ injury and shock, and then to curtail therapies in a standardized manner. The amount of fluid administered will depend on the phase of shock. In the salvage phase of treatment, fluid administration should be generous before monitoring is obtained. In the optimization phase, an individualized approach is needed. Signs of fluid responsiveness, including passive leg raising, can be helpful in a mechanically ventilated, deeply sedated patient. Evaluation of stroke volume changes during passive leg raising can be considered, but is not as easy. A fluid challenge technique is usually the best way to individualize fluid therapy. After the stabilization period, a de-escalation phase must be conducted, in which fluid balance should become negative (Hotchkiss & Vincent, 2016).

 

Font, M. D., Thyagarajan, B., & Khanna, A. K. (2020). Sepsis and Septic Shock - Basics of diagnosis, pathophysiology and clinical decision making. The Medical clinics of North America, 104(4), 573–585. https://doi.org/10.1016/j.mcna.2020.02.011 

Hotchkiss, R. S. & Vincent, J. L. (2016). Sepsis and septic shock. Nature reviews. Disease primers, 2, 16045. https://doi.org/10.1038/nrdp.2016.45

Q-3

The overview of treatment on Septic Shock follows the ABCs of healthcare and medicine (Hotchkiss et al., 2016); (Vucelic et al., 2020). Initial management of septic shock would be an assessment of the patient to determine their current status (Hotchkiss et al., 2016); (Vucelic et al., 2020). Is the patient tachypneic, tachycardic, and hypotensive, and if so, how can we treat it (Hotchkiss et al., 2016); (Vucelic et al., 2020). Treatment for septic shock includes a few initial interventions, for example, fluid resuscitation with normal saline that is dependent on fluid responsiveness is useful in restoring hemodynamics (Hotchkiss et al., 2016). A compliment to this is the use of vasopressors to increase blood pressure to above a mean arterial pressure of 65 (Hotchkiss et al., 2016).

Another initial treatment is ventilation, and it can be achieved by either non-invasive mechanical ventilation or invasive mechanical ventilation which depends on the patient's abg, work of breathing, and SPO2 saturation (Hotchkiss et al., 2016). Usually, the patient will be tachypneic as a response to decreased pH in the blood from an acid-base balance disturbance and restoration with a controlled breathing pattern is the recommended intervention (Hotchkiss et al., 2016).

Finally is the intervention that is more focused on the etiology of sepsis in this patient (Hotchkiss et al., 2016). Pan culturing the patient via blood, urine, and sputum, prior to the administration of antibiotics is imperative (Hotchkiss et al., 2016). Isolating an undisturbed organism is key to identifying and finding an appropriate sensitivity to antibiotics (Hotchkiss et al., 2016). After cultures are obtained, an antibiotic regimen consisting of broad-spectrum antibiotics is indicated (Hotchkiss et al., 2016). An example would be the use of vancomycin, zosyn, and merrem as coverage for gram-positive, negative, and atypicals (Hotchkiss et al., 2016).

Another subset of treatment that some providers do not think about is the establishment of a large-bore central venous catheter that is able to handle multiple infusions, and some of which are incompatible (Hotchkiss et al., 2016). Essentially the more lumens the better, but the standard is a triple lumen catheter placed in either internal jugular, subclavian, or femoral veins (Hotchkiss et al., 2016). The primary choice is the internal jugular as there is a decreased risk of CLABSI, and as you move down the body, the risk is increased (Hotchkiss et al., 2016).

We would want to avoid catheterizing the femoral veins, as hypotension and sepsis overall have a high incidence rate of acute renal failure (Hotchkiss et al., 2016). Usually, the patient's renal status can be recovered by targeting the underlying etiology, but in some instances, this is not enough (Hotchkiss et al., 2016). However, In septic shock patients, there is a mild to moderate chance that the patient would require hemodialysis or continuous renal replacement therapy (Hotchkiss et al., 2016).

The previous explanation would be for someone who is in full-blown septic shock, and in my experience, we have tailored each plan of care based on how the patient presents. For example, in some patients, it is caught early enough, where the administration of fluids and antibiotics alone have restored the patient's hemodynamics and results in ventilation and vasopressor support not being needed (Hotchkiss et al., 2016);(Vucelic et al., 2020). Each patient presents in different phases of sepsis and the worse the sepsis is, the more treatment and interventions are required (Hotchkiss et al., 2016);(Vucelic et al., 2020). The ideal applies in the reverse (Hotchkiss et al., 2016);(Vucelic et al., 2020). References:

Hotchkiss, R. S., Moldawer, L. L., Opal, S. M., Reinhart, K., Turnbull, I. R., & Vincent, J. L. (2016). Sepsis and septic shock. Nature reviews. Disease primers, 2, 16045.  https://doi.org/10.1038/nrdp.2016.45 Vucelić, V., Klobučar, I., Đuras-Cuculić, B., Gverić Grginić, A., Prohaska-Potočnik, C., Jajić, I., Vučičević, Ž., & Degoricija, V. (2020). Sepsis and septic shock - an observational study of the incidence, management, and mortality predictors in a medical intensive care unit. Croatian Medical Journal, 61(5), 429–439.