CCRN – 14%

 Bariatric complications

 Comorbidity in patients with

transplant history

 End of life

 Healthcare associated infections

 CLABSI

 CAUTI

 VAP (VAE)

 Hypotension

 Infections

 Multi-organ dysfunction (MODS)

 Multisystem Trauma

 Pain

 Palliative care

 Rhabdomyolysis

 Sepsis continuum

 Shock states

 Sleep disruption

 Thermoregulation

 Toxin/drug exposure

 Toxic Ingestions

(Drug/ETOH overdose)

CCRN – Behavioral/Psychosocial

 Agitation

 Antisocial behaviors,

aggression, violence

 Delirium

 Dementia

 Medical nonadherence

 Mood disorders,

depression, anxiety

 Post-traumatic stress

disorder (PTSD)

 Risk-taking behavior

 Substance dependence

(ie ETOH withdrawal,

drug seeking behavior,

chronic alcohol or drug

dependence)

 Suicidal ideation

and/or behaviors

CCRN - Integumentary

 IV infiltration

 Pressure ulcers

 Wounds (infectious,

surgical, trauma)

SIRS

 Systemic Inflammatory Response Syndrome

 Heart Rate > 90 bpm

 Respiratory Rate > 20 bpm

 Temperature > 38 °C or < 36°C

 WBC > 12,000 or < 4,000 or >10% immature bands

 Do you suspect an infection?

 SIRS + infection = Sepsis

Degrees of Sepsis

SIRS

HR > 90, RR > 20, Temp >38 or < 36,

WBC > 12 K or < 4 K

Sepsis

SIRS + infection

Severe

Sepsis

Sepsis + Organ dysfunction

Septic

Shock

Severe Sepsis + either:

SBP < 90, MAP < 65, lactate

> 4 after fluids

Sepsis

 Sepsis + organ dysfunction = Severe Sepsis

 Severe sepsis + refractory hypotension = Septic shock

 Abnormal function of > 1 organ =

Multi-Organ Dysfunction (MODS)

 Common organ involvement:

 Lungs

 Kidneys

 Cardiovascular system

 Central nervous system

6 Hour sepsis bundle

Early detection – 1st hour

 Obtain serum lactate

 Cultures & targeted

antibiotics

 Monitor for other signs of

hypoperfusion:

 MAP < 65 mmHg

 Lactate > 4 mmol/L

 UOP < 0.5 ml/kg/hr

 Initial fluid Bolus of 30 ml/kg

 Antibiotics

Critical Care

 CVP 8 – 12 mmHg

 Start vasopressors if MAP < 65

despite fluids:

 Norepinephrine 1 – 10 mcg/min

 Vasopressin 0.01 – 0.04 units/min

 ScvO2 > 70%

 Inotropes

 PRBCs if Hgb < 7

 Steroids only if persistent shock

 Hydrocortisone 200 – 300 mg IV

x 7 days

 Adrenal insufficiency ~ 15%

Severe Sepsis & beyond…

 Initial: Increased oxygen consumption

 Low ScvO2 or SVO2

 Capillary permeability

 Formation of Microvascular thrombi

 Impaired tissue oxygenation

 How do we measure or evaluate perfusion?

 Contractility measures

 Lactate

 ScvO2

Lactate

 In sepsis, lactate should be viewed as a marker of

tissue perfusion

 Lactate has some prognostic utility

 Sustained (>6 h) elevated lactate portends increased

mortality

 Mortality increases as lactate levels increase

0 – 2.5 mmol/L 4.9% mortality

2.5 – 4.0 mmol/L 9.0%

> 4.0 mmol/L 28.4%

Lactate Clearance

 111 severe sepsis pts.

 Survivors

 38.1% clearance

 Non-survivors

 12.0%

 P = 0.005

 Only significant variable

in logistic regression

model

SVO2 – true mixed venous O2 sat

 SVO2 65 – 75%

 Measured with a

pulmonary artery

catheter

 “True” Mixed Venous

 ScvO2 > 70%

 Surrogate of mixed

venous

 5 – 8% higher than

SVO2

SVO2 – true mixed venous O2 sat

What is ScvO2?

 Draw from distal tip of

TLC/PICC (thorax)

 Send to lab in ABG

syringe

 Mixed venous

 Surrogate

 Goal >70%

Oxygen Delivery & Consumption

INBOUND o2 in bloodstream to Heart in Veins

Returned O2

~ 65-75%

SVO2

65-75%

ScvO2

>70%

Used O2

25-35%

 From Heart to System Arteries

 SaO2

95-100%

Oxygen Delivery/Supply

Affected by 3 physiologic parameters:

The Hemoglobin

Affinity for O2

The Lungs

O2/CO2 exchange

The Pump

CO/CI

LVSWI

SV/SVI

Physiology of Hypotension

MAP = CO X SVR

CO = HR X Stroke Volume

STROKE VOLUME

Preload (Volume) + Contractility (Pump) + Afterload

Sepsis key points…

 Early recognition

In the 1st hour:

 Labs – Lactate, CBC with differential

 Fluids (30 ml/kg)

 Antibiotics

 Source Control

 Prevent critical care!!!

Anaphylaxis

 Inflammatory response

 Hypersensitivity reaction

 Common:

 Contrast dye*

 Food

 Antimicrobials

 Insect bites

 *Most common: 1 in 1,000

– 14,000 injections

 10% fatal

 Symptoms

 Minutes to hours

Less serious reactions:

 Flushing, erythema, rash,

urticarial, diarrhea

More serious:

 Angioedema, laryngeal edema,

tongue swelling, bronchospasm,

hypotension

Anaphylaxis treatment:

1^st line treatment

 Monitor airway!!!

 Epinephrine 1:1,000 strength

 0.3 mg IM thigh

 Blocks the release of

inflammatory mediators

 Can also nebulize the

Epinephrine to treat laryngeal

edema

 If taking BB, can give

Glucagon 5 – 15 mcg/min IV

continuous infusion

2^st line treatment

 Diphenhydramine 25 – 50 mg

IV/IM/PO

 H1 blocker

 Ranitidine 50 mg IV or 150

mg PO

 H2 blocker

 Synergistic effect

 Steroids – prevent 2nd phase

symptoms

 Prednisone 50 mg PO or

 Methylprednisolone 125 mg IV

If progression to anaphylactic shock

 MASSIVE VASODILATION!

 Volume resuscitation

 Massive vasodilation with fluid shifts

 Consider colloids

 Refractory Hypotension:

 Epinephrine 2 – 8 mcg/min

 Dopamine 5 – 20 mcg/kg/min

 Norepinephrine 2 – 8 mcg/min

Overdoses - Acetaminophen

Some facts:

 Included in over 600 drug

preparations

 Leading cause of toxic

ingestions & acute liver

failure

 Over 1/3 are unintentional

 80 – 90% metabolized

through the liver

 Toxic metabolite accumulates

& causes widespread

hepatocellular damage

4 Stages of Toxicity:

1st 24 Hours:\

 No or vague symptoms

 No lab value / evidence

of injury

24 – 72 Hours:

 No or vague symptoms

 ↑ AST

 Most sensitive

 Precedes hepatic

dysfunction

72 – 96 Hours:

 Progressive hepatic injury

 Peak AST levels

 Encephalopathy

 Coagulopathy

 Renal insufficiency

3 – 5 Days

 Start recovery or

 Death

Risk Assessment:

Acetaminophen Overdose

1. Determine ingested dose –

amount & time

 7.5 Grams to 15 Grams toxic

 Concomitant use of ETOH

increases risk

2. Assess plasma

Acetaminophen levels

 4 - 24° after ingestion to

predict risk

 If the level falls in the high

risk category, risk of

hepatotoxicity is ≥ 60%

 Antidote: N-Acetylcysteine

(Mucomyst)

 Goal: Limit accumulation of

the metabolite to prevent

hepatocellular damage

 Ideal to start within 24 hours

of ingestion

 IV sometimes preferred d/t

smell

 Activated charcoal is also an

option if used within 4 hours

of ingestion

 N-Acetylcysteine dosing:

 IV 150 mg/kg over 60 min

50 mg/kg over 4 hrs

100 mg/kg over 16 hrs

Total: 300 mg/kg over 21 hrs

 PO 140 mg/kg PO load

70 mg/kg Q 4 hours

Total: 1330 mg/kg over 72 hrs

Aspirin (Salicylate) Overdose

Diagnosis:

 Clinical presentation

 Anion gap

 + gap

 ABGs

 Respiratory alkalosis d/t brain

stimulation of resp. center

 Serum salicylate levels

 Acute ingestion of > 150 mg/kg can

cause severe toxicity

 Salicylate tablets may form

bezoars, prolonging absorption and

toxicity.

 Need to know if enteric coated

Signs:

 Vomiting

 Tinnitus

 Confusion

 Hyperthermia

 Respiratory alkalosis

 Metabolic acidosis

 Multiple organ failure

Treatment:

 Activated charcoal

 Alkaline diuresis

 Hemodialysis

 Supportive

 2nd most common overdose in

the US

 Usually involve a 2nd

respiratory depressant

Higher risk:

 Advanced age

 Accumulative dosing

 Concomitant use with opioids

 Antagonist: Flumazenil

(Romazicon)

 IV 0.2 mg repeated Q 1 – 6

min Up to 1 mg

 Onset: 1 – 2 min

 Peak: 6 – 10 min

 Duration: 60 min

 Duration of benzos longer than the antidote

 Monitor for re-sedation

 Can do continuous infusion 0.3 – 0.4 mg/hr

 Monitor for benzo withdrawal

 Can precipitate seizures is that was the use

Beta Blockers

 > 15 FDA approved in the US

 Side effects:

 Bradycardia

 Hypotension (d/t vasodilation

& renin blockade)

 Decreased C.O.

 B1 receptor blockade

 Heart block from prolonged

A-V conduction

 Neurotoxicity:

 Lethargy, ↓ LOC, seizures

 Seizures more common with

Propranolol

 Antidote: Glucagon

 3 mg IV initial dose (0.05

mcg/kg)

 5 mg IV repeated dose (0.07

mcg/kg)

 Continuous infusion 5 mg/hr if

needed

 Reverses the B1 blockade

 Mimics + inotropic effects of

beta receptor activation

 Side effects of Glucagon:

 N/V

 Mild hyperglycemia

 Hypokalemia

 Hypertension

Calcium Channel Blockers

 > 10 FDA approved

 Verapamil, Nifedipine &

diltiazem most common

 Ca++ influx into myocardial cell

is essential & determine strength

of contraction

Effects:

 Neg. inotropic effects

 Neg. chronotropic effects

 Prolonged AV conduction

 Vasodilation

 Bronchial dilation

 Neuro effects:

 Lethargy

 ↓ LOC

 Generalized seizures

 Hyperglycemia (inhibits

insulin release)

Treatment:

FOR CALCIUM CHANNEL BLOCKER ANTIDOTE

 Calcium!!!

CaCl 10% IV

 1 amp = 1.36 mEq/ml

 Prevent blockade – 3 ml

 Reverse blockade – 10 ml/13.6

mEq/ml

Ca Gluconate 10% IV

 1 amp = 0.46 mEq/ml

 Prevent blockade – 10 ml

 Reverse blockade – 30 ml/13.8

mEq

 Can use continuous IV since

effects are so short lived (10 –

15 min)

 0.3 – 0.7 mEq/kg/hr

Atropine 0.5 – 1.0 mg IV

 Reverse bradycardia

 Give Ca++ first!!!

 Atropine is enhanced by

Calcium administration

 If continued hypotension, use

catecholamine infusion:

 Epi, Norepi or Dopamine

Opioids

 Morphine most common in

hospitalized patients

 Heroin for street drugs

 Antagonist: Naloxone

 Binds to opioid receptors

 Dose: 0.4 mg IV or IM

 Onset IV: 2 - 3 min, IM 15 min

 Repeat in 2 min up to 1 mg

 Opioid dependency dose 0.1

– 0.2 mg

 Respiratory depression:

2 mg IV

repeat Q 2 min up to 10 mg

 Effects last 60 min

 Can also consider an infusion

Adverse effects of Naloxone:

 Anxiety

 Abdominal cramping

 N/V

 Piloerection

ETOH Withdrawal

 Potentially life threatening

 Heavy drinking for days to

months, then suddenly stop or

reduce consumption

 Symptoms can start as early

as 2 hours & continue for

weeks

Symptoms of withdrawal:

 Tachycardia

 Tachypnea

 Tremors

 Anxiety

 Irritation

 Sweating

 Seizures

 DTs – delirium tremens

 Mortality of DTs: 1 – 5%

CIWA Scale

 Nausea & vomiting

 Paroxysmal sweating

 Agitation

 Visual disturbances

 Tremor

 Tactile disturbances

 Headache

 Auditory disturbances

 Orientation/clouding

sensorium

Scoring:

< 8:

 No medications needed

9 – 14:

 Optional medications

15 – 19:

 Give medication

> 20:

 High risk for complications

Treatment DTs

Pharmacologic:

 Benzodiazepines

 Lorazepam

 Anti-seizure medications

 Low dose anti-psychotics

 Haldol

 Monitor for prolonged QT

 Quetiapine (Seroquel)

 IV fluids

 Electrolyte imbalance (Mg++)

 Supportive

Nursing:

 Safety

 Quiet environment

 Airway

 Seizure precautions

 Cardiac monitoring

 QTc

In general, elderly at higher

risk

 Brain dysfunction

 Inattention

 Confusion

 Can wax & wane

 Hyperactive &

hypoactive

Who is at risk?

 Hospitalized patients

 Elderly

 Stroke

 CNS issues

 Sepsis

 Sleep deprived

 Electrolyte imbalances

 Dehydration

 Memory impaired

 Severe burns

 Trauma

ABCDE Bundle - Vanderbilt

 AB – Awakening &

breathing trials daily on

vented patients

 C – Choose the right

sedative

 D – Delirium monitoring

 E – Early mobility &

exercise

 PREVENTION is key!!!

PAD Guidelines

 Pain

 Manage first!

 Agitation

 Avoid benzodiazepines

 Don’t over sedate

 Delirium

 Reorient

 Familiarize with surroundings

 Allow sleep!

 Anti-psychotic meds: monitor QTc

 Haldol, Seroquel

Monitoring for delirium

 CAM – ICU Assessment

 RASS or SAS

 Inattention

 Disorganized Thinking

Step 1:

Fluctuation from

baseline?

Step 2:

Assess RASS

2013 SCCM PAD Guidelines

Name that antidote:

Calcium channel blocker Calcium

Beta blocker Glucagon

Acetaminophen Mucomyst

Opioids Naloxone

Benzodiazepine Romazicon

Name that shock…

HR 133, BP 78/44 (56), lactate 4.3

Down Cardiac Output/Index Cardiac Index = 1.8 L/min

Down CVP CVP = 2 mmHg

Down PAOP PAOP = 6 mmHg

UP SVR SVR = 1800

Down SVO2 SVO2 = 46%

HYPOVOLEMIC SHOCK

Patient with GI Bleed. Hct is 21.

Name that shock

HR 126, BP 78/42 (56), lactate 5.6

Down Cardiac Output/Index Cardiac Index = 1.6 L/min

Up CVP CVP = 18 mmHg

Up PAOP PAOP = 22 mmHg

Up SVR SVR = 2150

Down SVO2 SVO2 = 42%

CARDIOGENIC SHOCK

Patient with Anterior Wall MI

Name that shock…

 HR 122, BP 84/46 (58)

Up Cardiac Output/Index Cardiac Index = 4.8 L/min

Down CVP CVP = 4 mmHg

Down PAOP PAOP = 8 mmHg

Down SVR SVR = 350

Down SVO2 SVO2 = 46%

SEPTIC SHOCK – Warm Stage (Hyperdynamic)

Patient presents with pneumonia. Elevated WBC.

Name that shock

 HR 132, BP 68/42 (50)

Down Cardiac Output/Index Cardiac Index = 1.7 L/min

Down CVP CVP = 2 mmHg

Down PAOP PAOP = 4 mmHg

Down SVR SVR = 450

Down SVO2 SVO2 = 52%

ANAPHYLACTIC SHOCK

Patient had a reaction to a bee sting. C/O tongue

swelling & difficulty breathing.