Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM...
-
Upload
noel-lester -
Category
Documents
-
view
222 -
download
1
Transcript of Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM...
![Page 1: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/1.jpg)
Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP
Education SpecialistLRM Consulting
Nashville, TN
![Page 2: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/2.jpg)
DefinitionDefinition tissue perfusion that is tissue perfusion that is
inadequate to maintain inadequate to maintain normal metabolic and normal metabolic and nutritional functionsnutritional functions
potentially fatal if not potentially fatal if not identified & treatedidentified & treated
![Page 3: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/3.jpg)
Introduction 12% to 18% of patients 12% to 18% of patients
presenting initially in severe presenting initially in severe shock have increased shock have increased mortality or morbidity related mortality or morbidity related to secondary organ failureto secondary organ failure
![Page 4: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/4.jpg)
![Page 5: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/5.jpg)
Clinical Signs of ShockClinical Signs of Shock
Preterminal StagesPreterminal Stages severe hypotensionsevere hypotension agonal respirationsagonal respirations thready pulsethready pulse tachy or bradydysrhythmiastachy or bradydysrhythmias
![Page 6: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/6.jpg)
Shock IndexShock Index HR / systolic blood pressureHR / systolic blood pressure inversely related to LVSWinversely related to LVSW abnormal > 0.9abnormal > 0.9 application:application: persistently abnormal persistently abnormal
shock index in patient with normal shock index in patient with normal VS suggests need for more VS suggests need for more invasive monitoringinvasive monitoring
Rady (1992) Resuscitation 23:227 - 234
![Page 7: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/7.jpg)
most important most important feature to the care of feature to the care of a critically ill patient a critically ill patient is delivery of oxygen is delivery of oxygen to the cellsto the cells
![Page 8: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/8.jpg)
CO X CaOCO X CaO2 2 X 10X 10 CaOCaO22 = Hgb x SaO = Hgb x SaO22 x 1.38 x 1.38
Normal 900 - 1100 mL/minNormal 900 - 1100 mL/min DODO22I = 360 - 550 mL/min/mI = 360 - 550 mL/min/m22
![Page 9: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/9.jpg)
oxygen consumptionoxygen consumption CO x (SaOCO x (SaO22 - SvO - SvO22) Hgb x 1.38 x 10) Hgb x 1.38 x 10
VOVO22 = 220 - 290 mL/min = 220 - 290 mL/min
VOVO22I = 108 - 165 mL/min/mI = 108 - 165 mL/min/m22
![Page 10: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/10.jpg)
normally VOnormally VO2 2 is is 25% of DO25% of DO22
![Page 11: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/11.jpg)
SvOSvO22
• SaOSaO22
• HgbHgb• COCO• VOVO22
![Page 12: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/12.jpg)
amount of oxygen extracted amount of oxygen extracted from blood as it passes from blood as it passes through the tissuesthrough the tissues
(CaO(CaO22 - CvO - CvO2 2 )/ CaO)/ CaO22
values > 0.30 abnormalvalues > 0.30 abnormal > 0.35 serious> 0.35 serious normal 22% to 27%normal 22% to 27%
![Page 13: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/13.jpg)
> 0.35> 0.35• increased VOincreased VO22
• decreased DOdecreased DO22
• bothboth
![Page 14: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/14.jpg)
CI 4.5 L/min/mCI 4.5 L/min/m22
DODO22I 600 L/min/mI 600 L/min/m22
VOVO22I 170 mL/min/mI 170 mL/min/m22
![Page 15: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/15.jpg)
inadequate pulmonary inadequate pulmonary gas exchangegas exchange
inadequate oxygen inadequate oxygen carrying capacitycarrying capacity
inadequate COinadequate CO
![Page 16: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/16.jpg)
![Page 17: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/17.jpg)
conditions and conditions and activities that alter activities that alter demand and demand and consumptionconsumption
![Page 18: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/18.jpg)
critically low DOcritically low DO22
vasodilated statevasodilated state vaso-obstructed statevaso-obstructed state diffusion distancesdiffusion distances
affinity of Hgb for Oaffinity of Hgb for O22
![Page 19: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/19.jpg)
increased extractionincreased extraction once extraction maximized – once extraction maximized –
consumption is dependent consumption is dependent on deliveryon delivery
demand > consumption = demand > consumption = OO22 debt debt
![Page 20: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/20.jpg)
may be may be or normal in or normal in presence of hypoxiapresence of hypoxia
not reliable reflection not reliable reflection of tissue hypoxia of tissue hypoxia
reliable indicator of reliable indicator of tissue perfusiontissue perfusion
![Page 21: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/21.jpg)
arterial more precisearterial more precise normal < 1 mEq/Lnormal < 1 mEq/L > 3 - 4 mEq/L significant > 3 - 4 mEq/L significant
hypoperfusionhypoperfusion will decrease 5 - 10% / hr will decrease 5 - 10% / hr
when appropriate when appropriate therapy usedtherapy used
![Page 22: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/22.jpg)
pHipHi early warning of early warning of
inadequate splanchnic inadequate splanchnic tissue oxygenationtissue oxygenation
low pH = poor prognosis low pH = poor prognosis (consistently < 7.3) (consistently < 7.3)
![Page 23: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/23.jpg)
Lab StudiesLab Studies Normal value: - 2 to + 2Normal value: - 2 to + 2 reflects the extent to which reflects the extent to which
the body buffers have been the body buffers have been exhaustedexhausted
rapidity of normalizing base rapidity of normalizing base deficit decreases morbidity deficit decreases morbidity & mortality& mortality
![Page 24: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/24.jpg)
Most Reliable Perfusion Most Reliable Perfusion MarkersMarkers
Serum lactateSerum lactate Base deficitBase deficit
![Page 25: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/25.jpg)
StO2
near infrared light illuminates tissue
light scatters and is absorbed differently by oxygenated and deoxygenated hemoglobin in the microcirculation
light returns to sensor and is analyzed and displayed as % StO2
![Page 26: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/26.jpg)
StO2
![Page 27: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/27.jpg)
StO2
.75 - .90
![Page 28: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/28.jpg)
volumevolume inotropesinotropes vasodilatorsvasodilators assess peripheral assess peripheral
circulation circulation
![Page 29: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/29.jpg)
Identify potentially Identify potentially inadequate DOinadequate DO2 2 statesstates
• clinical evidence clinical evidence of shockof shock
• SvOSvO2 2 < 50% < 50%• OO22ER > 30%ER > 30%
![Page 30: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/30.jpg)
Identify pathological Identify pathological flow dependency stateflow dependency state
DODO22 with fluids or with fluids or inotropeinotrope
–recalculate VOrecalculate VO22
–VOVO2 2 > 10-20 L/m> 10-20 L/m22
![Page 31: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/31.jpg)
ensure accurate parameters
index to body size eliminate sources of
error use parameters with
< 5-10% variance
![Page 32: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/32.jpg)
calculate actual VO2
estimate potential VO2 (look at factors that demand)
![Page 33: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/33.jpg)
delivery needs to delivery needs to
by at least sameby at least same
percentage as demandpercentage as demand
![Page 34: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/34.jpg)
OO2 2 demands are demands are 30-50%30-50%
triggers systemic triggers systemic inflammatory inflammatory responseresponse
![Page 35: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/35.jpg)
Hgb/Hct < 11/33 is Hgb/Hct < 11/33 is associated with delivery-associated with delivery-dependencedependence
mortality if therapeutic mortality if therapeutic targets reached < 12 - 24 targets reached < 12 - 24 hourshours
![Page 36: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/36.jpg)
CI > 4.5 DOI2 700
VOI2 170
![Page 37: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/37.jpg)
46 - year old male• motor vehicle crash• injuries: aortic disruption,
severe bilateral pulmonary contusions, bilateral rib fractures, splenic fracture
• traumatic shock due to injuries
![Page 38: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/38.jpg)
Which hemodynamic Which hemodynamic findings are abnormal?findings are abnormal?
![Page 39: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/39.jpg)
HR 67 BP 122/64/82 RAP / PAOP 10/11 CI 4.6 PVRI / SVRI 143/317RVSWI / LVSWI 17/61 PAP 46/22/32
![Page 40: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/40.jpg)
EDV / EDVI 237/107
EF 60%
O2ER 26.8
SvO2 .74
DO2 / DO2I 1603/722
VO2 / VO2I 430/194
![Page 41: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/41.jpg)
ABGs (.40 FiO2)pH 7.31
pCO2 42
pO2 157
SaO2 .99
HCO3 20.8
SvO2 74% P/F ratio 314.0
![Page 42: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/42.jpg)
Lab Values Hgb 12.1 Hct 31.0 Sodium 139 Chloride 112 Magnesium 1.7 Lactate 5.1 Base Deficit -5.1
![Page 43: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/43.jpg)
What is the underlying What is the underlying pathophysiology?pathophysiology?
![Page 44: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/44.jpg)
What is are the priority What is are the priority interventions?interventions?
![Page 45: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/45.jpg)
33 yr with GSW to chest 4 units of PRBC due to Hct of 27 SVO2 – 70 after blood administration
StO2 – 80% Lactate 1.2 Does he need further treatment?
StO2 and Hemodynamic Monitoring
![Page 46: Leanna R. Miller, RN, MN, CCRN,-CMC, PCCN-CSC CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.](https://reader036.fdocuments.in/reader036/viewer/2022062320/56649ce55503460f949b321a/html5/thumbnails/46.jpg)