Respiratory Failure: Hypoxemic vs. Hypercapnic
Respiratory Failure: Hypoxemic vs. Hypercapnic
Respiratory Failure: Hypoxemic vs. Hypercapnic
o
o
o
o
o
o
PaCO2 >45
pH <7.35
Causes: Asthma, COPD, Cystic Fibrosis,
BSI, OD, HI, Thoracic Trauma, MS, ALS,
Guillain-Barr
Clinical Manifestations: Dyspnea, Tripod
Positioning, Purse-Lipped Breathing,
RR, Tidal Volume
PAWP o
MAP
CO
SvO2
In high levels of fluid replacement in septic shock, we want to see CVP 8-12
within 6 hours. **May be first indication that fluid replacement is
successful**
Using a wedged balloon in a pulmonary catheter and inflated within a
pulmonary artery. When inflated, the balloon can measure left ventricular
end diastolic pressure.
Must have a Mean Arterial Pressure (MAP) of at least 60 to perfuse the
coronary arteries, brain, and kidneys.
DBP ( 2 ) + SBP
3
MAP =
o
o
CRT
LOC
Pulses
CO (4-8L)
o Hgb (M 13-17;
F 11-15)
o Hct (M 39-50%;
F 35-47%)
o UOP (30mL/hr. or
0.5mL/kg/hr.)
o Lactic Acid (4
indicative of organ
damage)
o O2 (<90% BAD)
o MAP (Ideal >65; >60
to sustain organ life)
o Albumin (3.4-5.4)
o SvO2: HR with SvO2 they are not tolerating activity. STOP! Space the care
out.
o > 80: Sepsis, Hypothermia, Anesthesia
o < 60: Anemia, Bleeding, Hyperthermia (Shivering), Hypoxemia, Seizures
Fluid Replacement:
o Monitor: Is&Os, BP, MAP, Lung Sounds, Signs of CO (BP, HR), FVO
o Types: Crystalloid (NS; LR), Colloid (Albumin), Blood Products (PRBC;
Clotting Factors) **Warm Fluids**
o All depends on the type of shock.
Medications:
o Antibiotics (Cultures first)
o Bicarbonate
o Vasodilators (Sodium Nitroprusside, Nitroglycerin, Vasopressin)
o Vasoconstrictors (Dopamine, Norepinephrine)
o Fluid Replacement before Vasoconstrictors (You have to have that fuel in
the tank)
o Mimics SNS ( SVR = Workload; shunts blood to vital organs)
o Goal is to maintain MAP >65
o Usually get 3L of fluid with shock!
o Enteral Feedings started within 24 hr. ( blood flow to the gut to maintain
GI tract)
o TPN (Protein, Calorie) (Prevent Stress Ulcers with IV Protonix)
Care:
o Daily Weight (Same Clothing, Same Time, No Extra Pillows)
o Increase in weight could be due to 3rd Spacing which is BAD.
o Frequent Mouth Care
o Proper Skin Care
o Monitor IV Site (Infiltration can occur)
o Dopamine and Norepinephrine causes blood to shut to vital organs which
can cause necrosis of the extremities. Check peripheral Pulses, Color, and
Temperature. If Necrosis occurs use Phentolamine (Regitine) to reverse.
o Bed Rest
o Labs: Glucose, Albumin (3rd Spacing), BUN, Creatinine, H&H, WBC,
Platelets, Protein, Electrolytes, ABG (1. Respiratory Alkalosis 2. Metabolic
Acidosis)
Stages of Shock
o May or may not have symptoms.
o Aerobic to Anaerobic (Lactic Acid Level Monitoring)
o Glucose related to release of glycogen
2. Compensatory o The body recognizes the problem and shunts fluid to the organs by
activating SNS response. Renin activated and releases Angiotensin.
Aldosterone to retain sodium and water. ADH increasing water
resorption.
o Clinical Manifestations: Restless, Tachycardia (Need O2), Tachypnea
(Need O2), Renal Flow (UOP NOT affected), Cool/Pale Skin
o Failure Begins. (1st Lungs, 2nd Kidneys, 3rd GI)
3. Progressive
o Leads to MODS, ARDS
o Clinical Manifestations: Perfusion, Respiratory Distress (Use of
accessory muscles), O2, Crackles/Cyanosis (EARLY), Agitation,
BP (40 from baseline), Pulses, UOP (LATE), GI (Ulcers), ECG
Changes (PVC, Dysrhythmias), Metabolic Acidosis, Lactic Acid,
Edema (3rd Spacing), Cold/Clammy, Bleeding (DIC)
o No Recovery. All Organs Failing.
4. Refractory
o Signs and Symptoms to differentiate.
o Clinical Manifestations: BP, Lactic Acid Levels, GI Function,
Kidney Failure, Hypoglycemis, Cerebral Ischemia, DIC, Tachycardia
leading to Bradycardia, Hypothermic, Cyanosis, Unresponsive
1. Initial
Shock Classification
Type
Cause
Cardiogenic
Shock
(Low Blood
Flow)
MI,
Cardiomyopathy,
systemic and
pulmonary HTN
and cardiac
tamponade
Clinical
Manifestations
o
o
o
o
o
o
o
o
Anxious
Cool/Clammy
Tachycardia
Hypotension
Tachypnea
Crackles or
Rhonchi
Increased PAWP
(FVO)
Decreased urine
output
Treatment
o
o
o
o
o
o
Thrombolytic therapy
Angioplasty w/wo stenting
IABP ( Ventricle Workload)
Nitrates ( Workload)
Diuretics (If PAWP,
Preload)
Beta blockers (HR &
Contractility; Contraindicated
for EF <40%)
Positive Inotropes
(Dobutamine, Dopamine)
Cardiac Output
Careful fluid replacement due
4
o
Hypovolemic
Shock
(Low Blood
Flow)
Goal is Stop
fluid loss (e.g.
trauma and
blood loss)
Septic Shock
(Maldistribution
of Blood Flow)
Hemorrhage, GI
loss, Diuresis,
Ascites, Third
spacing
o
o
o
o
o
o
o
o
o
o
Anaphylactic
Shock
(Maldistribution
of Blood Flow)
Goal is
Prevention
(know pts
allergies)
Systemic
inflammatory
response to an
infection=sepsis
1. bacteria
enters
bloodstream
from source (e.g.
abscess)
2. bacteria
release toxins
causing
inflammatory
response
3. response
becomes
systemic=tissue
hypoxia
Life threatening
situation due to
allergic reaction
(from inhalation,
topical, oral, or
parenteral
exposure to
allergen)
Neurogenic
Shock
(Maldistribution
Trauma to 5th
thoracic
vertebrae or
o
o
o
o
o
o
o
o
o
Anxious
Tachycardia
Tachypnea
Hypotension
Hypoactive or
Absent Bowel
Sounds
Decrease UOP
Cool/Clammy
Decreased H&H
(LATE)
Fever (+ or -)
Warm and Flushed
(EARLY)
Confusion
Tachycardia
Hypotension
Tachypnea
GI Dysfunction
Cold/Clammy Skin
(BAD)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Face swelling
Bronchospasm
Hypotension
Wheezing/Stridor
Skin Flushing
Tachycardia
o
o
o
o
o
Hypotension
Bradycardia
Hypothalamic
o
o
of Blood Flow)
Goal is to
correct
hypotension
and control
body
temperature
above,
o
Anesthesia
given improperly,
Drugs that affect
o
the autonomic
nervous system
Obstructive
Shock
(Physical
obstruction
impending the
filling or
outflow of
blood causing
reduced CO)
Cardiac
Tamponade,
Tension
Pneumothorax,
Superior Vena
Cava Syndrome,
Abdominal
Compartment
Syndrome, PE
o
o
o
o
o
o
o
o
Dysfunction
Warm r/t
Vasodilation; then
Cool
Poikilothermic (at
risk for
Hypothermia)
Dry Skin
Hypotension
Tachypnea leading
to Bradypnea
(LATE)
Pulsus Paradoxus
Decreased UOP
Pallor
Cool/Clammy
Decreased/Absent
Bowel Sounds
o
o
o
o
o
o
fluid loss
a-Adrenergic Agonist
(peripheral vasoconstriction)
NeoSynephrine (increases HR
and BP)
Atropine (0.5mg) if Bradycardic
Neurovascular Checks (CRT,
Extremity Pulse & Color)
Needle Decompression
Chest Tube
Pericardiocentesis
Fluid Resuscitation
Cause
Systemic
Inflammatory
Response
Syndrome
(SIRS)
Infection,
Pancreatitis,
Ischemia, Multiple
Trauma with tissue
injury, hemorrhagic
shock, Immunemediated organ
injury, aspiration of
gastric contents,
massive
transfusions, client
defense
mechanisms
(Hemolytic
Reaction)
Usually develops
from SIRS
Outcome is poor
Multiple
Organ
Dysfunction
Syndrome
(MODS)
Clinical
Manifestations
Treatment
and depletion of
glycogen stores