Shock & Multi-Organ Dysfunction Syndrome (MODS) PDF

Shock & Multi-Organ Disfunction Syndrome (MODS) NUR 470 Acute and Chronic Illness Management II Presented by Sara Dowdle Simmons MS,RN,CNE Fall 2024   “Shock is defined as a state of cellular and tissue hypoxia due to eithe...

Shock & Multi-Organ Disfunction Syndrome (MODS) NUR 470 Acute and Chronic Illness Management II Presented by Sara Dowdle Simmons MS,RN,CNE Fall 2024   “Shock is defined as a state of cellular and tissue hypoxia due to either reduced oxygen delivery, increased oxygen consumption, inadequate oxygen utilization, or a Definition combination of these processes.”(Gaieski,D., of Shock Mikkelsen, M., 2021)  https://www.uptodate.com/contents/ definition-classification-etiology-and- pathophysiology-of-shock-in-adults   Global oxygen delivery (DO2) is the total amount of oxygen Oxygen delivered to the tissues per minute Delivery DO2 Factors that affect how oxygen is delivered to tissues: Hemoglobin Cardiac Output (CO) Arterial oxygen saturation   Oxygen consumption (VO2) is the total amount of oxygen removed from the blood due to aerobic metabolism. Factors that affect how oxygen is Oxygen consumed Consumpti Fever on VO2 Inflammation Hyperthyroidism Adrenergic drugs Increased muscular activity seizures, pain, vent weaning   How cells extract Oxygen from blood Oxygen  Based upon energy needs  Think about what would increase Extraction energy needs? Oxygen Extraction:  https://www.youtube.com/watch where oxygen ?v=BYGPkRFvzOc unloads from hgb to replenish tissues with low oxygen  Oxygen Saturation vs concentration Partial Pressure of Oxygen- Affinity refers to the “hold start watching at 6:13 or grip” that the heme has on the 02 molecule.   Oxygen Extraction Ratio (O2 ER) Oxygen  Ratio of O2 consumption Extraction (VO2) / (DO2) Ratio O2ER The O2ER differs upon organs: Cardiac O2ER = >60% Hepatic O2ER = 45-55% Renal O2ER = 75% represent?   Nursing Assessment 10%  Positioning 30%  Dressing change 10% Activities  Bed bath 20% that  Restlessness and agitation increase 18% VO2  Weighing patient on sling bed Consumption scale 40%  Visitors 18%  Does clustering nursing care make a difference?  Practice  76 year old female has pneumonia and history of COPD (chronic bronchitis)  V/S T 100.8 (o) P 98 (regular) R 26 (at rest) BP 156/92  Cardiac output is 5 L/min (4L - 8L/min is normal)  Hemoglobin 15 dL/mL  Hematocrit 44.9%  Sa02 81% on 2 L oxygen by Nasal Canula Question What kind of problem is it, DO2 or VO2? What should be manipulated ?  Practice  42 year old male has a lower GI bleed  T 98.0 P 110 R 22 BP 102/58  Cardiac output 5 L (4L - 8L/min)  Hemoglobin 6.8 dL/mL HCT 20.4%  SaO2 99% on 2L oxygen nasal canula Question What kind of problem is it, DO2 or VO2? The nurse anticipates what orders from the physician?   Abnormally High O2ER  Decreased Oxygen delivery or increased consumption Hypoxia Anemia Question? Shock states Shivering (can burn 100 kcal/15 min) MODS When tissues are deprived of O2 anaerobic metabolism begins and this produces what byproduct? What affect does this have on O2 affinity?   What would a low O2ER suggest? Increased oxygen delivery (DO2) but decreased oxygen consumption (VO2) Malnutrition Hyperventilation Questions Hypometabolism sedation hypothyroidism paralysis Why would this present a problem?   “Shock is defined as a state of cellular and tissue hypoxia due to either reduced oxygen delivery, increased oxygen consumption, inadequate oxygen utilization, or a Definition combination of these processes.”(Gaieski,D., of Shock Mikkelsen, M., 2021)  https://www.uptodate.com/contents/ definition-classification-etiology-and- pathophysiology-of-shock-in-adults  Arterial pH (7.35 - 7.45) Serum Lactate (>2 mmol/L) Objective Base Deficit (the amount of base (HCO3) Parameter required to titrate 1 liter of arterial blood back to normal) s of Shock Procalcitonin for Septic Shock and MODS procalcitonin levels elevate in 4-12 hours of inflammatory processes and infections   Cardiogenic 16%  Hypovolemic 16%  Obstructive 2% Shock  Distributive 66% Classificatio  Septic ns   Neurogenic Anaphylactic  Initial- decreased cardiac output, decreased perfusion, decreased oxygenation=anaerobic metabolism -> Lactic Acidosis Compensatory- Neuroendocrine begins Shock to augment cardiac output, blood flow and restoring blood volume Phases Progressive- Compensatory changes not Defined working= poor perfusion, low blood flow, metabolic waste, Multiorgan Dysfunction Syndrome ( MODS) Refractory- Cellular destruction, not responsive to vasopressors, hypoxemic despite Oxygen therapy, circulatory failure, impending death.   Decreased CO  Decreased tissue perfusion Phase 1 Question: Initial What would your initial assessment findings be? What is your intervention?   Neuroendocrine responses to shock  Glucocorticoids  Result?  Catecholamines Phase 2  Result? Compensat  Vasopressin (ADH) ory  Hint- Released from the pituitary it promotes water retention which will have what result?  Consider the nursing assessments and interventions in this phase of shock, you can help turn it around!   Hypotension is persistent Systolic Septic Shock  Hypoperfusion Distributive  Hypotension  Lactic acidosis Sepsis  Oliguria  Fluid shifting from vascular space (relative hypovolemia/endotoxins)   Clinical Manifestations Classificatio Tachycardia and Hypotension   High Cardiac Output with Low n of Shock: Systemic Vascular Resistance Distributive High CO Heart Failure   Wide Pulse Pressures  Difference between the systolic and diastolic BP Sepsis  Bounding pulses  Fever or Hypothermia  Increased SVO2  Decreased CVP (decreased preload)   Prognosis/Mortality  Single organ failure 10-20% Classificatio  Two organ failure 20-45% n of Shock: Three organ failure 60-75%   Four organ failure 80-90% Distributive Sepsis related organ failure includes: Lungs, heart, kidneys, liver and Sepsis coagulation factors (think DIC) *Would this patient have a high or low SVO2? Classificatio  What are your nursing n of Shock: priorities for the patient in Distributive Septic shock?  What are some treatment options? Sepsis   Tension Pneumothorax  Compresses the heart - >emergent chest tube Classificatio  Cardiac Tamponade n of Shock:  Becks Triad  - Hypotension, Increased CVP (JVD), Obstructiv Muffled heart tones e  Pulmonary Embolism  Pulmonary artery blocked - >decreased filling of Left ventricle, decreased CO, Decreased O@ delivery   Pump Failure  Acute MI Classificatio  Cardiomyopathy n of Shock:  Myocardial contusion Cardiogen  Myocarditis ic  How would this patient present?  What drugs would you anticipate using and why?   Clinical Manifestations: Classificatio  Tachycardic, dysrhythmias n of Shock:  Decreased Cardiac output  Tachypnea Cardiogen  Crackles ic  Weak and thready pulses  Diminished heart sounds  Decreased urine output   Quick video on the different types of shock, let’s wrap it up  http://www.emdocs.net/em-in-5- shock/ Differentiati ng Shock States  Khan academy, this is good for studying  https://www.youtube.com/watch?v=CY oxfm0kcsQ  Mixed venous O2 can also be stated SVO2 (the video uses MVO2).   Sedatives will lower blood pressure, be cautious when you administer  Positive pressure ventilation decreases preload Pearls of  Mechanical ventilation can be helpful because respiratory distress greatly wisdom increases VO2 and contribute to lactic acidosis  This didn’t happen over night; we aren’t going to fix it overnight - slow and steady wins the race. Multiple Organ Dysfunction Syndrome MODS   Multiple Organ Dysfunction Syndrome (MODS) can be also called Systemic Inflammatory Response Syndrome (SIRS) Multiple  It can result from injury or infection Organ  It creates Dysfunction Hypoxia   Anaerobic metabolism Syndrome  Lactic Acidosis (MODS)  Unregulated apoptosis due to inflammation  Disrupted blood flow -> micro vascular coagulopathy DIC Pathway  MODS Discussion  CUES: ANALYZE: HYPOTHESIS:  Neuro  Cardiac (myocardium)  Pulmonary  Gastrointestinal  Hepatic  Pancreatic  Renal (think perfusion)  Hematologic   ASSESS and REASSESS  Control Infection  Enhance perfusion MODS  Initiate renal replacement Nursing therapy (CRRT) ECMO Actions &   Heparin Considerati  Mechanical Ventilation ons  Glucose Control and Enteral Feeds  Educate Family  Prognosis 40-80% mortality