Shock and Transfusion

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HuskerDevil
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87087
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Shock and Transfusion
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2011-05-21 22:36:32
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DPAP2012 Shock Transfusion
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Shock and Transfusion cards made by previous students
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  1. defined as any condition in which there is inadequate delivery of oxygen and nutrients to the tissues to meet metabolic demands
    Shock
  2. General signs/symptoms of shock
    • mental status changes,
    • acidosis,
    • oliguria,
    • poor cutaneous perfusion (cool, pale skin).
  3. a function of the cardiac output and the oxygen carrying capacity of the blood
    Oxygen delivery
  4. divisions of shock
    • failures of the heart,
    • failures of the blood,
    • failure the vessels
  5. hemodynamic responses to compressive cardiac shock
    • decreased cardiac output,
    • increased heart rate,
    • large increase in LV filling pressures
  6. hemodynamic responses to cardiogenic shock
    • large decrease in cardiac output,
    • increase in filling pressures
  7. hemodynamic responses to hypovolemic shock
    • decreased cardiac output,
    • increased heart rate,
    • large decrease in LV filling pressure,
    • increased systemic resistance
  8. hemodynamic responses to septic shock
    • increased cardiac output,
    • increased heart rate,
    • large decrease in systemic resistance
  9. shock due to pump failure can be due to
    extrinsic compression of the heart, or intrinsic heart failure
  10. results when compression of the great veins or heart itself retards blood return to the heart
    cardiac compressive shock
  11. examples of cardiac compressive shock
    • pericardial tamponade,
    • tension pneumo,
    • diaphragmatic rupture,
    • positive pressure ventilation
  12. With cardiac compressive shock, in addition to general signs of shock, physical exam reveals
    • hypotension,
    • distended neck veins,
    • pulmonary rales,
    • Kussmaul's sign,
    • pulsus paradoxus
  13. rise in JVP with inspiration
    Kussmaul's sign
  14. exaggerated decrease in systolic pressure with inspiration
    pulsus paradoxus
  15. definitive treatment for cardiac compressive shock
    correction of the mechanical abnormality
  16. can result from failure of the heart muscle, arrhythmia, valvular or septal defects, or excessive afterload
    cardiogenic shock
  17. Physical exam of a patient in cardiogenic shock may reveal
    signs of compensatory volume overload: distended neck veins, pulmonary rales, extra heart sounds, peripheral edema
  18. in cardiogenic shock due to inadequate pumping, improve pump function with
    inotrope (dopamine, dobutamine), intra-aortic balloon pump
  19. in cardiogenic shock due to excessive afterload, reduce afterload with
    vasodilators (ACEI's and nitrates)
  20. in cardiogenic shock due to arrhythmias, optimize heart rate and rhythm with
    • beta-blockers,
    • anti-arrhythmics,
    • pacemakers
  21. in cardiogenic shock optimize volume status by
    being cautious with fluid administration, and use diuretics if in CHF
  22. one of the most common causes of shock encountered in the practice of surgery
    hypovolemic shock
  23. Hypovolemic shock may be due to blood loss as well as from
    • third spacing,
    • protracted vomiting,
    • diarrhea,
    • sweat
  24. the sequestration of fluid into injured soft tissues or bowel
    third spacing
  25. hypovolemia leads to
    decreased venous return to the heart and decreased cardiac output
  26. decreased venous return to the heart
    preload
  27. mild hypovolemia
    • <20% blood volume loss-
    • decreased pulse pressure,
    • postural hypotension,
    • cutaneous vasoconstriction,
    • collapsed neck veins,
    • concentrated urine,
    • hemoconcentration
  28. moderate hypovolemia
    • 20-40% blood volume loss-
    • thirst,
    • tachycardia,
    • moderate hypotension,
    • oliguria
  29. severe hypovolemia
    • >40% blood volume loss-
    • mental status changes,
    • arrhythmias,
    • ischemic EKG changes,
    • profound hypotension
  30. systolic pressure - diastolic pressure = __
    pulse pressure
  31. treatment for hypovolemic shock
    • Large-bore IV.
    • Resuscitation should always begin with crystalloid infusion—30 cc/kg (2 liters for most adults) as fast as possible then titrate against signs of clinical improvement.
    • Blood products may be appropriate in situations of blood loss.
  32. loss of venous tone results in
    venous pooling with decreased blood return to the heart (preload) and decreased cardiac output
  33. loss of arterial tone results in
    decreased systemic vascular resistance (SVR) and hypotension.
  34. neurogenic shock
    is a failure of the autonomic nervous system due to spinal cord injury or regional anesthetics
  35. injury above the level of __ results in a loss of sympathetic tone and adrenergic stimulation
    T4
  36. physical signs of neurogenic shock may include
    warm, flushed skin, and bradycardia
  37. in neurogenic shock the loss of venous tone is exacerbated by
    the loss of muscle tone
  38. treatment of neurogenic shock
    • IV fluids are the initial therapeutic agent since loss of venous tone results in relative hypovolemia.
    • Peripheral vasoconstrictors are often required
  39. Septic shock is a complex phenomenon most commonly due to overwhelming infection from __ but can be due to any type of infection
    gram negative bacteria
  40. In early septic shock, the response is __
    hyperdynamic with tachycardia and increased cardiac output
  41. In late septic shock __
    the cardiovascular system decompensates and progresses to a hypodynamic state
  42. Early clinical manifestations of septic shock include __
    fever, chills, bounding pulses, and warm, flushed skin in the setting of hypotension
  43. signs of progression to late septic shock are __
    Hypothermia, coagulopathy, pulmonary failure (ARDS), and renal failure
  44. definitive treatment of septic shock
    clearance of the offending infection (surgical debridement or resection, appropriate antibiotic therapy)
  45. Potential indications for the transfusion of blood products
    • the restoration and maintenance of normal blood volume
    • the correction of severe anemia
    • the correction of bleeding and coagulation disorders
  46. effect of administration of one unit of PRBC's
    Hct increase by 3%
  47. effect of administration of one unit of platelets increases platelets county by __
    40000
  48. effect of administration of one unit of cryoprecipitate
    increase in fibrinogen by 3%
  49. indication for administration of PRBC's
    hypovolemia + anemia, symptomatic anemia
  50. indication for administration of platelets in the presence of bleeding
    plts <50,000 plts <15,000 (asymptomatic)
  51. indication for administration of FFP
    • bleeding + coagulopathy,
    • coumadin reversal
  52. indication for administration of Cryoprecipitate
    fibrinogen <100 mg/dL
  53. platelets are given for the correction of
    thrombocytopenia
  54. indication for administration of platelets for asymptomatic thrombocytopenia
    plts <15,000
  55. a pool of platelets from six donors
    six_pack
  56. FFP is given for the correction of the __
    vitamin K dependant clotting factors
  57. FFP contains
    • serum clotting factors (except VIII, and V),
    • antithrombin III,
    • fibrinogen,
    • proteins C and S
  58. is a plasma component that is enriched for high-molecular-weight proteins
    Cryoprecipitate
  59. is a plasma component that is enriched for fibrinogen, factor VIII, factor XIII, and von Willebrand's factor
    Cryoprecipitate
  60. occur when the recipient possesses antibodies against the donor RBC’s major (A, B, and Rh) or minor (Kell, Kidd, Duffy, et al.) antigens.
    Hemolytic reactions
  61. acute (major) hemolytic reactions occur at the rate of 1/__ units
    20000
  62. delayed(minor) hemolytic reactions occur at the rate of 1/__ units
    500
  63. symptoms of hemolysis
    • apprehension,
    • headache,
    • fever,
    • chills,
    • flank or chest pain,
    • hematuria,
    • and (in severe cases) hypotension
  64. Febrile nonhemolytic reactions may occur against
    donor WBC's
  65. Disease transmission due to transfusion
    is a rare but real phenomenon
  66. rates of CMV transmission from blood products __% unless CMV-negative requested
    50
  67. rate of HIV transmission from blood products
    1/400,000-1/600,000
  68. rate of Hep C transmission from blood products
    1/3000-1/6000
  69. rate of Hep B transmission from blood products
    1/50,000-1/200,000
  70. __due to the chelating action of the preservative sodium citrate can contribute to coagulopathy and should be corrected
    Hypocalcemia
  71. __ can be associated with multiple transfusions of PRBC’s.
    Dilutional coagulopathy
  72. Some hemolysis of cells occurs during storage and administration, delivering an additional __ load to the recipient
    potassium
  73. A __ device can filter blood collected during clean procedures and return it to the patient
    “cell-saver”
  74. Autotransfusion is an option for elective operations where significant blood loss is expected. The patient should ideally donate more than __ week prior to operation
    1
  75. most common congenital abnormality of platelets
    von Willebrand's disease
  76. five causes of shock
    • cardiogenic,
    • hypovolemic,
    • septic,
    • neurogenic,
    • anaphylactic
  77. MI, cardiomyopathy, valvular disease, rhythm disturbances, Pulm HTN, cardiac tamponade, tension PNX, diaphragm rupture (heart is compresed), PPV
    Cardiogenic shock
  78. hemorrhage, severe dehydration, vomiting, diarrhea
    Hypovolemic shock
  79. infection due to GNRs causing SIR, MOF, arterial vasodilation
    Septic shock
  80. Spinal cord injury above T4 results in loss of sympathetic tone/adrenergic stimulation, regional anesthetics
    Neurogenic shock
  81. hypersensitivity reaction
    Anaphylactic shock
  82. initial treatment for cardiogenic shock
    • optimized volume status without overloading lungs,
    • decrease afterload (ACEI, Nitrates),
    • Heart rate control (betablockers, anti-arrhythmics, pacemaker),
    • Inotropy (dobutamine, dopamine, milrinone, IABP, VAD’s, revascularization)
  83. initial treatment for hypovolemic shock
    fluid resuscitation
  84. initial treatment for neurogenic shock
    • vasoactive agents may be needed,
    • use fluid cautiously (watch for non-cardiac pulmonary edema)
  85. initial treatment for septic shock
    • treat underlying cause,
    • try to identify organism,
    • start broad spectrum empiric therapy, then narrow down when you find out the specific organism
  86. indication for administration of platelets as prevention before surgery
    plts <15,000
  87. most common reason for ABO mismatch
    clerical error
  88. every unit of blood you give __ the patient
    immunocompromises
  89. hypocalcemia can lead to
    decreased cardiac contractility, increased bleeding
  90. hyperkalemia in a transfusion patient can be due to
    hemolysis
  91. be cautious in transfusing patients who are __
    immunocompromised (HIV, on steroids, organ transplant)
  92. signs and symptoms of anemia
    • fatigue,
    • tachycardia,
    • hypotension,
    • mental sluggishness/disorientation,
    • shortness of breath
  93. __ reverses warfarin
    FFP or Vitamin K
  94. __ may need platelet transfusions no matter what the platelet count
    bleeding patients whose platelets have been impaired by aspirin or NSAIDs
  95. bleeding after cardiopulmonary bypass may be due to inadequate neutralization of heparin. Giving __ in this setting may worsen the bleeding because __ provides antithrombin III
    FFP
  96. microvascular bleeding often indicates a
    platelet defect
  97. __ impairs platelet function and can prolong bleeding
    hypothermia
  98. blood should never __
    be infused with medications or solutions other than saline
  99. __ may result in significant blood loss without obvious bleeding
    extensive tissue injury
  100. the first BP change seen in hypovolemia. when present it means class II hemorrhagic shock
    increase in diastolic pressure
  101. systolic hypotension is a sign of
    class III hemorrhagic shock
  102. agitation is another sign of
    shock
  103. profound hypotension and apathy are signs of
    class IV hypovolemic shock
  104. a normal 70 kg man has about __L of blood volume
    5
  105. Humoral host defenses
    antibody, complement
  106. ACT AS THE FIRST LINE OF CELLULAR DEFENSE
    macrophages
  107. cellular host defenses
    macrophages, t-cells
  108. What do cytokines do in infection
    recruit macrophages
  109. phases of wound healing-inflammation days __
    1-10
  110. epithelialization, PMNs & macrophages
    inflammation phase of wound healing
  111. proliferation phase of wound healing days __
    5-3 weeks
  112. neovascularization, collagen production, granulation tissue, fibroblasts
    proliferation phase of wound healing
  113. remodeling phase of wound healing weeks __
    3 weeks - 1 year
  114. type III collagen replaced by type I, collagen cross-linking
    remodeling phase of wound healing
  115. order of arrival of cells to wound
    PLTs, PMNs, macrophages, fibroblasts, lymphocytes
  116. organism from dog bites
    streptococcus viridans
  117. organism from cat bites
    pasteurella
  118. with animal bites consider
    tetanus, rabies, Augmentin, cephalexin
  119. uninfected operative wound in which no inflammation is encountered the respiratory, alimentary, genital or infected urinary tract is not entered
    clean wound
  120. Respiratory, alimentary, genital or urinary tracts are entered under controlled conditions, no unusual complications
    clean contaminated wound
  121. open, fresh, accidental wounds; operations with major breaks in sterile technique or gross spillage from the gastrointestinal tracteg. Gunshot wound to colon
    contaminated wound
  122. old traumatic wounds with retained devitalized tissue, those that involve existing clinical infection or perforated visceraeg. Abscess
    dirty
  123. perioperative antibiotics are given
    1 hour prior to skin incision
  124. choice of antibiotics depends on
    type of operation
  125. surgical prophylaxis with first generation cephalosporin (Ancef) if
    no anaerobes are expected
  126. surgical prophylaxis with second generation cephalosporin (Cefotetan) if
    anaerobic activity is likely
  127. in a rapidly spreading infection think about
    necrotizing fasciitis
  128. necrotizing fasciitis can be caused by
    clostridium perfringens, streptococcus (GABHS)
  129. aka. Strep gangrene, Fournier's gangrene, flesh eating disease
    necrotizing fasciitis
  130. severe infection that leads to necrosis of the subcutaneous tissue and adjacent fascia
    necrotizing fasciitis
  131. mortality rate in patients with necrotizing fasciitis __%
    40
  132. treatment for __ includes broad-spectrum antibiotics, including Penicillin G,+ aggressive surgical debridement!
    necrotizing fasciitis
  133. Must have high index of suspicion for __ when Skin discoloration, necrosis, crepitus, drainage of thin Watery, grayish, foul-smelling fluid present.
    necrotizing fasciitis
  134. antibiotics usually not helpful with
    Post-op Wound infection>48 hours 5-10 days post-op
  135. local infection of the dermis and subcutaneous tissue characterized by spreading redness, swelling and pain
    cellulitis
  136. blanching erythema
    cellulitis
  137. #1 risk factor for development of pneumonia after surgery
    bed rest
  138. most common post-operative infection
    UTI
  139. four W's of fever
    • wind,
    • water,
    • wound,
    • wonder drugs
  140. #1 cause of post op fever
    atelectasis
  141. atelectasis occurs < post operative day __
    3
  142. UTI occurs post operative day __
    3
  143. fever for wound infection occurs post operative day __
    5
  144. Abscess/pus collection in thorax
    Empyema
  145. diarrhea in the hospital is usually from infection due to overgrowth of
    clostridium difficile

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