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CRNA1982 2,712 Views

Joined Jun 14, '08. Posts: 99 (61% Liked) Likes: 135

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  • Nov 29 '11

    crna, and gilda are some pretty smart people....they know their stuff. i'd listen to them if they were talking to me......

    septic shock is a medical emergency caused by decreased tissue perfusion and oxygen delivery as a result of severe infection and sepsis, though the microbe may be systemic or localized to a particular site. it can cause multiple organ dysfunction syndrome (formerly known as multiple organ failure) and death. its most common victims are children, immunocompromised individuals, and the elderly, as their immune systems cannot deal with the infection as effectively as those of healthy adults. frequently, patients suffering from septic shock are cared for in intensive care units. the mortality rate from septic shock is approximately 25-50%.

    in humans, septic shock has a specific definition requiring several criteria for diagnosis:

    • first,sirs (systemic inflammatory response syndrome) must be met by finding at least any two of the following:
    tachypnea (high respiratory rate) > 20 breaths per minute, or on blood gas, a pco2 less than 32 mmhg signifying hyperventilation.white blood cell count either significantly low, < 4000 cells/mm or elevated > 12000 cells/mm.heart rate > 90 beats per minutetemperature: fever > 38.5 c (101.3 f) or hypothermia < 35.0 c (95.0 f)
    • second, there must be sepsis and not an alternative form cause of sirs. sepsis requires evidence of infection, which may include positive blood culture, signs of pneumonia on chest x-ray, or other radiologic or laboratory evidence of infection
    • third, signs of end-organ dysfunction are required such as renal failure, liver dysfunction, changes in mental status, or elevated serum lactate.
    • finally, septic shock is diagnosed if there is refractory hypotension (low blood pressure that does not respond to treatment). this signifies that intravenous fluid administration alone is insufficient to maintain a patient's blood pressure from becoming hypotensive
    a subclass of distributive shock, shock refers specifically to decreased tissue perfusion resulting in ischemia and organ dysfunction. cytokines released in a large scale inflammatory response results in massive vasodilation, increased capillary permeability, decreased systemic vascular resistance, and hypotension. hypotension reduces tissue perfusion pressure causing tissue hypoxia. finally, in an attempt to offset decreased blood pressure, ventricular dilatation and myocardial dysfunction will occur.

    "the syndrome of septic shock supervenes; the same cytokine and secondary mediators, now at high levels, result in systemic vasodilation (hypotension), diminished myocardial contractility, widespread endothelial injury and activation, causing systemic leukocyte adhesion and diffuse alveolar capillary damage in the lung activation of the coagulation system, culminating in disseminated intravascular coagulation (dic)."

    http://www.oucom.ohiou.edu/dbms-witm...2002-26-02.pdf

    the hypoperfusion resulting from the combined effects of widespread vasodilation, myocardial pump failure, and dic causes multiorgan system failure that affects the liver, kidneys, and central nervous system, among others. unless the underlying infection (and lps overload) is rapidly brought under control, the patient usually dies.

    treatment primarily consists of the following.
    1. volume resuscitation
    2. early antibiotic administration
    3. early goal directed therapy
    4. rapid source identification and control.
    5. support of major organ dysfunction.
    among the choices for vasopressors, norepinephrine is superior to dopamine in septic shock. both however are still listed as first line in guidelines.

    antimediator agents may be of some limited use in severe clinical situations however are controversial:

    1) low dose steroids (hydrocortisone) for 5 - 7 days led to improved outcomes.
    2) recombinant activated protein c (drotrecogin alpha) reviews comment that it may be effective in those with very severe disease.

    http://www.umm.edu/ency/article/000668.htm

    http://ccn.aacnjournals.org/content/25/2/14.full

    the drug choice for sedation, however, contributed to your patients instability and inability to be sedated effectively. i have worked at many facilities over the years and i have to say i am still amazed at what still goes on in some facilities to this very day in smaller corners of the united states that are sitting right in the middle of the research mecca in the northeast and i shake my head everytime i put someone in an ambulance for their 45 min ride for an angiogram and the tenacity if some phycisians that are the big fish of their little sea to absolutely refuse to reliquish their beliefs, preferances and control and that the only reason they haven't been eaten alive by the staff is that they are local(and the doctor is right) and usually (and that's a big usually) have never worked elsewhere.

    so for drug choice you are pretty stuck. i would ask for the fentanyl and ativan/versed the next ime this situation arises and avoid propofol unitl the patient has been properly fluid resuscitated. but given the circun=mstances i'd still say good job!!

  • Nov 29 '11

    A patient in septic shock needs aggressive fluid resuscitation, which 2L is not. You have to dump those fluids in as fast as you can; worry about fluid overload later.

    I agree, Fentanyl and Versed is a nice combo, and it wouldn't have hurt to get an order for a single dose of Vec.

    We use a LOT of Propofol in my ED; but, if the patient's pressure can't handle it, we have to look at alternatives.

    I'll never forget the kiddo with the skull fracture and head bleed I had to get to the OR with his ET tube still in place. I started the Propofol gtt at the pediatric dose, but it wasn't cutting it, and I had to keep bolusing the kid. I tried titrating the gtt, but our pumps have hard limits that you can't override, and I couldn't override the limit on the peds setting. I was bolusing the kid all the way from the ED to the OR to keep him from pulling out his tube (even with soft wrist restraints on, his efforts were admirable), and the anesthesiologist met us at the door to the OR with a syringe of Vec. It was like one of those moments where the clouds part and the shaft of light shines down. Lesson learned, do NOT use the pediatric settings on the IV pumps, and ask for an order for Vec prior to transport!

    Anyway, I agree, bad choice of drugs for the situation, but it sounds like you did a good job dealing with what you had to deal with. The fact that a lot of us have to do our learning on the job, in the moment, is unfortunately the nature of the beast. Better clinical education would help immensely!

  • Nov 26 '11

    Another agree regarding the atracurium. I am a big fan of fentanyl in patients who are haemodynamically compromised. Also, another good consideration in some septic patients is ketamine. You can have issues with catecholamine depleted patients; however, this is probably a better option than using large amounts of Diprivan.

    Another issue that we run into is blowing the ventilator management. We often neglect patient/ventilator interaction at the cost of having very uncomfortable patients and haemodynamic complications.

  • Nov 26 '11

    Quote from CRNA1982
    Wow! All the wrong drugs were used in this case for both muscle relaxation and sedation. What kind of a doctor orders these drugs? Atracurium is a dead drug.....I can't even believe that a pharmacy dispenses this to pts. on a unit. Atracurium causes significant histamine release; that is why it is rarely used anymore as there are much better muscle relaxants available at a similar price without histamine release. When dealing with a hemodynamically unstable pt. why give drugs causing histamine release leading to further hypotension? Then he orders a propofol gtt.....A little versed fentanyl get could have produced adequate sedation and analgesia without the massive drop in SVR that propofol would cause. Septic pts. already have no SVR, why add to the problem with a propofol gtt?
    I agree.....sounds like thie nurse did great in light of the fact being left with sedation orders that weren't the best. I have found that there are little corners in the US where these dead drugs are still being given because they are cheap or the medical directors are hanging on to their personal preferences leaving the nurse to fight with for the patient to have good care. The OP said "when I got him to the ICU" which must have meant the patient was on stepdown (on dopa prior to code) coded and cared for on gthe floor then finally transfered.

    OP the patient needed more fluid as septic patients can require massive amounts of fluid and the choice of drugs to be given could have been better.....Proprfol causes a drop in the SVR so in the septic patient that needs fluid when the SVR drops further and needs fluid hypotension ensues. MOre fluid would have helped but it sounds like you did a great job under the circumstances.

    As far as the ICU nurses glares.......simply ignore them, smile sweetly, offer to help and pretend not to see their display. They are just unhappy at the situation of moving someone out and a really sick one in and probably close to shift change. If I was the super I'd take the time later to call them out on bad behavior........I don't like that passive aggressive baloney......being an ICU nurse myself.

    Good Job.

  • Nov 15 '11

    If doctor tell the patient has cardiac arrest after putting up for 3 days on ventilator and we have reversed the arrest by giving shock and still the patient has been put on ventilator with full support and high dosage of drugs. And if there is movement in the eye balls and eye lashes are up and down , what does it mean?

  • Nov 11 '11

    Quote from CRNA1982
    I can't say I have ever seen a pt. with a carpal spasm secondary to C-spine nerve impingement. Usually they present with paresthesias (numbness/tingling in upper extremities)
    horses and zebras....

  • Sep 12 '11

    Quote from Mulan
    Don't the CRNAS usually read and post in the CRNA forum?
    Well, if that's the way it has to be, then I guess all of the students will have to hang out in the student forum and the CRNAs will hang out in their forum..and never the twain shall meet......Rhody won't like that one at all....

  • Sep 11 '11

    Quote from CRNA1982
    I often log on to Allnurses.com to read and discuss clinical issues to better my knowledge and understanding of medicine. Instead, I continue to find people complaining about lazy co-workers and inferior nurses. Everyone has lazy co-workers in any field of work.......Get used to it. How about discussing something relevant to our profession? That is why we are here....right?
    And this seems to be occuring at an alarming rate...I also would like to see more clinical issues discussed.
    As far as the student nurses finding these threads helpful on how NOT to act...well:

    1. I would think you would already have a clue as a future professional..how to act..not rely on a website to guide your actions in your clinical practice, this was pretty obvious. I was able to somehow muddle through quite successfully 18 years ago when I first started practice without consulting Allnurses.com.
    2. There is a perfectly good student nurse thread which should address all of your SN concens, perhaps you should log on to that site.
    It does get tedious after awhile with the lazy co worker vent......

  • Jun 5 '11

    Quote from naijanurse
    Last night while taking care of a patient, I was exposed to their bodily fluid. (I won't go into details, because it was kinda gross). I felt it hit my face, on my right cheek. I wasn't sure if it hit my eye or not, but immediately took my contacts off, and irrigated my eyes with water. This patient has known communicable diseases, so I was really freaked out. I told my charge, who said since I wasn't 100% sure it hit my eye, that rinsing it alone should be ok. I didn't feel comfortable with that, and ended up going to the ER for more aggressive irrigation. They also tested me for diseases. I was down there for longer than I thought I was going to be, and ended up giving report to the next oncoming nurse over the phone. I felt kinda bad leaving the floor short while I was in the ER, but my health comes first. What would you guys have done?
    Hmmm, well I guess I'm going to be the lone naysayer here. In the time between when your (possible) exposure first occurred, you flushed your eyes, spoke with your charge nurse, went to the ED, then received eye irrigation, I think that *if* (and odds are low) any transmission occurred, it would have already occurred by the time you got your eyes irrigated in the ED. I think the most significant outcome is that it made you feel better, but doubtful that it actually had any disease transmission preventing properties.

    As far as rapid testing goes, both HCV and HIV have incubation periods. The only thing accomplished by going to the ED and getting tested immediately is to determine that you aren't already infected. It has nothing to do with telling you whether disease transmission occurred during your (possible) exposure.

    I do think your charge nurse's attitude was a bit laissez faire, but it is reasonable that you could have waited to to to Employee Health on the next business day and have your blood drawn then, and be evaluated for risk of transmission. This is one of the many services that Employee Health provides.

    Before you ask, yes, I have experienced body fluid exposure. I know it's scary when this happens. However, I don't think it justified rushing off to the ED and leaving your floor down a nurse. You absolutely should have filled out whatever form is required, whether it be incident report or employee injury report, according to your facility's policy.

    Flame away. Just keep in mind that it's already been established that I am heartless, lack compassion, and am nuts.

  • Mar 11 '11

    You're absolutely right, CRNA1982, that was a generalized statement, and I apologize. In my haste to reply, I neglected to make it clear that I was referring only to this one CRNA and a few docs. I work with amazing anesthetists, surgeons, CRNA's, RN's, and techs every day. My message was in no way intended to malign the good, hardworking, patient-care minded folks. I offer my humblest apologies for my mis-statement.

  • Mar 11 '11

    Also - worth flipping it around too.
    Surgeons have had to tolerate me too ...with all my gaffes and relative lack of knowledge.
    And I'm sure not perfect - things have been known to fly out of my mouth sometimes

  • Aug 5 '08

    Forgive me for the tirade...but this is a peeve of mine:

    Besides the "minimum" pre-requisite for ICU experience.....

    What do you think it takes to be a CRNA? Or pass each hurdle as an SRNA?

    You need a variety of top-notch critical care experienceS. You have to understand invasive lines...be aggressive in treating patients. You need excellent hands-on skills. This doesn't come with "1 year" ICU experience. You need to be one of the best in the ICU...the one that races to codes. You should have the multi-tasking experience of floor nursing and the fast pace of ER.

    Plus, the most valuable thing that critical care provides is the extra "sense" when things just aren't right. That "sense" will save your butt way too many times....it will keep you from killing your patient.

    A surgeon once told me, "For me to kill my patient..almost impossible. FOR YOU (with anesthesia) you can kill every patient, in less than 2 minutes!"

    Think about that. Anesthesia is deadly. You need to be an expert in critical care and airway management, because you're the one putting that patient into the deadly situation.

    Would you want someone doing anesthesia on your family, with only a basic understanding of health care? The minimum ICU? Without that "critical care sense"?

    Even as a Paramedic for 13 years, CVICU, Neuro-surgical/Trauma ICU, and Trauma ER experience......it hasn't been enough.

    It's not just getting accepted....it's about surviving and excelling! It's about being at the top of your game, being thrown back to the bottom (trampled), and climbing your way back to the top. !

    Sorry if I sound harsh. But I guarantee anyone who's experienced anesthesia education will agree.



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