case study #2 pp
TRANSCRIPT
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Septic shock on pressor support
Megan Malek
BHS Dietetic Intern
Case Study #2
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Overview
• Stages of Sepsis
• Pressor Support
• Nutrition & Septic Shock
• Associated Research Articles
• Introduce Patient
• Review Patient Care
• Summary & Conclusion
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Stages of Sepsis
Sepsis Severe Sepsis
Septic Shock
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Sepsis1
Immune response to a severe infection that has spread via the bloodstream
• Fever >101.3°F • Hypothermia <96.8°F • Heart rate > 90 beats/min • Tachypnea (rapid breathing) • Altered mental status • Edema • Hyperglycemia
• Inflammatory variables • Hemodynamic variables • Hypotension
• Organ dysfunction variables • Tissue-perfusion variables
Symptoms: (+infection plus ≥ 1 of the following)
Definition:
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Severe Sepsis1
Definition:
Sepsis complicated by tissue hypoperfusion or acute organ dysfunction
Symptoms:
• Sepsis-induced hypotension • Elevated lactate (>0.5-1
mmol/L) • Low urine output (<0.5mL/
kg/hr for >2hrs depsite fluid replacement)
• Acute lung injury
• Creatinine >2.0 mg/dL • Bilirubin >2 mg/dL • Platelet Count <100,000 • Coagulopathy
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Septic Shock1,2
Definition:
Severe sepsis complicated by either hypotension that is resistant to fluid replacement or by hyperlactatemia
Symptoms:
• Any symptom of severe sepsis
• Hypotension
• Cold skin
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Etiology3
Sepsis can be caused by any type of infection-bacterial, fungal, or viral
Most Common:
• Pneumonia*
• Kidney infection
• Abdominal infection
• Bacteremia
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Risk Factors3
Risk Factors
• Age- Infants & Elderly
• Compromised immune system
• Preexisting illness, injury, or wound
• Presence of invasive device (intravenous catheter or intubation)
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Prevalence & Prognosis
Prevalence3
Incidence of sepsis appears to be increasing in the US, possibly due to:
• Aging population
• Drug-resistant bacteria
• Weakened immune systems
Prognosis4
• Mortality for septic shock is ~50%
• Higher risk for future infections
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Treatments1
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What are vasopressors?1
• Vasopressors: Compounds that raise reduced blood pressure via vasoconstriction
• Inotropes: Compounds that increase cardiac contractility.
• Many drugs have both vasopressor & inotropic effects
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Nutrition & pressors5
• ASPEN & SCCM suggest withholding EN in hemodynamically unstable patients on “high-dose” catecholamine therapy until stable, while advocating for the cautious use of EN in patients on “low-dose” catecholamines. • However, the definition of “low-dose” is not well defined.
• BHS guidelines: • Start feeds when pressors are ≤0.1 mcg/kg/min
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Terminology6
• Splanchnic circulation- Celiac artery (liver, stomach, spleen, pancreas); Superior mesenteric artery (pancreas, SI, colon); Inferior mesenteric artery (colon)
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Nutrition & pressors5
• In hemodynamically unstable patients, enteral nutrition will increase splanchnic oxygen demand, rather than increase cardiac output
• If the body is not able to meet this demandà splanchnic ischemia ensues
• Other complications include: small bowel necrosis (abdominal pain, distention, high NG output, ileus)à mortality
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Vasoactive agents4,5 Drug Recep
tor Typical Dosing mcg/kg/min
Pathophysiology Clinical Uses GI Effects
Epinephrine α β1 β2
Dose: 0.05 - 0.5 Max: 1
Arterial vasoconstriction, contracts heart, peripheral vasodilation
Shock, cardiac arrest, anaphylaxis, heart block, bradycardia
ê splanchnic blood flow
Norepinephrine (Levophed)
α* β1
Dose: 0.05 - 1.5 Max: 3
Arterial vasoconstriction, contract heart
Septic shock é gastric pH, é splanchnic blood flow, êmucosal blood flow
Dopamine Dopa α β1
Dose: 5 – 20 Max: 50
Vasodilation in renal & mesenteric beds, arterial vasoconstriction, contracts heart
Septic shock, bradycatdia
ê pH, éoxygen delivery, precapillary vasoconstriction, êmucosal blood flow
Phenylephrine α Dose: 0.4 – 9.1 Arterial vasoconstriction Septic shock, hypotension
Dobutamine β1 Dose: 2.5 Max: 40
Contracts heart Heart failure êGI mucosal blood flow, égastric intramucosal pH
Vasopressin (ADH)
V1 Dose: 0.01 – 0.04 U/min
Constricts vascular smooth muscle & increases uptake of catecholamines
Hypotension, septic shock, GI bleed, esophageal varices, diabetes insipidus, ê pressor needs
éintestinal vasoconstriction
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Tolerability & Safety of Enteral Nutrition in Critically patients receiving Intravenous Vasopressor therapy7 (Mancl & Muzevich, 2013)
Obj:
Evaluate the tolerability & safety of EN in critically ill patients receiving IV vasopressor therapy
Methods:
Retrospective medical record review was conducted in an urban academic medical center 259 adult ICU patients who received concomitant EN & IV vasopressor
therapy for ≥1 hr.
(EN tolerance was defined as an absence of gastric residuals ≥300 mL, emesis, positive finding on abdominal imaging, and evidence of bowel ischemia/
perforation.)
Vasopressor dosage was converted to norepinephrine equivalents using this formula: norepinephrine equivalents= [norepinephrine (mcg/min)] + dopamine
(mcg/kg/min) ÷ 2] + [epinephrine (mcg/min)] + phenylephrine (mcg/min) ÷ 10] + [vasopressin (units/h x 8.33]
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Tolerability & Safety of Enteral Nutrition in Critically patients receiving Intravenous
Vasopressor therapy7 (Mancl & Muzevich, 2013)
Results:
259 patients received 346 episodes of concomitant EN & IV vasopressor therapy with a 74.9% overall tolerability. Adverse events included:
• Rising serum lactate (30.6%)
• Elevated gastric residuals (14.5%)
• Emesis (9%)
• + findings on kidney/ureter/bladder imaging (4.3%)
• Bowel ischemia/perforation (0.9%)
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Tolerability & Safety of Enteral Nutrition in Critically patients receiving Intravenous
Vasopressor therapy7 (Mancl & Muzevich, 2013)
Results cont’d:
Patients who tolerated EN received a lower max norepinephrine equivalent dose compared with those who
did not tolerate EN (12.5 vs 19.4 mcg/min, P=.0009)
Patients who never prescribed vasopressin during the overlap periods were more likely to tolerate EN compared to those who received vasopressin (77.9% vs 58.9%,P=.0027) and
likewise for dopamine (77.6% vs 63.8%, P=.018)
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Application to patient
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Patient Overview
• Pseudo-name: Ms. A
• 62 y.o. female
• Caucasian
• Single
• Admit c/o: generalized weakness
• Initial Dx: Septic shock 2/2 PNA and/or + UTI, ARF
• LOS: 16 days
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Patient history
• Adolescence-onset paranoid schizophreniaà placed in state hospital at age 20 for most of lifeà moved around to numerous LTACs, shelters, and sister’s home
• All information obtained from current boarding home director
• Pt is “difficult to manage, must be watched very closely, poor boundaries, continuously tried to escape, will eat out trash cans, very aggressive at times, not suicidal, however quite paranoid”
• Pmh: CAD, CHF, HTN, hypothyroidism, DMT2, CKD, smoker
• Previous diet: Regular
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Anthropometrics
• Ht: 5’10 (70 in)
• Wt: 268 lb (122kg)
• IBW: 150 lb (68 kg)
• %IBW: 180
• ABW: 180lb (82kg)
• BMI: 38.4 - Obese
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Review of events prior to visit
• 1/27-PCU:+ UTI, hypotension (86/40) • Started on Rocephin antibiotic
• Fluids: NS @ 100ml/hr
• Chest X-rayà RLL infiltrate PNAà 2L n/c
• Choked on burger at dinner à NPO
• 1/28-2:20am: vomited à aspirated à developed bradycardia àasystolic àV-tach à 9 min code à CPR started & epinephrine given à 2 DC countershocks & bolus of Amiodarone à returned to a perfusing heart rhythm & given atropineà placed a central line & started Dopamine (2mcg/kg/min) à intubated & placed on a vent
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Early nutrition & outcomes of critically patients treated with vasopressors and
mechanical ventilation8 (Khalid et al, 2010)
Obj:
Determine the effect of early EN on the outcome of critically ill patients who are hemodynamically unstable.
Method:
1174 patients were identified who required mechanical ventilation for more than 2 days and were treated with
vasopressors. Patients were divided into 2 groups: those who received EN within 48 hrs of starting mechanical ventilation (n=707) & those who received EN after 48 hrs (n=467). End
points were ICU & hospital mortality.
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Results:
ICU mortality was lower in the early EN group compared to the late group (22.5% vs 28.3%, P=.03), and likewise for overall
hospital mortality (33.8% vs 43.9%, P=<.001).
However, there was no effect on vent-free days, days in ICU, or vent-associated PNA.
Early nutrition & outcomes of critically patients treated with vasopressors and
mechanical ventilation8 (Khalid et al, 2010)
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NCP Overview
• 4 total visits
• Initial assessment (1/30)
• 2 F/U (2/4, 2/6)
• End of NEB Rotation
• Last RD F/U (2/11)
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Initial Visit Assessment (1/30) s/p cardiac arrest, septic shock 2/2 PNA-on low pressors tappering off, ARF,
Acute Resp fail 2/2 asp PNA-on vent support, sev schiczo-mild sedation
Current Diet/Appetite
NPO-OGT for suction-d/c soon, placing dbhf. Failed bedside SS 1/28.
Hydration NS @ 50; generalized edema 2+/3+; I/O: 2,635/3,450
Estimated needs (VENT SUPPORT)
2123 kcals (PENN st) 82-98g protein (1-1.2g/kg ABW) 2050 ml fluid (25 ml/kg ABW)
Regimen provides 1200 ml fluid
Nutrition Status Severe
Nutrition Dx Inadequate energy intake
Etiology Respiratory failure
Symptoms NPO, vent support
Rec Nepro @ goal rate 50 ml/hr-initiate at 30 ml/hr & titrate as tolerated. Regimen will provide 2160 kcals, 97g pro, 870ml. When IVF d/c flush 200ml q 4hrs (2070ml total). If K+ <4.5, will switch to less concentrated formula.
Outcomes Pt to meet >75% of ENN within 24-48 hours, Maintain LBM, promote gradual wt loss toward IBW
F/U 5 days
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Initial Visit- Labs & Meds
Significant labs
1/30
Glucose 134 (H)
BUN 29 (H)
Na+2 134 (L)
K+ 6.1 & 5.2 (HH, 1/29); 4.9 (1/30)
CO2 20 (L)
Ca+2 8 (L)
Albumin 1.9 (L)
GFR 49 (L)
Mag 2.0
Lactate 2.4 (H)
TSH 5.56 (H)
Significant Meds 1/30
Usage Dosage
Norepinephrine
Pressor .02 mcg/kg/min
Fentanyl Narcotic 5 mcg/kg/hr
Klonopin Lorazepam Trazodone
Panic disorders 1mg 2mg 100mg
Colace Senna
Laxative 100mg 34.4mg
Pepcid Reflux 20mg
Arixtra Anti-thrombotic
2.5mg
Lasix Diuretic 40mg
Zosyn Antibiotic 2.25g
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2nd Visit Assessment (2/4) F/U. Pt extubated-on Cipap, off pressors, not following commands but able
to communicate somewhat, yells out, restrained. Last BM 2/3
Current Diet/Appetite Continues on Nepro @ 50 (goal rate). RN gave trial sips of water today-pt tolerated.
Hydration NS @ 50; generalized edema 2+; I/O: 2,730/2,750
Estimated needs 1850-2100 kcals (23-26 kcals/kg ABW) 82-98g protein (1-1.2g/kg ABW) 2050 ml fluid (25 ml/kg ABW)
Regimen provides 2160 kcals 97g pro 2070 ml (870ml TF, 1200ml IVF)
Nutrition Status Severe
Nutrition Dx Inadequate PO food intake
Etiology Swallowing difficulty, confused/disoriented
Symptoms Enteral intake
Rec Continuing current TF regimen. Rec swallow eval when appropriate.
Outcomes Pt to continue meeting >75% of ENN from EN.
F/U 5 days
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2nd Visit- Labs & Meds
Significant labs
2/4
Glucose 175 (H)
K+ 4
Phos 4.8 (H)
Albumin 1.8 (L)
Mag 1.5 (L)
WBC 11.4 (H)
Significant Meds 2/4
Usage Dosage
Klonopin Trazodone Trileptal Valporic acid
Panic disorders 0.5mg 50mg 300mg 500mg
Ambien Sedative 5mg
Pepcid Reflux 20mg
Arixtra Anti-thrombotic
2.5mg
Lasix Diuretic 40mg
Zosyn Antibiotic 4.5g
Mag sulf 1% Fluid balance 2g
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3rd Visit Assessment (2/6) F/U- On Bipap, restrained d/t aggressive behavior overnight. 10-day zosyn d/c’d
today for asp PNA. DNR.
Current Diet/Appetite
TF changed per MD to Glucerna 1.0 @ 50 (2/5). No consult sent. Pt tolerating TF-no residuals. Last BM 2/6. R heel intact blister & R sole skin tear
Hydration NS @ 50; generalized edema 2+; I/O: 2,250/2,100
Estimated needs 1850-2100 kcals (23-26 kcals/kg ABW) 120-125g protein (1.5g/kg ABW) 2050 ml fluid (25 ml/kg ABW)
Current regimen provides
1200 kcals 50g pro 2224ml (1024 ml TF, 1200ml IVF)
Nutrition Status Severe
Nutrition Dx Inadequate EN nutrition
Etiology Current regimen
Symptoms Estimated energy needs
Rec Glucerna 1.2 @ goal rate of 70 ml/hr + 1 pk Prostat daily to provide 2116 kcals, 116g pro, 1352 ml. When IVF d/c, flush 175ml q 6hrs (2050ml total). Rec ordering PAB w/ AM labs.
Outcomes Pt to meet >75% of ENN from EN
F/U 5 days
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3rd Visit- Labs & Meds
Significant labs
2/6
Glucose 93, 138, 133, 115, 123, 161, 110, 169
K+ 4.1
Phos 3.3
Albumin 1.8 (L)
CO2 39 (H)
WBC 11.78 (H)
Significant Meds 2/6
Usage Dosage
Klonopin Trileptal Valporic acid Geodon
Panic disorders 0.5mg 300mg 500mg 10mg
Colace Laxative 100mg
Pepcid Reflux 20mg
Arixtra Anti-thrombotic
2.5mg
Lasix Diuretic 20mg
Mag sulf 1% Fluid balance 1g
Zosyn Antibiotic 4.5g
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4th RD Visit & Endpoint
• 2/11: Moved to PCUà passed MBSS à tolerating regular diet w/ >70% intake
• 2/12: Passed away • Cause of death: septic shock, acute hypercapnic respiratory
failure, atelectasis of the lung
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Summary
• Is one vasopressor better than another? • While some researchers argue one is better than another;
the decision should be situational based on the therapeutic strategy chosen.4
• When is it safe to feed patients on vasopressors? • When pressors are ≤0.1 mcg/kg/min • Optimally within 48 hours post intubation8
• More research needs to be done on timing, duration, and amount of enteral vs parental nutrition with vasopressor therapy in critically ill patients.
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Thank you!!
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REferences 1. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39(2):165-228.
2. Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med. 2013;369(9):840-851.
3. Disease and Conditions: Sepsis. Mayo Clinic Website. http://www.mayoclinic.org/diseases-conditions/sepsis/basics/symptoms/con-20031900. Published July 23, 2014. Accessed April 4, 2015.
4. Hollenberg SM. Vasopressor support in septic shock. CHEST Journal. 2007;132(5):1678-1687.
5. Allen JM. Vasoactive substances and their effects on nutrition in the critically ill patient. Nutr Clin Pract. 2012;27(3):335-339.
6. Gelman S, Mushlin PS. Catecholamine-induced changes in the splanchnic circulation affecting systemic hemodynamics. Anesthesiology. 2004;100(2):434-439.
7. Mancl EE, Muzevich KM. Tolerability and safety of enteral nutrition in critically ill patients receiving intravenous vasopressor therapy. JPEN J Parenter Enteral Nutr. 2013;37(5):641-651.
8. Khalid I, Doshi P, DiGiovine B. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care. 2010;19(3):261-268.