1. Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, NP Education Specialist LRM Consulting Nashville, TN

2.  Objectives  Analyze the hemodynamic data of a patient with sepsis.  Identify key hemodynanic abnormalities seen in patients with cardiogenic shock.  Describe the priorities in the management of a patient with acute respiratory distress syndrome (ARDS).

3. Case Study 1  45 - year old woman  stab wounds to the abdomen x 2, multiple lacerations, probable aspiration  3 days post - op became restless  T 40.3  C (104.6  F)

4. Case Study 1 HR 106 BP 78 / 44 / 55 BP 78 / 44 / 55

5. Case Study 1 HR 106 RAP / PAOP 1 / 4 BP 78 / 44 / 55 BP 78 / 44 / 55 CI 4.5 CI 4.5 PAP 17 / 7 / 11 PAP 17 / 7 / 11

6. Case Study 1 PVRI 119 PVRI 119 SVRI 858 SVRI 858 SV 70.2 SV 70.2 LVSWI / RVSWI 26.5 / 8.0

7. Case Study 1 ABGs (.40 FiO 2 ) pH 7.26 pCO 2 35 pCO 2 35 pO 2 55 pO 2 55 SaO 2.88 SaO 2.88 HCO 3 12 HCO 3 12 SvO 2 82% SvO 2 82% P/F ratio 138

8. Case Study 1 PaO 2 / FiO 2 Ratio (P/F) 55 /.40 138 Normal = > 300 ALI = < 250 ARDS = < 200

9. Case Study 1  Laboratory Values Sodium 150 Chloride 98 Hgb / Hct 8.8 / 26.4 Hgb / Hct 8.8 / 26.4

10. Sepsis   O 2 demand 55%  peripheral shunting & delivery-limited VO 2 delivery-limited VO 2  sudden  in VO 2 = early warning warning  VO 2 remains low = poor outcome outcome

11.  CI > 5.5  DO 2 I 250 - 500  VO 2 I 70 - 90

12. Case Study 1 DOI 2 = CI ( 1.38 x Hgb x SaO 2 ) 10 4.5 X 1.38 X 8.8 X 0.88 x 10 481 mL/min/m 2 (normal = 360 - 600 mL/min/m 2 )

13. Case Study 1 VOI 2 = CO X 1.38 X Hgb X (SaO 2 - SvO 2 ) X 10 4.5 x 1.38 x 8.8 x (.88 -.82) x 10 33 mL/min/m 2 (Normal 220 - 290 mL/min/m 2 )

14. Case Study 2  54 - year old male with large anterioseptal MI  new episode pain  restless, dusky, new systolic murmur LLSB  12 – lead: ST elevation, T wave inversion & Q wave in V 2 - 4

16. Case Study 2 HR 118 BP 80 / 42 / 55

17. Case Study 2 HR 118 BP 80 / 42 / 55 CO / CI 3.2 / 1.56 CO / CI 3.2 / 1.56 PAP 58 / 32 / 40 PAOP / CVP 29 / 15

18. Case Study 2 PVRI 564 PVRI 564 SVRI 2051 SVRI 2051 LVSWI / RVSWI 8.84 / 5.78

19. Case Study 2 ABGs (.40 FiO 2 ) pH 7.49 pCO 2 25 pCO 2 25 pO 2 56 pO 2 56 SaO 2.88 SaO 2.88 HCO 3 21 HCO 3 21 SvO 2 60% SvO 2 60%

20. Case Study 2 PaO 2 / FiO 2 Ratio (P/F) 56 /.4056 /.40 140140 Normal = > 300 ALI = < 250 ARDS = < 200

21. Case Study 2  Laboratory Values Sodium144 Chloride 98 Hgb / Hct 12.1 / 36.3 CO 2 21 CO 2 21

22.  CO threatens DOI 2   CO threatens DOI 2 levels levels  O 2 demands are seldom  except when catecholamines are used

23.  DOI 2 300 - 400  VOI 2 > 125  SvO 2 > 60%  O 2 ER < 30%

24. Case Study 2 SIMV 8 FiO 2 / TV.60 /800 PaO 2 / SaO 2 65 /.92 pH 7.29 PaCO 2 / HCO 3 30 /16 Hgb / Temp 9.0 / 102 o F

25. Case Study 2 DOI 2 = CI ( 1.38 x Hgb x SaO 2 ) 10 1.56 X 1.38 X 12.1 X 0.88 x 10 229 mL/min/m 2 (normal = 360 - 600 mL/min/m 2 )

26. Case Study 2 VOI 2 = CI X 1.38 X Hgb X (SaO 2 - SvO 2 ) X 10 1.56 x 1.38 x 12.1 x (.88 -.60) x 10 73 mL/min/m 2 (Normal 220 - 290 mL/min/m 2 )

27. Case Study 2  Anion Gap Na – (CO 2 + Cl)Na – (CO 2 + Cl) 144 – (98 + 21)144 – (98 + 21) 2525 (Normal = 12 – 15)

28. Case Study 3  62 - year old male – 2 ppd smoking history – acute bacterial pneumonia – intubated & mechanically ventilated

29. Case Study 3 BP100/90/93 HR 122

30. Case Study 3 BP 100/90/93 HR 122 RAP / PAOP 6/8 PAP 38/18/25 C0 4.0 SvO 2.30

31. Case Study 3 PaO 2 / FiO 2 Ratio (P/F) 65 /.6565 /.65 108108 Normal = > 300 ALI = < 250 ARDS = < 200

32.  PEEP can  DOI 2  WOB  VOI 2  triggers inflammatory response  maldistributed blood flow   VOI 2  ideal Hgb is 12

33.  DOI 2 until VOI 2 plateaus

34. Case Study 3 DO 2 = CO ( 1.34 x Hgb x SaO 2 ) 10 4.0 X 1.34 X 9.0 X 0.92 x 10 457 mL/min (normal = 900 - 1100 mL/min)

35. Case Study 3 VO 2 = CO X 1.34 X Hgb X (SaO 2 - SvO 2 ) X 10 4.0 x 1.34 x 9.0 x (.92 -.30) x 10 308 mL/min (Normal 220 - 290 mL/min)

36. IN CONCLUSION

38. THE END