AACN advanced critical care
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Severe sepsis is a complex syndrome often resulting in multiple organ dysfunction. This is an extremely challenging problem to manage in the intensive care unit, with mortality rates remaining at unacceptably high levels. Death of patients afflicted by this condition generally results from organ dysfunction syndromes related to hypoperfusion abnormalities. ⋯ Pharmacologic support of patients with severe sepsis or septic shock primarily involves agents to support and improve perfusion at the microvascular level. It is important to understand the pharmacologic properties of the medications utilized to manage patients with these conditions. The information presented in this article is based on the best evidence currently available in order to assist the critical care nurse in understanding the pharmacologic therapy related to treatment of severe sepsis and septic shock.
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Hemodynamics in sepsis change as sepsis develops. Initial hemodynamics of sepsis often are much different from later stages of sepsis, shifting from low cardiac output states to high cardiac output states. Tissue oxygenation also changes with initial mixed venous oxyhemoglobin (Svo2) or central venous oxyhemoglobin (Scvo2) levels below normal, with later stages reflecting high values. ⋯ Fortunately, hemodynamic monitoring techniques are markedly improved from older techniques such as the pulmonary artery catheter. With noninvasive techniques such as esophageal and external Doppler for measuring hemodynamics, clinicians beyond the intensive care unit can make hemodynamic assessments that were not possible until just recently. This improved assessment should make it much easier to properly identify sepsis and initiate appropriate treatments in a timely manner.
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Central line-associated bloodstream infections are considered to be an avoidable complication of care delivery. In addition to considerable morbidity and use of resources, central line-associated bloodstream infections carry an attributable morality between 12% and 25%. ⋯ A significant reduction or elimination of central line-associated bloodstream infections can occur with implementation of a comprehensive central line-associated bloodstream infection prevention program that includes staff education, hand hygiene, use of maximal sterile barrier precautions, chlorhexidine gluconate skin antisepsis, avoidance of femoral lines, empowerment of staff to stop the procedure if sterile technique is broken, and daily assessment of the continued need for a central line. This article focuses on strategies for implementing a comprehensive central line-associated bloodstream infections prevention program and a tool and process for defect analysis as part of a statewide collaborative in Michigan.
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Major resuscitation goals in the management of shock include restoration of adequate tissue perfusion and oxygen balance and normalization of cellular metabolism. Identification of the most appropriate endpoints of resuscitation is difficult and often debated in the literature. ⋯ Additional resuscitation endpoints that more closely evaluate the adequacy of perfusion and oxygenation at the tissue level should also be used when managing the critically ill. Selected endpoints should include a variety of global and regional indicators to guide and evaluate the effectiveness of treatment.
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Hemodynamic monitoring in the care of the critically ill neuroscience patient provides information that assists the clinician in minimizing secondary neuronal injury. Whereas no technology replaces the critical care nurse's physical assessment, hemodynamic and neurological monitoring provides additional data beyond what is possible with the clinical examination alone. ⋯ Although improved outcomes have not been scientifically substantiated, multimodality monitoring of intracranial dynamics and systemic hemodynamics and manipulation of these parameters during hypertensive hypervolemic hemodilution therapy may lessen the incidence of cerebral infarction secondary to vasospasm. Monitoring systemic hemodynamics and intracranial dynamics simultaneously assists in prevention, prompt recognition, and effective treatment of neurological deterioration.