Naama Experience

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  • Slide 24: Septic Shock Is Unique —Signs of Septic Shock Differ
    From Hypovolemic and Cardiogenic Shock
    In septic shock the patient’s calculated cardiac output may be normal, increased, or decreased.
    In hypovolemic and cardiogenic shock, cardiac output is redistributed (diverted away from the skin, intestines, and kidneys) to maintain flow to the brain and heart. In septic shock blood flow is maldistributed so that some tissue beds (typically including the skin) receive excellent blood flow whereas others receive inadequate blood flow. Hypotension may be present despite skin perfusion that appears to be good.
    Early signs of septic shock include fever or hypothermia plus tachy-cardia and tachypnea. The number of white blood cells may be increased (leukocytosis) or severely decreased (leukopenia), and the number of immature (band) forms of white blood cells is increased.
  • Naama Experience

    1. 1. ‫الرحمن‬ ‫ال‬ ‫بسم‬‫الرحمن‬ ‫ال‬ ‫بسم‬ ‫الرحيم‬‫الرحيم‬
    2. 2. NAAMA experienceNAAMA experience ByBy Yasser ElboraiYasser Elborai, MD, MD Assisstent Lecturer of PediatricAssisstent Lecturer of Pediatric OncologyOncology NCI – Cairo UniversityNCI – Cairo University
    3. 3.  NAAMA “National Arab American MedicalNAAMA “National Arab American Medical Association” is a Non GovernmentalAssociation” is a Non Governmental Organization (NGO) composed of an ArabianOrganization (NGO) composed of an Arabian doctors living in Americadoctors living in America  They are trying to help doctors in Egypt andThey are trying to help doctors in Egypt and other Arabian countries by different ways likeother Arabian countries by different ways like offering training courses and research workoffering training courses and research work
    4. 4.  Due to collaboration between National CancerDue to collaboration between National Cancer Institute (NCI) – Egypt and National ArabInstitute (NCI) – Egypt and National Arab American Medical Association (NAAMA) –American Medical Association (NAAMA) – USA, there was a 3 months training course forUSA, there was a 3 months training course for Pediatric Intensive Care Unit (PICU)Pediatric Intensive Care Unit (PICU)  This training course was in DeVos children’sThis training course was in DeVos children’s hospital – Michigan – USAhospital – Michigan – USA
    5. 5. Pediatric Intensive Care UnitPediatric Intensive Care Unit (PICU(PICU((  What is the aim of building PICU ?What is the aim of building PICU ?  How do you construct PICU ?How do you construct PICU ?  How do you manage PICU ?How do you manage PICU ?
    6. 6. What is the aim of building PICUWhat is the aim of building PICU??  To give our critically illTo give our critically ill patients a proper treatmentpatients a proper treatment  To create a new subspecialty inTo create a new subspecialty in our pediatric departmentour pediatric department  To decrease the load of workTo decrease the load of work on main ICU in our instituteon main ICU in our institute
    7. 7. How do you construct PICUHow do you construct PICU??  Number of roomsNumber of rooms  Number of bedsNumber of beds  Isolation roomsIsolation rooms  EquipmentsEquipments  SuppliesSupplies  Aeration of the roomAeration of the room  Design of the roomDesign of the room  Character of walls and floorCharacter of walls and floor
    8. 8. Comparison between PICU in DeVosComparison between PICU in DeVos children’s hospital-Michigan andchildren’s hospital-Michigan and newly developing PICU in NCI-Caironewly developing PICU in NCI-Cairo  # rooms 16 rooms 1 room# rooms 16 rooms 1 room  # beds 16 beds 4 beds# beds 16 beds 4 beds  Isolation 2 rooms No roomsIsolation 2 rooms No rooms DeVos children’s hospital-Michigan newly developed PICU in NCI-Cairo
    9. 9. Each room has allEach room has all equipments to beequipments to be an operativean operative room for anyroom for any minor or majorminor or major proceduresprocedures Each bed hasEach bed has monitor, infusionmonitor, infusion pump, syringepump, syringe pump, commonpump, common ECG apparatusECG apparatus and blood warmerand blood warmer apparatus for allapparatus for all bedsbeds newly developed PICU in NCI-Cairo DeVos children’s hospital-Michigan • Equipments • Supplies All types of syringes, lines, tubes, masks,…All types of syringes, lines, tubes, masks,… • Aeration Air conditionedAir conditioned Air conditionedAir conditioned
    10. 10. The bed is in theThe bed is in the center of thecenter of the room to beroom to be accessible fromaccessible from all sides thatall sides that facilitate thefacilitate the workwork The bed is onlyThe bed is only accessible from 3accessible from 3 sides as usualsides as usual newly developed PICU in NCI-Cairo DeVos children’s hospital-Michigan • Design of room • Character of walls and floor The walls and floors are washable and can be easily cleanedThe walls and floors are washable and can be easily cleaned by anti septic measuresby anti septic measures
    11. 11. How do you manage PICUHow do you manage PICU??  Criteria of admissionCriteria of admission  Nursing notesNursing notes  Doctor’s notesDoctor’s notes  Multidisciplinary team to dealMultidisciplinary team to deal with the patientwith the patient  Computer based systemComputer based system  Ratio between nurses andRatio between nurses and patientspatients  Criteria of dischargeCriteria of discharge
    12. 12.  Criteria of admission:Criteria of admission: There are many indications for PICU admissionThere are many indications for PICU admission but the most common cause here in ourbut the most common cause here in our institute will be shock specially septic shockinstitute will be shock specially septic shock ►► if the patient is hemodynamically unstable:if the patient is hemodynamically unstable: - Heart rate greater than:  90 beats per minute at the age of puberty or more.  110 beats per minute at the age of 10 years.  120 beats per minute at the age of 4 years or less.
    13. 13. - Systolic arterial pressure lower than:  90 mm Hg at the age of puberty or more.  70 mm Hg at the age of 10 years.  50 mm Hg at the age of 4 years or less. for at least 30 minutes despite adequate fluid replacement and more than 5 µg/kg of body weight of dopamine or current treatment with epinephrine or norepinephrine. - Urinary output of less than 0.5 mL/kg of body weight for at least 1 hour - Arterial lactate levels higher than 2 mmol/L
    14. 14. Stages of shockStages of shock 1- Early shock1- Early shock:: tachycardia, poor capillary perfusiontachycardia, poor capillary perfusion cold extremities, but in septic shock may be wormcold extremities, but in septic shock may be worm extremities because ischemia of precapillary sphincterextremities because ischemia of precapillary sphincter 2- Established shock2- Established shock: clinical triad: clinical triad tachycardia,tachycardia, hypotension, peripheral hypoperfusionhypotension, peripheral hypoperfusion will be evident.will be evident. The patient looksThe patient looks palepale andand anxiousanxious
    15. 15. 3- Advanced shock3- Advanced shock: the blood flow will increase to more vital: the blood flow will increase to more vital organs (brain, heart) at the expenses of the less vital organsorgans (brain, heart) at the expenses of the less vital organs (kidneys, lungs, GIT)(kidneys, lungs, GIT) kidneys: acute renal failure (oliguria, metabolic acidosis)kidneys: acute renal failure (oliguria, metabolic acidosis) Lungs : Adult Respiratory Distress Syndrome (ARDS)Lungs : Adult Respiratory Distress Syndrome (ARDS) GIT : Ischemia, stress ulcer, hemorrhage, ileusGIT : Ischemia, stress ulcer, hemorrhage, ileus Blood : Disseminated Intravascular Coagulation (DIC)Blood : Disseminated Intravascular Coagulation (DIC) Metabolic: metabolic acidosis, electrolytes disturbanceMetabolic: metabolic acidosis, electrolytes disturbance Brain : Hypoxic ischemic encephalopathyBrain : Hypoxic ischemic encephalopathy Heart : Myocardial ischemia, arrhythmiaHeart : Myocardial ischemia, arrhythmia
    16. 16. 4- Irreversible shock4- Irreversible shock: irreversible cellular damage: irreversible cellular damage (mitochondria, cell membrane) clinically, serious(mitochondria, cell membrane) clinically, serious arrhythmia, deep coma, pH below 7.0 in spite ofarrhythmia, deep coma, pH below 7.0 in spite of vigorous correction with sodium bicarbonatevigorous correction with sodium bicarbonate So, our role is how to detect thisSo, our role is how to detect this hemodynamically unstable patient in his early stagehemodynamically unstable patient in his early stage of shock to give him the best supportive treatmentof shock to give him the best supportive treatment and careful observation to get a better out comeand careful observation to get a better out come
    17. 17. SIRS/Sepsis/Septic shockSIRS/Sepsis/Septic shock Mediator release:Mediator release: exogenous & endogenousexogenous & endogenous MaldistributionMaldistribution of blood flowof blood flow CardiacCardiac dysfunctiondysfunction Imbalance ofImbalance of oxygenoxygen supply andsupply and demanddemand Alterations inAlterations in metabolismmetabolism Outcomes of mediator release in systemic inflammatory responseOutcomes of mediator release in systemic inflammatory response syndrome (SIRS), sepsis, and septic shocksyndrome (SIRS), sepsis, and septic shock Septic ShockSeptic Shock
    18. 18. Septic Shock Is UniqueSeptic Shock Is Unique  Cardiac output may be normal, increased,Cardiac output may be normal, increased, or decreased.or decreased.  Hypotension and poor end-organ perfusion may beHypotension and poor end-organ perfusion may be present despite “good” skin perfusion.present despite “good” skin perfusion. HypotensionHypotension is still a sign of decompensationis still a sign of decompensation..  Early signs of sepsis/septic shock includeEarly signs of sepsis/septic shock include — Fever or hypothermiaFever or hypothermia — Tachycardia and tachypneaTachycardia and tachypnea — Leukocytosis, leukopenia, or increased bandsLeukocytosis, leukopenia, or increased bands
    19. 19. Septic Shock: “Warm ShockSeptic Shock: “Warm Shock””  Early, compensated, hyperdynamic stateEarly, compensated, hyperdynamic state  Clinical signsClinical signs  Warm extremities with bounding pulses, tachycardia,Warm extremities with bounding pulses, tachycardia, tachypnea, confusion.tachypnea, confusion.  Physiologic parametersPhysiologic parameters  widened pulse pressure, increased cardiac output andwidened pulse pressure, increased cardiac output and mixed venous saturation, decreased systemic vascularmixed venous saturation, decreased systemic vascular resistance.resistance.  Biochemical evidence:Biochemical evidence:  Hypocarbia, elevated lactate, hyperglycemiaHypocarbia, elevated lactate, hyperglycemia
    20. 20. Septic Shock: “Cold Shock”Septic Shock: “Cold Shock”  Late, uncompensated stage with drop in cardiacLate, uncompensated stage with drop in cardiac output.output.  Clinical signsClinical signs  Cyanosis, cold and clammy skin, rapid, thready pulses,Cyanosis, cold and clammy skin, rapid, thready pulses, shallow respirations.shallow respirations.  Physiologic parametersPhysiologic parameters  Decreased mixed venous sats, cardiac output and CVP,Decreased mixed venous sats, cardiac output and CVP, increased SVR, thrombocytopenia, oliguria, myocardialincreased SVR, thrombocytopenia, oliguria, myocardial dysfunction, capillary leakdysfunction, capillary leak  Biochemical abnormalitiesBiochemical abnormalities  Metabolic acidosis, hypoxia, coagulopathy, hypoglycemia.Metabolic acidosis, hypoxia, coagulopathy, hypoglycemia.
    21. 21. Cold Shock rapidly progresses to MOSF orCold Shock rapidly progresses to MOSF or death, if untreateddeath, if untreated Multi-Organ System Failure: Coma, ARDS,Multi-Organ System Failure: Coma, ARDS, CHF, Renal Failure, Ileus, hemorrhage,CHF, Renal Failure, Ileus, hemorrhage, DICDIC More organ systems involved, worse theMore organ systems involved, worse the prognosisprognosis Therapy: ABCs, fluidTherapy: ABCs, fluid Appropriate antibiotics, treatment ofAppropriate antibiotics, treatment of underlying causeunderlying cause Septic Shock (con’tSeptic Shock (con’t((
    22. 22. Nursing notes:Nursing notes: the nurse should take a brief history about the patient’sthe nurse should take a brief history about the patient’s illness and his previous vital signsillness and his previous vital signs Doctor’s notes:Doctor’s notes: The doctor should take a full detailed history about theThe doctor should take a full detailed history about the present and past illness and medicationspresent and past illness and medications Multidisciplinary team to deal with the patient:Multidisciplinary team to deal with the patient: Interactions between other department e.g. surgery,Interactions between other department e.g. surgery, radiotherapy, radio diagnosis, and clinical pathology isradiotherapy, radio diagnosis, and clinical pathology is extremely essential for the sake of the patientextremely essential for the sake of the patient
    23. 23. Computer based system:Computer based system: If the system is computer based that will facilitateIf the system is computer based that will facilitate detection of any deterioration of the patients’ clinicaldetection of any deterioration of the patients’ clinical condition through the curves drawn temperature,condition through the curves drawn temperature, blood pressures, urine output,……..blood pressures, urine output,…….. Ratio between nurses and patients:Ratio between nurses and patients: nurse to patient ration should be 1:1 or at least 1:2nurse to patient ration should be 1:1 or at least 1:2 Criteria of discharge:Criteria of discharge: If the patient is hemodinamically stable for at least 24 h,If the patient is hemodinamically stable for at least 24 h, he can transferred to normal floor to continue hishe can transferred to normal floor to continue his treatmenttreatment
    24. 24. We are trying to create a new pediatric care unit similar to that we observed in DeVos children’s hospital-Michigan-USA But as an initial step it will be a pediatric intermediate care unit and in the near future it will be a pediatric intensive care unit

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