Capturing Shok in the ICU Setting HCPro Providing ：捕捉激波在ICU设置hcpro提供

1、cindy pritchett, rn, bsn, ccdscdi specialistmedical city dallas hospital hca dallas, txcapturing shock in the icu settingobjectivesparticipants will be able to:differentiate shock types and treatment modalitiesidentify clinical indicators and treatments for shock that trigger queriesreview specific

2、“shock” cases that resulted in successful query generationreview the importance of relationship building with intensivistsdiscuss strategies to capture mid-level involvement in cdi programs shock: what does it look like?the main symptom of shock is low blood pressureshock typesanaphylacticcardiogeni

3、chemorrhagichypovolemicneurogenicsepticanaphylactic shockcauseallergic responsetreatmentantihistaminesepinephrinesteroidseverityccsee sample at: http:/ shockcausedamaged hearttreatmentaddress underlying causeiabpvasopressorsseveritymcccourtesy of 3dshemorrhagic shockcauseblood losstreatmentblood/blo

4、od productsseveritymcccourtesy of 3dshypovolemic shockcause fluid losstreatmentfluid replacementseveritymcc neurogenic shockcausespinal cord injurytreatmentimmobilizationanti-inflammatoriesseveritymcccauseanxietytreatmentanti-anxiety/psychotropic medicationsseveritynoneunderstanding sepsis terminolo

5、gyinfectionbacteremia sirs (systemic inflammatory response syndrome)septicemiasevere sepsisseptic shocksirssystemic disease manifested by 2 or more of the following conditions:t 100.4f or 90resp 20 or co2 12,000 or 10% immature (band) formssirssirs (systemic inflammatory response syndrome) 995.90 du

6、e to:infectious processes 995.91with organ dysfunction 995.92noninfectious process 995.93with acute organ dysfunction 995.94septicemiaacute illness associated with pathogens in bloodpositive blood cultures not requireddoes not mean sepsis courtesy of 3dssepsisdocumented infection with 2 or more sirs

7、 indicators present without organ dysfunctiont 100.4f or 90resp 20 or co2 12,000 or 10% immature (band) formscourtesy of 3dssevere sepsissepsis withorgan dysfunction ardsarfencephalopathyhepatic failurechfdichypoperfusionoliguria 30 cc/hrhypoxemia pao2 75 mm hg on room airlactic acidosis ph 7.35 or

8、hypotensionsbp 100.4f or 12,000leukopenia 4,000tachycardiahyperventilationmetabolic acidosis (ph 96 hours410.71 ami96.04 insertion of et tubecoding sequence for septic shock & e. coli septicemia:038.42 due to other gram-neg orgs, e. coli as pdx995.92 for 785.52 as secondary diagnosiscoding septi

9、c shockother shocked organsshock kidneys shock lungshock liveratn acute tubular necrosis severity = mccards adult respiratory distress syndromeseverity = cc ast & altseverity = mccalll images courtesy of 3dscase study78/m s/p balloon aortic valvuloplasty pleural effusionatelectasisckd iiimetabol

10、ic alkalosispulmonary edemarespiratory distress 4 days postop reintubatediv antibiotics initiated/pan-cultured sbp dropped 80s90s levophed initiatedcxr “moderate right and mild left basilar atelectasis/edema/pneumonia present”documented after intubationrespiratory failure? pnashock query“based on yo

11、ur clinical judgment, can you specify the diagnosis (cardiogenic shock, septic shock, hypovolemic shock, unspecified shock, other more appropriate diagnosis) for the below abnormal clinical findings and associated treatment plan?”clinical indicators:sbp 8090sinitiation of levophedhr 100swbc 12.0drg

12、impactwith ccscreen capture of the 3m coding and reimbursement system provided with written permission from 3m. 3m 2011. all rights reserved. drg impactwith mccscreen capture of the 3m coding and reimbursement system provided with written permission from 3m. 3m 2011. all rights reserved. mortality r

13、ate impactto query or not to query67/m admitted with: picc infection chronic systolic heart failure sbp 4050s day #3 vasopressin/dopamine initiated catheter tip + sc neg wbcs 13.5md documented “suspect cardiogenic vs. hypovolemic shock.”screen capture of the 3m coding and reimbursement system provid

14、ed with written permission from 3m. 3m 2011. all rights reserved. case review74/f with aortic stenosis s/p balloon aortic valvuloplasty dropped sbp into 70s on pod #3. vasopressin initiated. all cultures negative. wbcs normal. temp 100.2.chronic resp failureacute blood loss anemiahyponatremiabilater

15、al infiltrate on cefthiazonepost-event md documentedhypotensive shockpneumoniascreen capture of the 3m coding and reimbursement system provided with written permission from 3m. 3m 2011. all rights reserved. case review75/m admitted with af/rvr who underwent a cardiac catheterization. subsequently de

16、veloped ischemic bowel requiring an exploratory lap. patient dropped sbp into 7080s leading to initiation of vasopressin. “suspect drop in bp is volume related.” query md for shockcase review67/m admitted with pneumonia, confusion, and hypotension (sbp 70s) received levophed in the emergency departm

17、ent. attending queried for shock based on above.cdiscase review91/f admitted with hypotension, bradycardia, and acute bronchitis. bp on admit in ed was 62/37. dopamine was initiated. urine culture showed + citrobacter freundii 100k. iv antibiotics initiated. blood cultures negative. patient afebrile

18、 with normal wbcs.relationship building intensivistsphysician championrounding/one-on-one educationtoolsonboarding educationjit trainingsharing data case-specific improvement opportunitiesmedical staff meetingspraise/edification76/m with aortic stenosis underwent bav with iabp insertion. sbp 70s wit

19、h initiation of vasopressin. med weaned after iabp inserted. patient remained on vent. cardiogenic shock and respiratory failurepatient experienced postop bradysystolic arrestcardiac arrestsuccessful investmentwhat the future holds3 codesicd-9-cm038.9unspecified septicemia995.92severe sepsis785.52septic shock2 codesicd-10-cma41.9septicemia, unspecifiedr65.21severe sepsis with septic shockreferenceshaik, md, william, understand clinical terminology and indications of sepsis, hcpro, inc., 2008.wedro