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Acute medicine Lecture Series 2010

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ACUTE MEDICINE LECTURE SERIES 2010 SHOCK HOW TO WATER A GARDEN? Ahmad F. Mady MD In septic shock due to bacterial infection, circulatory insufficiency occurs when ... – PowerPoint PPT presentation

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Title: Acute medicine Lecture Series 2010


1
Acute medicine Lecture Series 2010
Shock How to water a garden?
  • Ahmad F. Mady MD

2
Before we go anywhere, lets start at the
beginning
  • What do you need to maintain a nice garden?
  • WATER

3
  • What do you need to get the water to the garden ?

4
4 things
  • Water pump
  • Release valve
  • Hose
  • Water amount

5
What is Shock?
  • Theoretical
  • Inability to meet cellular requirements for
    oxygen
  • Practical
  • When the nurse calls you for a low blood pressure

6
what are the types of shock?
  • Think about the garden
  • The garden will die without enough water
  • Pump failure
  • Release valve failure
  • Hose failure
  • Water failure

7
What the hell are you talking about?
8
Aetiological Shock Categories
  • Pump failure Cardiogenic shock
  • Release valve failure Obstructive shock
  • Hose failure Distributive shock
  • Water failure Hypovolemic shock

9
Hypovolemic Shock
  • Not enough stuff
  • Blood
  • plasma

10
Hemorrhagic Shock
Parameter I II III IV
Blood loss (ml) lt750 7501500 15002000 gt2000
Blood loss () lt15 1530 3040 gt40
Pulse rate (beats/min) lt100 gt100 gt120 gt140
Blood pressure Normal Decreased Decreased Decreased
Respiratory rate (bpm) 1420 2030 3040 gt35
Urine output (ml/hour) gt30 2030 515 Negligible
CNS symptoms Normal Anxious Confused Lethargic
11
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12
Cardiogenic Shock
  • The heart cannot pump enough blood to meet the
    metabolic demands of the body
  • Causes
  • Muscle
  • Valve
  • Heart rate
  • Too fast
  • Too slow
  • Poor coordination
  • Mortality ( 60-90)

13
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14
Obstructive Shock
  • Tension pneumothorax
  • Cardiac tamponade
  • Pulmonary embolism
  • Aortic stenosis

15
Distirutive shock
  • Caused by systemic vasodilatation from
  • Infection -Septic shock (35-40 ,1 month
    mortality)
  • Spinal / Neurogenic Shock
  • Anaphylaxis

16
Septic shock
17
  • Heart rate

temperature
SIRS
Respiratory rate
WBC
18
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19
Pathophysiology
  • DO2 Q X CaO2
  • DO2 Q X (1.34 X Hb X SpO2)
  • Normal DO2 is 520 to 570 mL/min/m2
  • VO2 Q X (CaO2 - CvO2)
  • VO2 Q X 13.4 X Hb X (SpO2-SvO2)
  • Normal VO2 is 110-160 ml/min/ m2
  • O2ER VO2 / DO2 X 100
  • Normal O2ER 0.2-0.3 (20 to 30)

20
Pathophysiology
  • MRO2
  • The metabolic demand for oxygen at the tissue
    level.
  • The rate at which oxygen is utilized in the
    conversion of glucose to energy and water through
    glycolysis and Krebs cycle.
  • VO2 MRO2 Normal Metabolism
  • VO2 lt MRO2

SHOCK
21
Pathophysiology
  • When demand is insufficient the first
    compensatory mechanism is increase in CO.
  • autonomic responses.
  • Arteriolar vasoconstriction.
  • Increase in HR and contractility .
  • Constriction of venous capacitance, which
    augments VR.
  • Release of vasoactive hormones epi, norepi,
    dopamine, and cortisol to increase arteriolar and
    venous tone.
  • Release of ADH and activation of the
    renin-angiotensin axis

22
Pathophysiology
  • The cellular response to a decrease in systemic
    O2 delivery is ATP depletion leading to ion-pump
    dysfunction (influx Na and efflux K) leading to
    membrane instability and cellular dysfunction.
  • When compensatory mechanisms failure the body
    starts anaerobic metabolism forming lactic acid.

23
Clinical manifestation
  • Characterized by three stages
  • Preshock (warm shock, compensated shock)
  • Shock
  • End organ dysfunction
  • Compensated shock
  • Low preload shock tachycardia,
    vasoconstriction, mildly decreased BP
  • Low afterload (distributive) shock peripheral
    vasodilation, hyperdynamic state

24
  • Shock
  • Initial signs of end organ dysfunction
  • Tachycardia
  • Tachypnea
  • Metabolic acidosis
  • Oliguria
  • Cool and clammy skin

25
  • End Organ Dysfunction
  • Progressive irreversible dysfunction
  • Oliguria or anuria
  • Progressive acidosis and decreased CO
  • Agitation, obtundation, and coma
  • Patient death

26
Invasive hemodynamic monitoring
Etiology of shock Example Filling p. CO SVR VO2 sat
Preload Hypovolemic Low Low High Low
Contr, Cardiogenic High Low High Low
Afterload Distributive
Hyperdynamic Septic Low/High High Low High
Hypodynamic Septic Low/High Low High Low/High
Neurogenic Low Low Low Low
Anaphylactic Low Low Low Low
27
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28
Also diagnosis of hyperdynamic septic shock
optimizing fluids/intorops/vasopressors
Invasive hemodynamic monitoring
  • Arterial line
  • CVP
  • Is CVP or PAOP reliable in shock ???
  • Is there a role for Swan-Ganz in shock ?!

PAOP PAP
Cardiogenic Increased Decreased
Obst PE Normal Increased
Obst C. Tamponad Increased Increased
29
  • General Nursing Management of Shock
  • Maintenance of patient airway.
  • Patient positioning.
  • Maintenance of body temperature.
  • Maintenance of skin integrity.
  • Psychological support.

30
Treatment
  • General objective
  • Rapid recognition and restoration of perfusion

Hypovolemic Volume resuscitation by crystaloids and blood
obstructive Maxmize preload relife of obstruction
cardiogenic Maximize preload and cardiac performance reducing afterload
distributive Supplement preloadaugment BPTTT cause
Fluids vasopressors
inotrops
31
Fluids
  • Two broad categories related to a shock
    discussion
  • Crystalloids
  • Colloids
  • Crystalloids
  • Hypoosmolar D5, 1/4, ½ NS
  • not helpful for our patient in shock
  • Iso-osmolar NS, RL
  • RL has lower chloride concentration vs.
    NS so tendency
  • of non-AG metabolic acidosis
  • Hyper mannitol, 3NS no great advantage..cell
    dehydration

32
Fluids
  • Colloids
  • Natural vs Synthetic
  • Natural
  • Blood
  • FFP
  • Platelets
  • Human albumin
  • Drawbacks
  • Limited supply
  • High cost
  • Possible allergic reactions
  • Risk of infection

33
Fluids
  • Synthetic
  • Dextran
  • HES
  • high MW , medium MW , low MW
  • Drawbacks
  • Alterd hemostasis if large dose
  • relative High cost
  • Hyperamylesmia....? misinterpretation
  • Dextrane (bleeding,x-matched RBCs,anaphylaix,renal
    )

34
Which is best ?
  • Crystalloid vs Colloid
  • Evidence has been conflicting
  • Tailoring the type of resuscitation fluid to the
    specific clinical condition seems a more logical
    approach than using the same type of fluid
    without exception for all ICU patients

35
Vasopressors / Inotropes
  • Essential few principles to remember
  • Alpha Peripheral squeeze on vessels
  • Beta Inotropic and/or chronotropic effect .
  • with most beta effect, comes a
    degree of
  • vasodilation gtdecreased afterload
  • Other pathways exist
  • c AMP
  • Phosphodiesterase inhibitors

36
Vasopressors / Inotropes
  • epinepherin
  • Alpha and beta effect
  • Great increase on cardiac O2 demand
  • Splanchnic vasoconstriction
  • Should be 2nd or 3rd line trope
  • Dopamine
  • Alpha and beta depending on dose BUT Overall
    alpha effect is weaker than levo
  • Beta effect increases cardiac O2 requirements
  • Beta also increases amount of dysrhythmias
  • works indirectly at nerve endings to release
    norepi and epi.

37
Vasopressors / Inotropes
  • Norepinepherine (levophed)
  • Mostly alpha, some beta
  • Potent vasoconstrictor, less effect on increase
    in HR
  • Reflex bradycardia in response to increase in
    MAP, HR remains unchanged or even slight decrease
  • Vasopressin
  • Vasoconstriction of peripheral blood vessels via
    V1 receptor
  • Weak pressor in normal patients
  • Patel 1999, Sharshar 2003- 1/3 of septic patients
    have relative vasopressin deficiency
  • Although used commonly, needs future studies.

38
Vasopressors / Inotropes
  • Dobutamine
  • Mostly beta effect
  • Increase in inotropy
  • Increase in chronotropy
  • Peripheral vasodilation
  • Overall will increase cardiac output and decrease
    afterload
  • Others

39
So
  • Now we discuss shock types
  • We discuss fluid principles
  • We discuss pressors/tropes
  • Lets put it all together to treat shock

40
Case 1
  • 52 yr old male with crushing retrosternal chest
    pain, diaphoresis.
  • ECG depression in V56, II, III, aVF
  • BP 110/70, HR 110, in CCU BP drops to 80/60
  • Cardiogenic shock
  • Treatment
  • Judicious fluid
  • Inotropes
  • Little need for pressors

41
Case 2
  • 60 yr female with chest pain and shortness of
    breath
  • Sa02 82 BP 75/50
  • Elevated JVP, S1Q3T3
  • CT chest massive saddle pulmonary embolism
  • Obstructive Shock
  • Treatment
  • Fluids pressors or tropes ?
  • RELIEVE THE OBSTRUCTION
  • Pulmonary embolism Thrombolysis
  • Tension pneumo Needle decompression
    and ICT
  • Tamponade Pericardiocentesis

42
Case 3
  • 78 yr female with productive cough, fever,
    confusion
  • BP 85/35, HR 125
  • CXR RLL infiltrate, 25 bands, urea 19
  • Distributive Shock
  • Treatment
  • fluids, pressors, inotropes?
  • ANTIBIOTICS (in under one hour)

43
Septic Shock
  • Rivers et al. Early Goal Directed Therapy in the
    Treatment of Severe Sepsis and Septic Shock. NEJM
    2001 3451368-77
  • randomized partially blinded
  • 263 patients 130 Tx, 133 control
  • Standard therapy vs. six hours of EGDT
  • CVP 8-12 MAP gt65
  • SvO2 gt70 UOP
    gt0.5cc/kg/hr

Total fluids(L) 0-6hr 7-72hr 0-72hr
Standard 3.5L 10.6L 13.3L
EGDT 5.0L 8.6L 13.4L
Inhospital mortality
46.5
30.5
44
So...
  • You have to Fill the tank...early
  • A dry patient not in heart failure will die much
    sooner than a resuscitated patient in heart
    failure
  • What about pressors/inotropes ?
  • If your MAP lt65, likely will need vasopressor
  • If your MAPgt65, and Scv02lt70, may benefit from
    inotrope

45
Treatment Algorithm
46
Case 4
  • 53 yr old male on GI ward, Hx of Portal HTN,
    esophageal
  • varices, recent sever hematemesis
  • HR 135, BP 80/60, 8L 02.
  • Anxious, confused, diaphoretic
  • Hypovolemic shock
  • Treatment
  • Your staff will bring the scope in about 30
    minutes
  • The MET team will respond in 15 minutes
  • Your patient will be dead in 10 minutes
  • Stop the bleeding
  • fluids, pressors, inotropes?

47
Resuscitation endpoints....??
  • Blood pressure
  • Heamatocrite/Hb
  • Filling pressures
  • All of the above
  • Non of the above

48
Resuscitation endpoints
  • Lactic acid production
  • Elevated serum lactate is an indirect
    measure of the
  • oxygen debt, and an approximation of the
  • magnitude and duration of the severity of
    shock.
  • The rate of clearance of lactate is a
    better marker of
  • adequate resuscitation rather than
    absolute value.
  • Base deficit
  • BD is the amount of base in millimoles that
    is required to
  • titrate 1 L of whole blood to a pH of 7.40
    with the
  • sample fully saturated with O2 at 37C and
    a PaCO2 of 40.
  • Elevated BD correlate with the severity of
    shock.
  • Correction of BD is a guide for
    resuscitation.

49
Resuscitation endpoints
  • Intramucosal pH monitoring
  • Mesenteric organs have earlier and greater
    hypoperfusion than other organs.
  • Gastric tonometry measure intragastric
    intramucosal pH and is an early indicator of
    hypoperfusion in shock and correlate with the
    mortality.(technically difficult to use)

50
Sowhat was our objective ?
  • Have a nice garden

51
Soour objectives were
  • Definition of shock
  • Pathophysiology
  • Shock Categories
  • Management of shock
  • Case scenarios

52
?
any question..
53
  • Thank you

  • A
  • H
  • M

  • A
  • D
  • F.
  • M
  • A

  • D

  • y
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