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Shock States Beyra Rossouw Intensive Care Unit Red Cross War Memorial Children’s Hospital University of Cape Town. Shock. Pathophysiology Different shock states Treatment principles. Shock is:. Reduced Tissue Perfusion Cellular Hypoxia & Energy Failure. ↑ O2 Demand. - PowerPoint PPT Presentation
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Shock StatesBeyra Rossouw
Intensive Care UnitRed Cross War Memorial Children’s Hospital
University of Cape Town
Cardiac Output
Heart Rate Stroke Volume
O2 Content
PaO2 SaO2 Hb
Synchrony
Preload Afterload Contractility
Oxygen Content of Blood
ArterialInflow (Q)
capillary
O2
O2
O2
O2
O2 O2
O2
VenousOutflow (Q)
Cell
(Adapted from the ICU Book by P. Marino)
=(O2 carried by Hb) + (O2 in solution)
= (1.34 x Hb x Sats x 0.01) + (0.023 x PaO2) O2
O2
Shock States
Capillary leak & Vasculopathy
Distributive
Clot
Cardiogenic Obstructive
Dissociative
Hypovolemic
Adapted from JL Vincent, ESICM 25 Years of Progress & Innovation
Reduced Tissue Perfusion & Energy Failure
Distributive Shock
Septic ShockAnaphylaticNeurogenic
Hypovolemic Shock
HemorrhageBurnsGIT loss
Cardiogenic
Myocarditis
Arrythmia
Septic
Congenital lesions
Valvular lesions
Glucose
Pyruvic Acid
Lactic Acid
Acetyl Co-A
Krebs
CycleCO2
H+
38x ATP
2x ATP
Anaerobic
Aerobic
Fatty Acids Amino Acids O2
Stages of shock
CompensatedDecomp
O2 delivery
ATP Supply =ATP Demand
ATP Supply <<ATP Demand
Anaerobic metabolism
Cell death
Membrane leak
Redistribution of blood flow
Vasoconstriction tachycardia
Irreversible
O2 delivery
Septic shockHypovolaemic Cardiogenic Obstructive
Timing of decompensation
JL Vincent, De Backer . Oxygen Delivery Controversy ICM 2004;30:1990
Hemodynamic Response to Shock
Heart rate
Blood pressure
Cardiac output
CompensatedShock
DecompensatedShock
J Carcillio. Fluid Resuscitation of Hypovolemic Shock. ICM 2006;32:958
Key Issues In ShockFalling BP = LATE sign.Pallor, tachycardia, slow CFT, restlessness
= Shock until proven otherwise.BP is NOT same as perfusion.
De Baker CCM 2006 34 :403-408
Normal Septic shock with normal BP
Hemodynamic Profiles
Capillary flow
Arterial constriction
Cardiac output
Hypovolemic
Cardiogenic
Septic Cold
Septic Warm
M Pinsky. Functional hemodynamic Monitoring. Current Opinion Critical Care 2007;13:318
Key Issues
Recognize & Treat during compensatory shock phase
Mortality increase 2-fold for every hour in treatment delay.Han, Carcillo. Pediatrics 2003;112:793-799
Multisystem effect of shockResp: Resp failure, ARDSRenal: ATN, acute renal failureCNS: infarcts & bleedingLiver: centrilobular necrosisGIT: bleeds, necrosis, ileus, bacterial
translocation Haemat: DIC, vasculopathy, capillary leak
Robbins & Cotran Pathologic Basis of Disease: 2005
Treatment principles1. Increase O2 delivery
2. Reduce O2 demand
• Fever
• Tachycardia
• Tachypnea
• Anxiety & restlessness
• Pain
• Seizures & shiveringO2 delivery O2 demand
Resuscitation PrioritiesIncrease O2 delivery
V: Ventilate & Oxygenate.I: Infuse:
Fluids, fluids, fluids Electrolytes Blood- Hb >10
P: ↑Pump Function: Inotropes Rhythm control Electrolytes & glucose
E: Etiology: - Treat the cause.
FLUID, FLUID, FLUIDRegardless of etiology - fluid bolus x3
5ml/kg cardiac10ml/kg trauma 20ml/kg sepsis
Delayed fluid resuscitation ↑ mortality. Rivers NEJM 2001, Han Pediatrics 2003
Reassess liver & lungs.Septic shock may need up to 200ml/kg. No evidence one is fluid superior.
Finfer NEJM 2004
Permissive Hypotension forUncontrolled Hemorrhage
Roberts et al Lancet 2001
Re-bleedin
g
Haemodilution
Coagulation disorders
Aggressive Volume Loading
AnaemiaHypothermi
a
SBPIncrease
Mechanic effect on vascular clot
NORADRENALINE
ADRENALINE
DOPAMINE
ADRENALINE
DOBUTAMINE
1
Inotropes in fluid resistance
NORADRENALINE
DOPAMINE
Pediatric Cardiac Intensive Care . Chang & Wernovsky
↑Stroke volume, ↑ HRVasoconstriction
More expensive than dopamineUse to contractility when BP stableDrug of choice for cardiacs & PHTAge –specific sensitivityPeripheral IV
B1 B2
+++ + +
Low dose (< 0.3mcg/kg/min) effect - Contractility
High dose effect - BPIdeally via central lineSide effects
Renal dysfunction, gut ischaemia Glucose Lactate & metabolic acidosis Myocardial necrosisB1 B2
+++ ++ +++
Resuscitation endpointsNo difference between peripheral & central
pulsesWarm skin, CFT < 2secNormal BP for ageDecreasing lactate & BEImproving mental stateUO >1ml/kg/h
Trend of improvementPeters ICM 2008;34
Common errors:Failure to recognize severity. Early recognition & Rx
Regular reassess
Ventilation delayed till arrest Prioritise A & B
Crash intubation Plan & prepare intubation
Myocardial depressant drugs for intubation.
Slow administration.•Ketamine•Fentanyl•Etomidate
Common errors:
•No secure IV access•Wasting time on IV access
IO needle after 90 sec.
Inadequate fluid •Fluidx3•Pushed in•Reassess liver & lungs
Rx increase O2 demand •Cooling •Sedation & pain control•Seizure control
Delayed antibiotics Antibiotics within 1 hour
Not improvingCoexisting cause of shockChanging hemodynamicsCardiogenic shock ? EchoNeonate & cardiacs ? Pulm HTNeonante ? prostinAdrenal insufficiency ? SteroidsTension pneumothoraxElectrolytes & glucose
Reassess ABC’s & secondary survey
Take home message1. Early recognition.2. Prioritise A, B, C’s.3. Don’t Ever Forget Glucose & elects.4. Fluid, Fluid, Fluid. 5. Reassess frequently & individualize.6. Early antibiotics.7. Look for coexisting etiologies.
Shock statesSimilarities Differences
Reduced tissue perfusion Etiology
Cellular energy failure &Multi-organ failure
Coexisting etiology
Histopathology changes
Changing hemodynamics
Inflammatory response (SIRS)
Etiologic specific Rx
Impaired immune response
Resuscitation to improve tissue perfusion