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Update on shock management

Update on shock management. Dr. Manal Al Maskati Oct, 2011 - Kuwait. Objectives. Briefing about pathophysiology of shock. Initial steps of pt’s stabilization. Work-up in A/E. Some important procedures ,which considered beneficial for shock management.

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Update on shock management

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  1. Update on shock management Dr. Manal Al Maskati Oct, 2011 - Kuwait

  2. Objectives • Briefing about pathophysiology of shock. • Initial steps of pt’s stabilization. • Work-up in A/E. • Some important procedures ,which considered beneficial for shock management. • How ?When? and What ? medications are important to know to manage any type of shock.

  3. Pathophysiology • Shock  inadequate delivery of substrates and oxygen to meet the metabolic needs of tissues. • Cell  anaerobic metabolic pathway  accumulation of lactic acid. • Hypoxic-ischemic injury widespread cellular death  multiple system organ failure  death.

  4. Pathophysiology • DO2 (mL O2/min) = CaO2 (mL O2/L blood) X CO (L/min) • DO2amount of oxygen delivered to body tissues/ min. • CaO2oxygen-carrying capacity depends on: • Hemoglobin (Hb) content • Arterial oxygen saturation (SaO2). • CO cardiac output depends on: • stroke volume (SV) • heart rate (HR). • CO = HR (beats/min) X SV (mL/beat) • SV stroke volumedepends on: • Preload • Afterload • Contractility • BP = CO X SVR

  5. Treatment • ABC • Non-invasive monitors • Abx in septic shock with empiric coverage • Neonates : combination of ampicillin and gentamicin. • Older infants and children: third-generation cephalosporin,withvancomycin if indicated. • Baseline work-up

  6. Treatment • Volume expansion Children with hypovolemic shock receive appropriate aggressive fluid resuscitation within the 1st hr of resuscitation  optimal chance of survival and recovery. • Place 2 large-bore IV catheters or IO access. • Administer 20 mL/kg isotonic crystalloid infusion  re-evaluate administer additional 20 mL/kg if needed. • If > 2-3 of 20-mL/kg volumes crystalloid given to patient at risk for hemorrhage  packed RBCs. • In study of survival in children with septic shock  children received an average 65 mL/kg of volume in 1st hr had statistically increased chance of survival compared with other groups received < 40 mL/kg in 1st hr. • Exception to repetitive volume resuscitation cardiogenic shock.

  7. Work-Up • CBC count • Hboxygen-carrying capacity. • orwhite cell countseptic shock. • Thrombocytopenia bleeding disorder or DIC.

  8. Work-Up • Acid-base status • Shock produces lactic acid metabolic acidosis with anion gap. • Diarrhea leads to direct bicarbonate loss. • Measurement of serum lactate level distinguish bicarbonate loss from lactic acidosis due to shock.

  9. Work-Up • Complete metabolic panel • Hypernatremia intravascular volume contraction hypovolemic shock. • serum carbon dioxide metabolic acidosis. • Hypovolemia BUN and creatine levels. • liver enzymes hypoxic-ischemic damage to liver.

  10. Work-Up • B-type natriuretic peptide • BNP : hormone produced by ventricular myocytes in response to myocardial wall stress. • Plasma BNP levels (adult and pediatric studies) in sepsis and congestive heart failure with cardiogenic shock. • Elevated levels of BNP myocardial stress, and improvement in cardiac function normalization of BNP levels.

  11. Work-Up • Imaging Studies Never delay resuscitation of patient in shock CXR • Cardiomegaly incardiogenic shock. • Small heart size in hypovolemic shock . • ARDS from pneumonia and sepsis.

  12. Work-Up • Other Tests • Near-infrared spectroscopy (NIRS) • Values correlate with venous oxygen saturations noninvasive measurements of increased or decreased tissue oxygen saturation (adequate or inadequate DO2 ). • Cardiac index • CO divided by body surface area (BSA) • Normal CI is 3.5-5.5 L/min/m2 • Cardiac index invasive or noninvasive measurements (Doppler echocardiography, or classic pulmonary artery catheter).

  13. Procedures • Mixed Venous Oxygen Saturation (SvO2) • Blood gas from central venous catheter or Swan-Ganz catheter. • In patient with normal SaO2 (90-100%)  SvO2 70-80%. • Tissues extract 28-33% of oxygen delivered to them. • If oxygen extraction difference > 33%  poor tissue perfusion  state of shock. • If oxygen extraction difference < 25%  oxygenated blood shunting  distributive shock.

  14. Procedures • Central venous pressure and pulmonary capillary wedge pressure • Low CVP or PCWP  inadequate intravascular volume. • Normal CVP  1-3 cm H2 O. • Pressures > 10 cm H2 O  volume overload or poor right-sided heart function • PCWP of 12-18 cm H2o  good perfusion.

  15. Medications • Dextrose administration often necessary • If glucose level low 0.5-1 g/kg IV Dextrose. • Shock with documented hypocalcemia, or caused by arrhythmias (hyperkalemia, hypermagnesemia, or calcium channel blocker toxicity) calcium therapy. • Recommended dose is 10-20 mg/kg (0.1-0.2 mL/kg of calcium chloride 10%) IV at infusion rate 100 mg/min.

  16. Medications • Sodium bicarbonate use in treatment of shock is controversial. • No better effect on • Ability to defibrillate • DO2 • Survival rates in shock and cardiac arrest

  17. Medications • In patients with persistent shock or ongoing bicarbonate loss (eg, severe diarrhea) careful replacement of bicarbonate. HCO3- (mEq) = Base deficit X patient's weight (in kg) X 0.3 • Half of calculated bicarbonate deficit administered initially. OR • 0.5-1 mEq/kg/dose IV infused over 1-2 minutes.

  18. Medications • Vasopressors/inotropic agents • Increase myocardial contractility + variable effects on peripheral vascular resistance • Dopamine • 1st inotrope fluid-refractory septic shock . • Low dose (2-5 mcg/kg/min IV) vasodilatory effect on end-organ perfusion . • Intermediate dose (5-10 mcg/kg/min IV) improves myocardial contractility + CO + enhancing conduction. • Higher dose (10-20 mcg/kg/min IV ) increases peripheral vasoconstriction + BP.

  19. Medications • Dobutamine • Good for cardiogenic shock. • Increases cardiac contractility + peripheral vasodilation (afterload and improve tissue perfusion). • Less likely to precipitate ventricular dysrhythmias than epinephrine. • Dose begins with 5 mcg/kg/min IV , gradually increased to 20 mcg/kg/min IV.

  20. Medications • Epinephrine • For fluid refractory dopamine resistant, non-vasodilatory(cold)shock. • Increases myocardial contractility + peripheral vasoconstriction. • Risk of ventricular dysrhythmias+ extremities ischemia • Dose : 0.1 mcg/kg/min IV , titrated upward according to effect and adverse effects. • Severe cases 2-3 mcg/kg/min IV or higher.

  21. Medications • Norepinephrine • For fluid-refractory, dopamine-resistant vasodilatory (warm) shock. • Increases peripheral vasoconstriction BP. • Best pressor agent increases BP in shock persists after adequate fluid replacement. • Dose : 0.1 mcg/kg/min IV ,titrated upward according to effect and adverse effects.

  22. Medications • Phosphodiesterase Enzyme Inhibitor • Inamrinone + milrinone • Useful for shock with adequate intravascular volume, but need increased cardiac contractility and better peripheral perfusion ( compensated shock with poor peripheral perfusion). • Improve cardiac inotropy+ peripheral vasodilation. • Phosphodiesterase inhibitor used together with catecholamines increase myocardial contractility + reducing systemic vascular resistance and afterload.

  23. Medications • Inamrinone + milrinone • Inamrinone : loading dose of 0.75 mg/kg IV over 2-3 minutes followed by continuous IV infusion of 5-10 mcg/kg/min. • Milrinone : loading dose of 25-50 mcg/kg over 10 minutes, followed by continuous IV infusion of 0.375-0.75 mcg/kg/min. • Adverse effects: arrhythmias + thrombocytopenia

  24. Medications • Prostaglandin E1 • Neonates with shock (large liver, enlarged cardiac silhouette, or heart murmur) obstructive shock(PDA closure) . • PDA allow sufficient systemic blood flow to bypass obstructive lesion. • PGE1 maintains patency of PDA. • Dose 0.05-0.1 mcg/kg/min IV as continuous infusion. • Adverse effects : fever, apnea, or hypotension due to vasodilation.

  25. Medications • Corticosteroid • Use of corticosteroids in septic shock controversial • Adrenocortical failure or infarction (Waterhouse-Friderichsen syndrome) cardiovascular failure +hyporesponsiveness to catecholamines. • Initiation of stress-dose hydrocortisone (50-100 mg/m2/d IV), may be lifesaving. • A serum cortisol level drawn prior to first dose of corticosteroids serum cortisol level low replacement doses.

  26. Medications • Corticosteroid • Study of adult patients with septic shock survived 48 hours ,dependent on inotropic agents showed some benefit when treated with supraphysiologic doses of corticosteroids. • Patients developed adrenal insufficiency 1-2 mg/kg hydrocortisone IV every 6 hours OR 50 mg/kg bolus followed by same amount infused over 24 hours. • Therapy continued for patients absolute baseline cortisol level < 20 mcg/dL.

  27. Take Home Message • Initial steps of stabilization make tremendous difference in pts survival. • In non-cardiogenic shock fluid fluidfluid. • Early Abx improved survival in septic shock. • Arrange for ICU bed. • Don’t forget the Team-Work management.

  28. Thank you Discussion

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