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SHOCK

SHOCK. Peter E. Morris, MD Pulmonary and Critical Care X64649, x69087 806-6898. ASSESSMENT OF THE PATIENT WITH A LOW BLOOD PRESSURE. WHAT IS AN ABNORMAL BLOOD PRESSURE? HYPOVOLEMIA HYPOTENSION SHOCK ADEQUATE PERFUSION. BLOOD PRESSURE GOAL MAP = 60-70 mmHg. CEREBRAL PERFUSION PRESSURE.

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SHOCK

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  1. SHOCK Peter E. Morris, MD Pulmonary and Critical Care X64649, x69087 806-6898

  2. ASSESSMENT OF THE PATIENT WITH A LOW BLOOD PRESSURE WHAT IS AN ABNORMAL BLOOD PRESSURE? HYPOVOLEMIA HYPOTENSION SHOCK ADEQUATE PERFUSION

  3. BLOOD PRESSURE GOAL MAP = 60-70 mmHg

  4. CEREBRAL PERFUSION PRESSURE MAP-ICP = CPP 65-5 = 60 mmHG <60  risk of brain ischemia and neuronal damage

  5. Relative CBF Normal Hypertensive (Autoregulation) 200 50 100 150 MAP

  6. REASONS FOR SHOCK Hemorrhage Myocardial dysfunction (cardiomyopathy, ischemia, pharmacologic, toxic, valvular) Circulatory obstruction (pulmonary embolus, cardiac tamponade, pneumothorax)

  7. REASONS FOR SHOCK Hypovolemia (gastrointestinal [GI], insensible losses, third-space fluid sequestration) Central sympathetic disruption (Drug overdose) Arteriovenous fistula

  8. REASONS FOR SHOCK Vascular Endothelial Cell Dysfunction/Disruption Sepsis (bacterial, viral, fungal) Anaphylaxis Dyshemoglobinemia (carbon monoxide, methemoglobinemia) Cellular poisons (cyanide sulfur, iron, lithium) Traumatic or massive tissue destruction Heat shock, Hypothermia

  9. Age Variation Compensatory reflexes may be more prominently demonstrated in young adults. Considerable variability exists at extremes of age. Most notably, younger individuals are able to maintain normal blood pressure until vascular and cardiac decompensation is imminent.

  10. FOR MOST ACUTELY HYPOTENSIVE PTS WITHOUT SIGNS OF PULMONARY EDEMA FLUID CHALLENGE IS AN APPROPRIATE FIRST RESPONSE

  11. BOLUS OF FLUID? FLUID CHALLENGE? HOW MUCH? HOW FAST? LENGTH OF TUBING DIAMETER OF CATHETER LENGTH OF CATHETER PRESSURE BAGS

  12. DEHYDRATION LOW URINE OUTPUT HYPOTENSION

  13. DURING RESUSCITATION • REMEMBER TO MONITOR: • MENTAL STATUS • VITAL SIGNS (MAP - O2 SATS) • URINE OUTPUT • SKIN PERFUSION • (LACTATE)

  14. ADRENAL FUNCTION Schroeder S. Wichers M. Klingmuller D. Hofer M. Lehmann LE. von Spiegel T. Hering R. Putensen C. Hoeft A. Stuber F. The hypothalamic-pituitary-adrenal axis of patients with severe sepsis: altered response to corticotropin-releasing hormone. Critical Care Medicine. 29(2):310-6, 2001 Feb. Shenker Y and Skatrud JB Adrenal Insufficiency in Critically Ill Patients Am. J. Respir. Crit. Care Med., Volume 163, Number 7, June 2001, 1520-1523

  15. Randomized, non-blinded trial of traditional vs early goal-directed therapy (EGT) Septic shock unresponsive to 20 mL/kg crystalloids, or Lactate 4 mmol/L Standard CVP 8-12 mm Hg Vasopressors for SBP 90 mm Hg Maintain UOP 0.5 mL/kg/hr MAP 65 mm Hg Goal-directed Above, plus Patients monitored with CVP and SVO2 If SVO2 <70% RBCs until Hct 30% If SVO2 still <70%, add dobutamine to dose of 20 μg/kg/min Early Goal-Directed Therapy for Septic Shock Rivers E, et al. N Engl J Med 2001;345:1368-77.

  16. EGT Pts Received More Fluids, RBCs and Dobutamine Fluids in mL Patients Receiving Treatment (%) 6000 5000 4000 3000 2000 1000 0 Pressors First 6 hours Rivers E, et al. N Engl J Med 2001;345:1368-77.

  17. EGT* in patients with severe sepsis produced the following: 42%  in relative risk of in-hospital and 28-day mortality (P=0.009, P=0.01) 33%  in relative risk of death at 60 days (P=0.03) NNT to prevent 1 event (death) = 6-8 Early Goal-Directed Therapy for Septic Shock Mortality (%) *Aggressive resuscitation begun in emergency department. Rivers E, et al. N Engl J Med 2001;345:1368-77.

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