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Objectives:

Objectives:. Identify a patient in shock Learn the different types of shock and their acute management With a focus on septic shock, identify best practices Familiarize yourself with vasopressors and advanced medical therapies. MKSAP Question.

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Objectives:

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  1. Objectives: • Identify a patient in shock • Learn the different types of shock and their acute management • With a focus on septic shock, identify best practices • Familiarize yourself with vasopressors and advanced medical therapies

  2. MKSAP Question • A 71 y/o female is brought to the ED from a SNF because of confusion, fever and flank pain. Her temperature is 38.5 C, BP 82/48, pulse 123, RR 27. Mucous membranes are dry, there is CVA tenderness, poor skin turgor and no edema. Hgb 10.5, WBC 15.6, UA with 50-100 wbc/hpf and many bacteria. There is an anion gap metabolic acidosis. A CVC is placed and antibiotic therapy is started. • Which of the following interventions is most likely to improve survival for this patient? • A) Aggressive fluid resuscitation • B) Hemodynamics monitoring with a PA catheter • C) Maintaining Hgb concentration above 12g/dL • D) Maintaining Pco2 below 50 mmHg

  3. INTRO to shock

  4. Shock • What is shock? • Hypotension? • Vasopressor-o-penia? • Inadequate cellular oxygenation • Oxygen delivery equation • DO2 = CaO2 x Q • CaO2 = (1.34 x Hgb x SaO2) + (0.003 x PaO2) • Q = HR x SV • “The final common pathway before death” • Josh Farkas, MD in IBCC

  5. Multiple Organ System Failure

  6. Shock • Identifying the patient in shock • Exam findings • The “other” look • Supreme Court Justice Potter Stewart • Hemodynamics • SBP • MAP • CVP • SvO2 • PCWP • Lactate?

  7. Shock • Cardiogenic • AMI, Cardiomyopathy, Valvular Disease, Myocarditis, Arrhythmia • Hypovolemic • Fluid loss, internal or external • Obstructive • Pneumothorax, Cardiac Tamponade, Acute PE • Distributive • Sepsis, Anaphylaxis

  8. Shock

  9. Determining type of shock • History taking • Physical exam • Invasive testing • Central line – CVP, ScvO2 • PA catheter – PCWP, SvO2 • Measures of cardiac output • Bioimpedence • Vigileo • Lidco • Esophageal doppler • Echocardiogram/POCUS He’s been having diarrhea for the last week, today he was too weak to get out of bed. He said he was feeling dizzy earlier.

  10. Determining type of shock - POCUS • https://twitter.com/emuss_uk/status/966353653815656448 • https://twitter.com/EM_RESUS/status/606157034980032513 • https://twitter.com/EM_RESUS/status/1102288034538668035] • https://twitter.com/DrAndrewDixon/status/732314227340271616

  11. Septic Shock: Management

  12. Rivers, NEJM 2001 • SIRS Criteria + SBP <90 mmHg or Lactate >4 mmol/L • 130 patients in each group • Standard vs EGDT • EGDT = ScvO2 monitoring x 6 hours • Fluid resus to CVP goal • Vasopressors if <65 • PRBC, Dobutamine • Standard therapy had lower MAP, higher HR, lower SvO2 • Higher mortality in standard therapy Rivers, NEJM 2001

  13. Rivers, NEJM 2001 Rivers, NEJM 2001

  14. ProCESS 2014 • Multicenter Study • United States • Academic Medical Centers • Similar inclusion criteria • Randomized 1:1:1 (450 in each) • EGDT • Protocol based (CVC not necessary, volume assessment) • SI = HR/SBP • Standard Therapy ProCESS investigators, NEJM 2014

  15. ProCESS 2014 • Less IV fluid use in usual care • 2.8L vs 3.3L vs 2.3L @ 6hr • 7.3L vs 8.2L vs 6.6L @ 72hr ProCESS investigators, NEJM 2014

  16. ARISE 2014 • Multicenter • Australia, New Zealand, Hong Kong, Ireland, Finland • Tertiary and non-tertiary hospitals • Similar inclusion criteria • Randomized 1:1 (800 in each) • EGDT • Usual care (ScvO2 not permitted) • Less fluid in usual care: • 1.9L vs 1.7L • CVC placed in 60.9% usual care ARISE Investigators NEJM 2014

  17. ProMISe 2015 • Multicenter study • English NHS hospitals • Similar inclusion • Randomized 1:1 (600 in each) • EGDT • Usual care • EGDT group received more IV fluids • 1.7L.vs 1.5L • CVC placed in 50.9% usual care Mouncey NEJM 2015

  18. ProMISe 2015 Mouncey NEJM 2015

  19. Surviving Sepsis • Initially conceived following the Rivers trial and before ProCESS. • Quality improvement in the care of sepsis • 1 hour bundle • Measure lactate, obtain cultures, start antibiotics, fluid resuscitate (30cc/kg) and start vasopressors

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