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Approach and Hemodynamic Evaluation of Shocks

Mazen Kherallah, MD, FCCP King Faisal Specialist Hospital & Research Center. Approach and Hemodynamic Evaluation of Shocks. Shock Definition. Question #0. Which of the following is necessary in the definition of shock? (a) A drop in the systolic blood pressure of less than 90 mm Hg

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Approach and Hemodynamic Evaluation of Shocks

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  1. Mazen Kherallah, MD, FCCP King Faisal Specialist Hospital & Research Center Approach and Hemodynamic Evaluation of Shocks

  2. Shock Definition

  3. Question #0 Which of the following is necessary in the definition of shock? (a) A drop in the systolic blood pressure of less than 90 mm Hg (b) A drop in the mean arterial pressure of less than 60 mm Hg (c) A drop in the SBP of 40 mm Hg or 20% from baseline (d) An elevated lactic acid of ≥ 4 mmoL/L (e) Any of the above

  4. Question #1 • Which of the following is necessary in the definition of shock? • (a) Hypotension • (b) Tissue hypoxia • (c) Use of pressors • (d) Multiple organ dysfunction

  5. Shock • Profound and widespread reduction in the effective delivery of oxygen leading to first to reversible, and then if prolonged, to irreversible cellular hypoxia and organ dysfunction” Kumar and Parrillo • Leads to Multiple Organ Dysfunction Syndrome (MODS)

  6. Pathophysiology

  7. Pathophysiology DO2 Oxygen delivery VO2 Oxygen extraction ratio Oxygen uptake

  8. Physiologic Oxygen Supply Dependency Oxygen Consumption Lactic Acidosis Critical Delivery Threshold Oxygen Delivery Mizock BA. Crit Care Med. 1992;20:80-93.

  9. sepsis sepsis sepsis Sepsis

  10. Pathologic Oxygen Supply Dependency Pathologic Physiologic Oxygen Consumption Oxygen Delivery Mizock BA. Crit Care Med. 1992;20:80-93.

  11. Pathophysiology • Most forms of shock • Low cardiac output state • Supply-dependency of systemic VO2 • Septic shock • Systemic DO2 and VO2 are both supranormal, but an oxygen deficit remains • Peripheral oxygen extraction may be deranged and VO2 is pathologically supply-dependent • Possible microvascular maldistribution of perfusion

  12. Question #2 • Which is not an important determinant of oxygen delivery? • (a) Hemoglobin level • (b) Cardiac output • (c) pO2 • (d) SaO2

  13. Oxygen Delivery (DO2) Cardiac Output x Oxygen Content COx [(1.3 xHgbx SaO2) + (0.003 x PaO2)] • Hemoglobin concentration • SaO2 • Cardiac output • PaO2 (minimal)

  14. Cardiac Output Afterload Preload Contractility

  15. Preload • Determined by end-diastolic volume • Pressure and volume related by compliance of the ventricle

  16. Left ventricular end-diastolic pressure versus left ventricular end-diastolic volume

  17. Cardiac Output • Sterling relationship Cardiac output Volume loading

  18. Clinical Adaptation of the Sterling Myocardial Function Curves

  19. Global Hemodynamic Relationships Afterload Preload Contractility

  20. Question #3 • Which can cause low preload? • (a) High PEEP • (b) Tension pneumothorax • (c) Third spacing • (d) Positive pressure ventilation • (e) All of the above

  21. Pathophysiology • Inadequate/ineffective DO2 leads to anaerobic metabolism • Large/prolonged oxygen deficit causes decrease of high-energy phosphates stores • Membrane depolarization, intracellular edema, loss of membrane integrity and ultimately cell death

  22. Effects of Shock at Cellular Level

  23. Common Histopathology Associated with Tissue Hypoperfusion and Shock?

  24. Myocardium Lung Coagulative necrosis Contraction bands Edema Neutrophil infiltrate Diffuse alveolar damage Exudate, atelectasis Edema Hyaline membrane Histopathology of Tissue Hypoperfusion Associated with Shock Robbins & Cotran Pathologic Basis of Disease: 2005

  25. Liver Small Intestine Mucosal infarction Hemorrhagic mucosa Epithelium absent Centrilobular hemorrhagic necrosis Nutmeg appearance Histopathology of Tissue Hypoperfusion Associated with Shock Robbins & Cotran Pathologic Basis of Disease: 2005

  26. Brain Brain Bland infarct Punctate hemorrhages Eosinophilia and shrinkage of neurons Neutrophil infiltration Histopathology of Tissue Hypoperfusion Associated with Shock Robbins & Cotran Pathologic Basis of Disease: 2005

  27. Kidney Pancreas Tubular cells, necrotic Detached from basement membrane Swollen, vacuolated Fat necrosis Parenchymal necrosis Histopathology of Tissue Hypoperfusion Associated with Shock Robbins & Cotran Pathologic Basis of Disease: 2005

  28. Incidence of Ischemic Histopathology in Patients Dying with Shock McGovern VJ, Pathol Annu 1984;19:15

  29. Shock Syndromes

  30. Shock • Cardiogenic shock - a major component of the the mortality associated with cardiovascular disease (the #1 cause of U.S. deaths) • Hypovolemic shock - the major contributor to early mortality from trauma (the #1 cause of death in those < 45 years of age) • Septic shock - the most common cause of death in American ICUs (the 13th leading cause of death overall in US)

  31. Cardiac Performance Left ventricular size Peripheral resistance Preload Stroke volume Myocardial fiber shortening Cardiac output Contractility Heart rate Afterload Arterial pressure

  32. Compensatory Mechanisms

  33. Case 1 • 34 year old involved in a motor vehicle accident arrived to emergency room with blood pressure of 70/30 and heart rate of 140/min

  34. Question #5 • Which is typical of hypovolemic shock? • (a) High SVR • (b) High cardiac output • (c) High oxygen delivery • (d) Normal wedge pressure

  35. Left ventricular size Peripheral resistance Preload Stroke volume Myocardial fiber shortening Cardiac output Contractility Heart rate Afterload Hypovolemic Shock Arterial pressure Compensatory Mechanism Adrenaline

  36. Hypovolemic Shock Hemodynamics CO SVR PWPEDV Hypovolemic Cardiogenic Obstructive afterload preload Distributive pre-resusc post-resusc

  37. Hypovolemic Shock • Hemorrhagic • Trauma • Gastrointestinal • Retroperitoneal • Fluid depletion (nonhemorrhagic) • External fluid loss - Dehydration - Vomiting - Diarrhea - Polyuria • Interstitial fluid redistribution - Thermal injury - Trauma - Anaphylaxis • Increased vascular capacitance (venodilatation) • Sepsis • Anaphylaxis • Toxins/drugs Kumar and Parrillo, 2001

  38. Case 2 • 54 year old with acute onset chest pain arrived to emergency room with blood pressure of 70/30 and heart rate of 140/min

  39. Question #5 • Which is typical of cardiogenic shock? • (a) Low SVR • (b) High cardiac output • (c) Low oxygen delivery • (d) Low wedge pressure

  40. Left ventricular size Peripheral resistance Preload Stroke volume Myocardial fiber shortening Cardiac output Contractility Heart rate Afterload Cardiogenic Shock Arterial pressure Compensatory Mechanism Adrenaline

  41. CO SVR PWPEDV Hypovolemic Cardiogenic Obstructive afterload preload Distributive pre-resusc post-resusc Cardiogenic Shock Hemodynamics

  42. Cardiogenic Shock • Myopathic • Myocardial infarction (hibernating myocardium) • Left ventricle • Right ventricle • Myocardial contusion (trauma) • Myocarditis • Cardiomyopathy • Post-ischemic myocardial stunning • Septic myocardial depression • Pharmacologic • Anthracycline cardiotoxicity • Calcium channel blockers • Mechanical • Valvular failure (stenotic or regurgitant) • Hypertropic cardiomyopathy • Ventricular septal defect • Arrhythmic • Bradycardia • Tachycardia Kumar and Parrillo, 2001

  43. Case 3 • 67 year old with fever, chills, SOB, and ugly looking abdominal wound arrived to emergency room with blood pressure of 70/30 and heart rate of 140/min

  44. Question #6 • Which is not typical of sepsis? • (a) Low SVR • (b) High cardiac output • (c) Low oxygen delivery • (d) Low wedge pressure

  45. Left ventricular size Peripheral resistance Preload Stroke volume Myocardial fiber shortening Cardiac output Contractility Heart rate Afterload Distributive Shock Arterial pressure Compensatory Mechanism Adrenaline

  46. CO SVR PWPEDV Hypovolemic Cardiogenic Obstructive afterload preload Distributive pre-resusc post-resusc Distributive Hemodynamics

  47. Distributive Shock • Septic (bacterial, fungal, viral, rickettsial) • Toxic shock syndrome • Anaphylactic, anaphylactoid • Neurogenic (spinal shock) • Endocrinologic • Adrenal crisis • Thyroid storm • Toxic (e.g., nitroprusside, bretylium) Kumar and Parrillo, 2001

  48. Left ventricular size Peripheral resistance Preload Stroke volume Myocardial fiber shortening Cardiac output Contractility Heart rate Afterload Obstructive Shock Arterial pressure Compensatory Mechanism Adrenaline

  49. CO SVR PWPEDV Hypovolemic Cardiogenic Obstructive afterload preload Distributive pre-resusc post-resusc Obstructive Shock Hemodynamics

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