SHOCK

1. SHOCK Department of Surgery Ruijin Hospital Shanghai Second Medical University

2. 正规培养 严格训练 形成习惯 How to Learn Shock 理 念 救死扶伤，防微杜渐 实 践 完美流畅，收效卓著 理 论 刻苦钻研，融会贯通 观察和判断 技术、技巧和技能 Timing, sequence of selected items, and its meaning The ART bring with JOY

3. I. Historical Aspect Ancient term about shock 问题 提出 • First use the word shock • to refer to violent impact or blow, 1743 • to refer to physiologic instability, 1815 • 厥症

4. Initial Recognition of shock 开始探索 • Thomas Latta, 1831 • Patients with Cholera • Infusion of intravenous fluids → improvement Hypovolemia

5. the Rise of Physiology in 19 CN 继续探索 • Burgeoning of Cardiovascular physiology in the end of 19CN, Crile • CVP dropped after hemorrhage • Animal survival was increased after the infusion of saline

6. with the Combination of Biochemistry and Physiology • Toxin theory of shock, Cannon & Bayliss, Physiology • impairment of oxygen transport • development of acidosis • toxin in severe muscle injury →loss of vasomotor tone →venous sequestration of blood →hypotension • the Use of Cardiac Catheterization • Blood volume loss →fall in Cardiac Output 继续探索

7. Antedate the Era of Critical Care Medicine • Extensive physiologic research of Wigger, in early 1940s • the concept of irreversible shock • progressive systemic circulatory decompensation • integrating the Concepts of • impaired oxygen delivery • oxygen debt • tissue injury / death 认识突破

8. Organ Failure • More prompt and aggressive resuscitation • Incidence of ARF ↓ • ARDS • Introduction of the flow directed pulmonary artery catheter, in 1970 • Noncardiogenic nature Not due to volume overload 认识突破 ATN Why it happens: shock － Hypovolemia / Toxin /Cytokine Defects in Cell Membrane Function and Vascular Permeability Hypoxia ARDS

9. 休克 本质 II. Summary - Definition of shock • A syndrome that results from inadequate perfusion of tissues • insufficient to meet metabolic demand • lead to cellular dysfunction, elaboration of inflammatory mediators, and celluar injury • which may be limited, or widespread • A continuum, ranging from subclinical deficits in perfusion to MODS or frank organ failure. • Tissue hypoxia • Oxygen less available • increased organ demands

10. 休克的根本问题是: A. 组织细胞缺氧B. 低血压C. 酸中毒D. 心功能不全E. 以上都不对

11. III. Classificaion of Shock (i) • Hypovolemic Shock • Hemorrhage - • Plasma losses - • Cardiogenic Shock • Intrinsic - • Extrinsic • Compressive - • Obstructive - Trauma GI Bleeding Ruptured aneurysms Burn Bowel obstruction Valvular Heart Disease Cardiac Rhythm disturbance Cardiomyopathy Myocardial infarction Myocardial depression Tension pneumothorax Pericardial tamponade High level of positive-pressure ventilation Pulmonary embolism

12. III. Classificaion of Shock (ii) • Neurogenic Shock • e.g. • Vasogenic Shock • SIRS, toxin • Septic despite adequate fluid resucitation • Traumatic • Anaphylactic and Anaphylactoid • Hypoadrenal Severe head injury Spinal cord anesthesia Spinal cord injury

13. 各型休克的共同特点是： A. 血压下降B. 中心静脉压下降C. 脉压缩小D. 尿量减少E. 有效循环血量锐减

14. IV. Pathophysiology of shock • Impaired tissue perfusion • Wider spectrum of shock presentations • Ranging from occult tissue hypoxia to full-blown cardiovascular collapse or Multiple organ dysfunction • Implication • alarm earlier • treat earlier

15. Tissue hypoperfusion • tissue hypoxia • anaerobic metabolism, acidosis • inflammatory mediaters • circulatory redistribution • early involvement of splanchnic circulation • cellular injury • septic complications • MODS

16. Role of Hypoxia • O2Extraction Ratio=VO2/ DO2 • in resting state: 1/4, 1/3 • under the condition of either increased energy expenditure or decreased DO2 2 Oxygen consumption(vO ) DO2crit DO2ERcrit Oxygen delivery(DO2)

17. A Decrease in O2ER in Septic patients • Microcirculatory derangement • A-V shunting • maldistribution • defective oxygen utilization at the cellular level • late sepsis, hemorrhage, or traumatic shock • early shock with inadequate volume resuscitation • down-regulation of oxidative metabolism • endotoxin may cause a decrease in oxidative metabolism in skeletal muscle

18. Circulatory redistribution • Concept • Homeostatic response to hypoperfusion to preserve oxygen delivery to heart and brain by selective diverting blood • Mechanism • catechols, angiotension II, Vasopressin, endothelin,TXA2 • Consequence • Cellular and organ derangement → MODS • Breakdown of the intestinal epithelial barrier • bacterial and toxin translocation→ SIRS→MODS

19. The changes in MicrocirculataryLevel • intrinsic obstruction of cap. Bed • low-flow states, hypothermia, and increased viscosity • cap. Sludging: intravascular coagulation, platelet aggregation, other intraluminal debris • preventing RBC from reaching the tissues • extrinsic obstruction of cap. Bed • local tissue inflammation, edema, or hemorrhage, ACS • Damage to EC

20. 关于休克代偿期微循环改变， 下列那一项是错误的： A. 动静脉短路开放B. 直捷通道开放C. 微动脉收缩D. 微静脉收缩E. 毛细血管内血液淤积

21. V. Diagnosis and patient mornitoring • Conventional monitoring • Mental status • Skin temperature • Blood pressure, Pulse rate • Urinary output (30ml/hr) • Special monitoring • CVP (<5, 5~10cmH2O, >15, >20) • PCWP(6~15mmHg) • CO CI • Serum lactate concentration • Arterial blood gas analysis • DIC

22. VI. Measurement of Shock • 一般紧急处理 • Urgent measurement • 补充血容量 • Resuscitation • 积极处理原发病 • Treat inciting cause of shock • 纠正酸碱平衡失调 • Control electrolytes, and acid base derangement • 血管活性药物的应用 • Inotropic agent • 治疗DIC，改善微循环 • Treat DIC, improve microcirculation • 皮质类固醇和其它药物的应用 • Corticosteroids

23. Optimize Oxygen Delivery Keep SaO2>90% Optimize Cardiac IndexOptimize Hb Supply supplemental O2 Early hemodynamic monitoring 11-13 g/dl Ventilator, if necessary Assess volume status(preload) PCWP: <15, Volume expansion; <18, Consider volume; >18 Diurese Reassess Keep: PCWP15-18 mmHg, MAP 60-80mmHg, Delivery independent O2 consumption Goal meet Goal not meet Treat inciting cause of shock Control SIRS Nutritional support Inotropic support beta agonism Goal meet Goal not meet Consider Vasodilator, alpha agonist Initial resucsitation of patients in Shock

24. Optimize Oxygen Delivery Keep SaO2>90% Optimize Cardiac IndexOptimize Hb Supply supplemental O2 Early hemodynamic monitoring 11-13 g/dl Ventilator, if necessary Assess volume status(preload) CVP < 6 cmH2O, Volume expansion; <12, Consider volume; >12 Diurese Reassess Keep: CVP 6-12cmH2O, MAP 60-80mmHg, Delivery independent O2 consumption Goal meet Goal not meet Treat inciting cause of shock Control SIRS Nutritional support Inotropic support beta agonism Goal meet Goal not meet Consider Vasodilator, alpha agonist Initial resucsitation of patients in Shock (Modified)

25. 休克病人经补液后，血压仍低。5 ~ 10 min 内经静脉注入等渗盐水250ml，如血压上升，而中心静脉压不变，提示： A. 心功能不全B. 血容量不足C. 血容量过多D. 血管张力升高E. 以上都不是

26. 思考题 • 试述休克治疗的基本原则 • 试述休克的监测方法，尿量和CVP在休克监测中的意义 • 试述低血容量性休克的处理原则 • 试述感染性休克的处理原则 • 有何病理生理特点？

27. 1. Hypovolemic shock • Symptom • a decrease in pulse pressure • tachycarida and hypotension • urine output falls • normal skin turgor is lost • mental status changes - in a progressive fashion • apprehension, anxiety, complete obtundation • Treatment • Resuscitation & Control the inciting cause of shock Aggressive fluid resucitation before surgical control of hemorrhage may lead to disruption of thrombus, increased bleeding, and decreased survival.

28. Initial end-points volume resuscitation • reestablishment of urinary output • to a rate of 0.5-1.0ml per kg. Per hour • a normal heart rate and blood pressure • adequate capillary refill • normal sensorium • Normal CVP and PWCP

29. 2. Traumatic shock • Type • Vasogenic shock that begins as hypovolemic shock • Character - refractory to fluid replacement therapy • Larger volume losses, greater fluid sequestration • More intense activation of inflammatory mediators • Development of SIRS • Devastating soft tissue injuries • Machanism • increasing microvascular permeability, Excessive fluid requirement • Frequently Require • mechanical ventilation, Pulmonary artery catheter monitoring • Cardiovascular support • Operation

30. 3. Septic shock • Type • Vasogenic shock, Refractory to fluid replacement therapy • Definition • Sepsis with hypotension despite adequate fluid resuscitation • along with the presence of manifestations of hypoperfution • such as lactic acidosis, obliguria, or acute alteration in mental status • Mechanism • Cytokines • Vasodilatation, Increasing microvascular permeability, Excessive fluid requirement

31. Treatment of Septic shock • Resuscitation • Control infection • Normalization of electrolytes, acid base dearangement • Inotropic agent • Corticosteroids • Nutritional support, deal with DIC, organ function support

32. 正规培养 严格训练 形成习惯 How to Learn Shock 理 念 救死扶伤，防微杜渐 实 践 完美流畅，收效卓著 理 论 刻苦钻研，融会贯通 观察和判断 技术、技巧和技能 Timing, sequence of selected items, and its meaning The ART bring with JOY

33. 复苏 失败 死亡 (24h) 感染 创伤 烧伤 SAP 代谢 紊乱低氧 乏氧代谢 血 管 源 性 SIRS 休克 痊愈 复苏 成功 MODS 好转 MODS Primary 第 二 次 打 击 Secondary 低血容量 心源性、神经源性因素 （感染） Shock and MODS： Prevention, early Identification, prompt and proper treatment, passive treatmentCOST-EFFECTIVE?

34. Become a:Provide the: Specialized Service Surgeon Clinician Educated Under Mal Partial Absolute • Morality, make us to be complete, help us to get a best perception. • Theory, help us to think and practice rationally. • Technique, help us to realize, or achieve our goal.