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Shock States Beyra Rossouw Intensive Care Unit Red Cross War Memorial Children’s Hospital

Shock States Beyra Rossouw Intensive Care Unit Red Cross War Memorial Children’s Hospital University of Cape Town. Shock. Pathophysiology Different shock states Treatment principles. Shock is:. Reduced Tissue Perfusion Cellular Hypoxia & Energy Failure. ↑ O2 Demand.

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Shock States Beyra Rossouw Intensive Care Unit Red Cross War Memorial Children’s Hospital

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  1. Shock States Beyra Rossouw Intensive Care Unit Red Cross War Memorial Children’s Hospital University of Cape Town

  2. Shock • Pathophysiology • Different shock states • Treatment principles

  3. Shock is: Reduced Tissue Perfusion Cellular Hypoxia & Energy Failure ↑O2 Demand O2 Delivery

  4. Oxygen Delivery to Tissues Ventilation Gas exchange Alveoli O2 Delivery O2 extraction ATP O2 consumption Cell

  5. Oxygen Delivery Components O2 Content Cardiac Output x O2 Content

  6. Oxygen Delivery Components O2 Content Cardiac Output Heart Rate Stroke Volume SaO2 PaO2 Hb Preload Afterload Contractility Synchrony

  7. Cell Venous Outflow (Q) Arterial Inflow (Q) O2 O2 O2 capillary O2 O2 O2 O2 (Adapted from the ICU Book by P. Marino) Oxygen Content of Blood =(O2 carried by Hb) + (O2 in solution) = (1.34 x Hb x Sats x 0.01) + (0.023 x PaO2) O2 O2

  8. Shock States Adapted from JL Vincent, ESICM 25 Years of Progress & Innovation Cardiogenic Dissociative Obstructive Clot Capillary leak & Vasculopathy Distributive Hypovolemic

  9. Reduced Tissue Perfusion & Energy Failure Common Shock States Distributive Shock Septic Shock Anaphylatic Neurogenic Hypovolemic Shock Hemorrhage Burns GIT loss Cardiogenic Myocarditis Arrythmia Septic Congenital lesions Valvular lesions

  10. Glucose Anaerobic 2x ATP Pyruvic Acid Lactic Acid Fatty AcidsAmino Acids Acetyl Co-A Aerobic O2 Krebs Cycle 38x ATP CO2 H+

  11. Lactate, BP & Mortality in Sepsis Howell MD et al. ICM 2007; 33: 1892–1899

  12. Stages of shock ATP Supply <<ATP Demand ATP Supply =ATP Demand Vasoconstriction tachycardia Redistribution of blood flow Anaerobic metabolism O2 consumption Membrane leak Cell death Decomp Compensated Irreversible O2 delivery

  13. Timing of decompensation JL Vincent, De Backer . Oxygen Delivery Controversy ICM 2004;30:1990 Hypovolaemic Cardiogenic Obstructive Septic shock O2 consumption O2 delivery

  14. Hemodynamic Response to Shock J Carcillio. Fluid Resuscitation of Hypovolemic Shock. ICM 2006;32:958 Heart rate Blood pressure Cardiacoutput Compensated Shock Decompensated Shock

  15. Key Issues In Shock • Falling BP = LATE sign. • Pallor, tachycardia, slow CFT, restlessness = Shock until proven otherwise. • BP is NOTsame as perfusion. Normal Septic shock with normal BP De Baker CCM 2006 34 :403-408

  16. Hemodynamic Profiles M Pinsky. Functional hemodynamic Monitoring. Current Opinion Critical Care 2007;13:318

  17. Key Issues Recognize & Treat during compensatory shock phase Mortality increase 2-fold for every hour in treatment delay.Han, Carcillo. Pediatrics 2003;112:793-799

  18. Multisystem effect of shock • Resp: Resp failure, ARDS • Renal: ATN, acute renal failure • CNS: infarcts & bleeding • Liver: centrilobular necrosis • GIT: bleeds, necrosis, ileus, bacterial translocation • Haemat: DIC, vasculopathy, capillary leak Robbins & Cotran Pathologic Basis of Disease: 2005

  19. Novel strategies for the treatment of sepsis. Riedemann Nature Medicine 2003

  20. Shock states coexistChanging hemodynamicsIndividualize treatment

  21. Treatment principles 1. Increase O2 delivery 2. Reduce O2 demand • Fever • Tachycardia • Tachypnea • Anxiety & restlessness • Pain • Seizures & shivering O2 delivery O2 demand

  22. Resuscitation PrioritiesIncrease O2 delivery • V: Ventilate & Oxygenate. • I: Infuse: • Fluids, fluids, fluids • Electrolytes • Blood- Hb >10 • P: ↑Pump Function: • Inotropes • Rhythm control • Electrolytes & glucose • E: Etiology: - Treat the cause.

  23. FLUID, FLUID, FLUID • Regardless of etiology - fluid bolus x3 5ml/kg cardiac 10ml/kg trauma 20ml/kg sepsis • Delayed fluid resuscitation ↑ mortality. Rivers NEJM 2001, Han Pediatrics 2003 • Reassess liver & lungs. • Septic shock may need up to 200ml/kg. • No evidence one is fluid superior. Finfer NEJM 2004

  24. Permissive Hypotension forUncontrolled Hemorrhage Aggressive Volume Loading Re-bleeding SBP Increase Mechanic effect on vascular clot Haemodilution Anaemia Hypothermia Coagulation disorders Roberts et al Lancet 2001

  25. Inotropes in fluid resistance Vasoconstriction ↑Stroke volume, ↑ HR  1 NORADRENALINE ADRENALINE ADRENALINE DOBUTAMINE DOPAMINE DOPAMINE NORADRENALINE Pediatric Cardiac Intensive Care . Chang & Wernovsky

  26. Drug of choice ACCM/PALS in septic shock. CCM 2009; 37: 2, CCM 2002; 30:6 Low dose: DA effect -  Splanchnic vasodilatation Medium dose:  effect - Contractility High dose:  effect -  BP Age –specific sensitivity Peripheral IV Dopamine

  27. More expensive than dopamine Use tocontractility when BP stable Drug of choice for cardiacs & PHT Age –specific sensitivity Peripheral IV Dobutamine

  28. Low dose (< 0.3mcg/kg/min)  effect - Contractility High dose  effect -  BP Ideally via central line Side effects Renal dysfunction, gut ischaemia  Glucose  Lactate & metabolic acidosis Myocardial necrosis Adrenaline

  29. Resuscitation endpoints • No difference between peripheral & central pulses • Warm skin, CFT < 2sec • Normal BP for age • Decreasing lactate & BE • Improving mental state • UO >1ml/kg/h Trend of improvement Peters ICM 2008;34

  30. Not improving • Coexisting cause of shock • Changing hemodynamics • Cardiogenic shock ? Echo • Neonate & cardiacs ? Pulm HT • Neonante ? prostin • Adrenal insufficiency ? Steroids • Tension pneumothorax • Electrolytes & glucose Reassess ABC’s & secondary survey

  31. Take home message • Early recognition. • Prioritise A, B, C’s. • Don’t Ever Forget Glucose & elects. • Fluid, Fluid, Fluid. • Reassess frequently & individualize. • Early antibiotics. • Look for coexisting etiologies.

  32. Get The Basics Right All The Time ?

  33. Shock states

  34. Drug of choice for Warm shock Myocardial contractility not severely impaired Central line Noradrenaline

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