Section of Critical Care Medicine Section of Infectious Diseases University of Manitoba, Winnipeg, Canada UMDNJ-Robert Wood Johnson Medical School Cooper Hospital, NJ Anand Kumar, MD SHOCK Classification and Approach to Management
Diagnosis Remains Undefined or Hemodynamic Status Requires Repeated Fluid Challenges of Vasopressors
Pulmonary Artery Catheterization
Diagnosis Using Pulmonary Artery Catheterization Pulmonary Artery Cardiac Miscellaneous Diagnosis Occlusion Pressure Output Comments Cardiogenic Shock Cardiogenic shock Usually occurs with due to myocardial evidence of extensive dysfunction myocardial infarction (40% of LV infarcted), severe cardiomyopathy, or myocarditis. Cardiogenic shock due to a mechanical defect Acute VSD LVCO Predominant shunt is and RVCO left to right, pulmonary >LVCO blood flow is greater than systemic blood flow: oxygen “step-up” occurs at RV level. Kumar and Parrillo, 2001
Diagnosis Using Pulmonary Artery Catheterization Pulmonary Artery Cardiac Miscellaneous Diagnosis Occlusion Pressure Output Comments Cardiogenic Shock Acute mitral Forward V waves in pulmonary regurgitation CO artery occlusion pressure tracing. Right ventricular Normal or Elevated RA and RV filling infarction pressures with low or normal pulmonary artery occlusion pressures. Extracardiac obstructive forms of shock Pericardial or RA mean, RV end- tamponade diastolic, pulmonary artery occlusion mean pressures are elevated and within 5 mmHg of one another. Kumar and Parrillo, 2001
Diagnosis Using Pulmonary Artery Catheterization Pulmonary Artery Cardiac Miscellaneous Diagnosis Occlusion Pressure Output Comments Extracardiac obstructive forms of shock Massive pulmonary Normal or Usual finding is embolism elevated right-sided pressures. Hypovolemic shock Distributive forms of shock Septic shock or normal or normal, Pre-resuscitation rarely cardiac output is Anaphylactic or normal or normal decreased shock Kumar and Parrillo, 2001
Clinical Approach to Diagnosis and Management Immediate Goals in Shock Hemodynamic support MAP >60mmHg PAOP = 12-18 mmHg Cardiac Index >2.2 L/min/m 2 Maintain oxygen delivery Hemoglobin >9 g/dL Arterial saturation >92% Supplemental oxygen and mechanical ventilation Reversal of oxygen dysfunction Decreasing lactate (<2.2 mM/L) Maintain urine output Reverse encephalopathy Improving renal, liver function tests MAP = mean arterial pressure; PAOP = pulmonary artery occlusion pressure.
Results of Current Therapy Inotropic support 90 + Thrombolysis 80-90 + IABP 80 + CABG 50-60 + PTCA if successful 50-60 if unsuccessful 80-90 Treatment In-hospital Strategy Mortality Rate (%) From Klein L. W.: Intra-aortic balloon pumping. In Parrillo J.E., Bone R.C. (eds), Critical Care Medicine : Principles of diagnosis and management, St. Louis, 1995: Mosby.