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  • Sept
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    • 1. SHOCKSHOCK NGA B. PHAM, MD, FAAPNGA B. PHAM, MD, FAAP CRITICAL CARE MEDICINECRITICAL CARE MEDICINE CHILDREN’S HEALTHCARE OF ATLANTACHILDREN’S HEALTHCARE OF ATLANTA EGLESTONEGLESTON 20062006
    • 2. ObjectivesObjectives  Review basic physiologic aspects of shockReview basic physiologic aspects of shock  Define shock and its different categoriesDefine shock and its different categories  Describe management of shockDescribe management of shock
    • 3. What is Shock?What is Shock? Pathophysiology of shockPathophysiology of shock OxygenOxygen Demand > SupplyDemand > Supply
    • 4. Definition of ShockDefinition of Shock  Inadequate tissue perfusion to meet tissueInadequate tissue perfusion to meet tissue demandsdemands  Usually result of inadequate blood flowUsually result of inadequate blood flow and/or oxygen deliveryand/or oxygen delivery  Shock is not a blood pressureShock is not a blood pressure diagnosisdiagnosis
    • 5. Determinants of Oxygen DeliveryDeterminants of Oxygen Delivery  OxygenOxygen Delivery = Content x Cardiac outputDelivery = Content x Cardiac output
    • 6. Determinants of Oxygen DeliveryDeterminants of Oxygen Delivery  Oxygen content = 1.34 (Hgb x SaO2) + (PaO2 xOxygen content = 1.34 (Hgb x SaO2) + (PaO2 x 0.003)0.003)  SaO2: Oxygen saturationSaO2: Oxygen saturation  Hgb: Hemoglobin concentrationHgb: Hemoglobin concentration  PaO2: partial pressure Oxygen in plasmaPaO2: partial pressure Oxygen in plasma  To improve Oxygen contentTo improve Oxygen content  Increase Hemoglobin concentrationIncrease Hemoglobin concentration  Increase saturationIncrease saturation
    • 7. Determinants of Oxygen DeliveryDeterminants of Oxygen Delivery  Cardiac outputCardiac output  C.O. = Heart rate x stroke volumeC.O. = Heart rate x stroke volume  To improve Cardiac outputTo improve Cardiac output  Increase Heart rateIncrease Heart rate  Increase Stroke VolumeIncrease Stroke Volume  Preload – volume of blood in the ventriclePreload – volume of blood in the ventricle  Afterload – resistance to contractionAfterload – resistance to contraction  Contractility – force appliedContractility – force applied
    • 8. Secondary Organ DysfunctionSecondary Organ Dysfunction  Respiratory failureRespiratory failure  TachypneaTachypnea  Decreased complianceDecreased compliance  Pulm edema, pulm infiltrate, etc.Pulm edema, pulm infiltrate, etc.  Increased resistanceIncreased resistance  Diaphragm fatigueDiaphragm fatigue  Central vs peripheralCentral vs peripheral  Demand >> supplyDemand >> supply  Inadequate O2 deliveryInadequate O2 delivery
    • 9. Secondary Organ DysfunctionSecondary Organ Dysfunction  CNS – altered mental statusCNS – altered mental status  Renal insufficiency – pre-renalRenal insufficiency – pre-renal  Coagulation abnormalities – DICCoagulation abnormalities – DIC  Hepatic/GI dysfunction – bowel ischemiaHepatic/GI dysfunction – bowel ischemia  Endocrine – Calcium, hypo-adrenalism,Endocrine – Calcium, hypo-adrenalism, vasopressinvasopressin
    • 10. Classification of ShockClassification of Shock  Hypovolemic Shock (#1 cause world wide)Hypovolemic Shock (#1 cause world wide)  Dehydration, hemorrhagicDehydration, hemorrhagic  Cardiogenic ShockCardiogenic Shock  Pump failure, obstructive, L-R shuntPump failure, obstructive, L-R shunt  Distributive ShockDistributive Shock  NeurogenicNeurogenic  AnaphylaxisAnaphylaxis  Septic Shock – All of the aboveSeptic Shock – All of the above
    • 11. Classification of ShockClassification of Shock  CompensatedCompensated  Organ perfusion is maintainedOrgan perfusion is maintained  UncompensatedUncompensated  Circulatory failure with end organ dysfunctionCirculatory failure with end organ dysfunction  IrreverisbleIrreverisble  Irreparable loss of essential organsIrreparable loss of essential organs
    • 12. Mechanical Requirements forMechanical Requirements for Adequate Tissue PerfusionAdequate Tissue Perfusion  FluidFluid  PumpPump  VesselsVessels  FlowFlow
    • 13. Hypovolemic ShockHypovolemic Shock  #1 cause of death world wide#1 cause of death world wide  GastroenteritisGastroenteritis  Hemorrhagic – Trauma, GI bleedHemorrhagic – Trauma, GI bleed
    • 14. Diagnosis of Hypovolemic ShockDiagnosis of Hypovolemic Shock  EarlyEarly  Increase HRIncrease HR  Decrease perfusionDecrease perfusion  Normal BP, decrease pulse pressureNormal BP, decrease pulse pressure  LateLate  Sign increase HRSign increase HR  Sign decrease perfusionSign decrease perfusion  Decrease BPDecrease BP  End organ dysfunctionEnd organ dysfunction
    • 15. Pathophysiology ofPathophysiology of Hypovolemic ShockHypovolemic Shock  Decrease intravascular volumeDecrease intravascular volume  Compensation – increase endogenousCompensation – increase endogenous catecholaminescatecholamines  Increase HR – increase C.O., O2 deliveryIncrease HR – increase C.O., O2 delivery  Increase SVR – increase BP (esp diastolic)Increase SVR – increase BP (esp diastolic)  Compensation for <15% dehydrationCompensation for <15% dehydration
    • 16. Cardiogenic ShockCardiogenic Shock Pump failure/malfunctionPump failure/malfunction (decreased contractility)(decreased contractility)
    • 17. Cardiogenic ShockCardiogenic Shock  Electrical FailureElectrical Failure  ArrhythmiasArrhythmias  Mechanical failureMechanical failure  CardiomyopathyCardiomyopathy  Metabolic – acidosisMetabolic – acidosis  AnatomicAnatomic  Hypoxia/ischemiaHypoxia/ischemia  ObstructionObstruction
    • 18. Cardiogenic ShockCardiogenic Shock SymptomsSymptoms  TachycardiaTachycardia  TachypneaTachypnea  Respiratory distressRespiratory distress  Mental status changeMental status change  Cool extremitiesCool extremities  Poor perfusionPoor perfusion  Signs of dehydrationSigns of dehydration
    • 19. Cardiogenic ShockCardiogenic Shock Obstruction of FlowObstruction of Flow  CausesCauses  Pericardial tamponadePericardial tamponade  Pulmonary embolismPulmonary embolism  Pulmonary hypertensionPulmonary hypertension
    • 20. Cardiogenic ShockCardiogenic Shock Obstruction of FlowObstruction of Flow Cardiac tamponadeCardiac tamponade  CausesCauses  PericarditisPericarditis  Post-traumaticPost-traumatic  Post-cardiac surgeryPost-cardiac surgery  Complication of central line placementComplication of central line placement  RecognitionRecognition  TachycardiaTachycardia  Low C.O., narrow pulse pressure (inc. diastole)Low C.O., narrow pulse pressure (inc. diastole)  Inc. CVP, JVDInc. CVP, JVD  PULSUS PARADOXUS (>10mmHg)PULSUS PARADOXUS (>10mmHg)  Muffled heart sounds (??rub)Muffled heart sounds (??rub)  NO RALESNO RALES
    • 21. Distributive ShockDistributive Shock  Abnormal vessel toneAbnormal vessel tone (decreased afterload)(decreased afterload)
    • 22. Distributive ShockDistributive Shock VasodilitationVasodilitation Venous PoolingVenous Pooling Decreased AfterloadDecreased Afterload Maldistribution of regional blood flowMaldistribution of regional blood flow
    • 23. Distributive ShockDistributive Shock  Neurogenic or Anaphylactic ShockNeurogenic or Anaphylactic Shock  Diminished or absent sympathetic toneDiminished or absent sympathetic tone  Reduce peripheral vascular toneReduce peripheral vascular tone  Peripheral pooling of blood volumePeripheral pooling of blood volume  Inadequate venous returnInadequate venous return  Decreased perfusion, acidosis,Decreased perfusion, acidosis, hypotensionhypotension
    • 24. Septic ShockSeptic Shock  Terminology in SepsisTerminology in Sepsis  Infection = response to micro organismInfection = response to micro organism  Bacteremia = bug in bloodBacteremia = bug in blood  Systemic Inflammatory Response SyndromeSystemic Inflammatory Response Syndrome (SIRS)(SIRS)  T>38, <36T>38, <36  Increase HRIncrease HR  Increase RR, paCO2<32Increase RR, paCO2<32  WBC>12,000, <4,000, >10% bandsWBC>12,000, <4,000, >10% bands
    • 25. Septic ShockSeptic Shock  Terminology in SepsisTerminology in Sepsis  Sepsis = SIRS as response to a knownSepsis = SIRS as response to a known infectioninfection  Severe sepsis = Sepsis + organ dysfunctionSevere sepsis = Sepsis + organ dysfunction  Septic Shock = Sepsis + inadequate oxygenSeptic Shock = Sepsis + inadequate oxygen deliverydelivery  Multiple Organ Dysfunction SyndromeMultiple Organ Dysfunction Syndrome (MODS) – organ dysfunction that requires(MODS) – organ dysfunction that requires interventionintervention
    • 26. Septic ShockSeptic Shock  Components of Septic shockComponents of Septic shock  Decreased volumeDecreased volume  Decreased pump functionDecreased pump function  Abnormal vessel toneAbnormal vessel tone
    • 27. Septic ShockSeptic Shock  Therapy for Caridovascular SupportTherapy for Caridovascular Support PreloadPreload VolumeVolume ContractilityContractility InotropesInotropes AfterloadAfterload VasodilatorsVasodilators
    • 28. Septic ShockSeptic Shock EtiologiesEtiologies  Inflammatory: too much, too littleInflammatory: too much, too little  Coagulation pathway: DIC-bleeding, pro-Coagulation pathway: DIC-bleeding, pro- coagulant, microthombosiscoagulant, microthombosis  Multiple organ system failureMultiple organ system failure
    • 29. Recognition of Septic ShockRecognition of Septic Shock  Early –Early – warm shockwarm shock – similar to– similar to neurogenic shockneurogenic shock  Late –Late – Cold shockCold shock – similar to– similar to cardiogenic shockcardiogenic shock
    • 30. Diagnosis of Septic ShockDiagnosis of Septic Shock  Establish presence of infectionEstablish presence of infection  Inc. HR, normal or dec. BP & perfusionInc. HR, normal or dec. BP & perfusion  Latic acidosisLatic acidosis  Muti-organ dysfunctionMuti-organ dysfunction
    • 31. Early vs Late Septic ShockEarly vs Late Septic Shock EarlyEarly LateLate Heart rateHeart rate TachycardiaTachycardia Tachycardia/Tachycardia/ bradycardiabradycardia Blood pressureBlood pressure NormalNormal decreaseddecreased PeripheralPeripheral PerfusionPerfusion Warm/coolWarm/cool Dec./inc. pulsesDec./inc. pulses CoolCool Dec. pulsesDec. pulses
    • 32. Early vs Late Septic ShockEarly vs Late Septic Shock EarlyEarly LateLate End-organ: skinEnd-organ: skin Dec. cap refillDec. cap refill Very dec. capVery dec. cap RefillRefill BrainBrain Irritable,Irritable, restlessrestless Lethargic,Lethargic, unresponsiveunresponsive KidneysKidneys OliguriaOliguria Oliguria, anuriaOliguria, anuria
    • 33. Treatment Strategies inTreatment Strategies in ShockShock
    • 34. Principles of ResuscitationPrinciples of Resuscitation  Increase Oxygen DeliveryIncrease Oxygen Delivery  Increase Oxygen contentIncrease Oxygen content  Increase Cardiac outputIncrease Cardiac output  Increase blood pressureIncrease blood pressure  Decrease DemandDecrease Demand  Sedation/analgesiaSedation/analgesia  IntubationIntubation
    • 35. Initial Treatment in ShockInitial Treatment in Shock  AAirwayirway  Supplemental oxygen, intubationSupplemental oxygen, intubation  Carefull with cardiovascular collapse post intubation due toCarefull with cardiovascular collapse post intubation due to positive thoracic pressure decrease venous returnpositive thoracic pressure decrease venous return  BBreathingreathing  CCirculationirculation  Intravenous access – go early, go IOIntravenous access – go early, go IO  Volume expansion (40cc/kg NS, repeat prn)Volume expansion (40cc/kg NS, repeat prn)  Carefull with cardiogenic shock (5cc/kg then reassess)Carefull with cardiogenic shock (5cc/kg then reassess)  Optimize cardiac function, oxygenationOptimize cardiac function, oxygenation
    • 36. Restoration of CirculationRestoration of Circulation VolumeVolume Fluids, fluids, fluidsFluids, fluids, fluids Crystalloids vs ColloidsCrystalloids vs Colloids
    • 37. Restoration of CirculationRestoration of Circulation VolumeVolume  CrystalloidsCrystalloids  NS is the fluid of choice, availabilityNS is the fluid of choice, availability  Rapid redistribution out of intravascular spaceRapid redistribution out of intravascular space – capillary leak– capillary leak
    • 38. Restoration of CirculationRestoration of Circulation VolumeVolume  Colloids: albumin, bloodColloids: albumin, blood  AlbuminAlbumin  Worsening of edema due to cap leak in earlyWorsening of edema due to cap leak in early sepsissepsis  BloodBlood  Great volume expandersGreat volume expanders  Side effects: with massive transfusion >1.5 bloodSide effects: with massive transfusion >1.5 blood volumesvolumes  Risk of infectionRisk of infection  Dilutional thrombocytopenia and factors V & VIIIDilutional thrombocytopenia and factors V & VIII  Calcium binding hemodynamic instability (citrate)Calcium binding hemodynamic instability (citrate)
    • 39. Restoration of CirculationRestoration of Circulation Volume – Fluid ChoicesVolume – Fluid Choices  Based on:Based on:  Type of deficitType of deficit  Urgency of repletionUrgency of repletion  Pathophysiology of shockPathophysiology of shock
    • 40. Restoration of CirculationRestoration of Circulation Volume – Fluid ChoicesVolume – Fluid Choices  Crystalloids for initial resuscitationCrystalloids for initial resuscitation  Colloids/PRBC’s to replace blood lossColloids/PRBC’s to replace blood loss
    • 41. Treatment of ShockTreatment of Shock Cardiac SupportCardiac Support AlphaAlpha DopamineDopamine BetaBeta EpinephrineEpinephrine NorepinephrineNorepinephrine DobutamineDobutamine NeosynephrineNeosynephrine
    • 42. InotropesInotropes AgentAgent Site of ActionSite of Action DoseDose Mcg/kg/minMcg/kg/min EffectsEffects DopamineDopamine DopaminergicDopaminergic BetaBeta Alpha > BetaAlpha > Beta 1-31-3 5-105-10 11-2011-20 Renal vasodilationRenal vasodilation Inotrope/vasoconstrictionInotrope/vasoconstriction Increase perip. Vasc. resistanceIncrease perip. Vasc. resistance DobutamineDobutamine Beta 1 & 2Beta 1 & 2 1-201-20 InotropeInotrope VasodilationVasodilation EpineprhineEpineprhine Beta > alphaBeta > alpha 0.05 – 1.00.05 – 1.0 Inotrope, vasoconstrictionInotrope, vasoconstriction TachycardiaTachycardia NorepinephrinNorepinephrin ee Alpha > betaAlpha > beta 0.05 – 1.00.05 – 1.0 Profound vasoconstrictionProfound vasoconstriction inotropeinotrope NitroprussideNitroprusside VasodilatorVasodilator (art > venous)(art > venous) 0.5 – 1.00.5 – 1.0 VasodilationVasodilation MilranoneMilranone PhosphodiesterasePhosphodiesterase inhibitorinhibitor 0.5 – 0.750.5 – 0.75 InotropeInotrope vasodilationvasodilation
    • 43. ““New” Therapies in Septic ShockNew” Therapies in Septic Shock  VasopressinVasopressin  SteroidsSteroids  Activated protein C (Xigris) in SepticActivated protein C (Xigris) in Septic ShockShock
    • 44. New” “ Therapies in Septic ShockNew” “ Therapies in Septic Shock VasopressinVasopressin  Unclear mechanism of actionUnclear mechanism of action  Bridging vascular instability in highBridging vascular instability in high exogenous catecholamines requirementexogenous catecholamines requirement septic shock, therefore decrease sideseptic shock, therefore decrease side effects of toxic dosage of catecholamineseffects of toxic dosage of catecholamines  Also shows greater blood flow diversionAlso shows greater blood flow diversion from non-vital to vital organsfrom non-vital to vital organs
    • 45. New” “ Therapies in Septic ShockNew” “ Therapies in Septic Shock VasopressinVasopressin  Dosage 0.01 – 0.04U/min up to 0.08U/minDosage 0.01 – 0.04U/min up to 0.08U/min
    • 46. New” “ Therapies in Septic ShockNew” “ Therapies in Septic Shock SteroidsSteroids  Hypo-adrenalism: abnormalHypo-adrenalism: abnormal hypothalamus-pituitary-adrenal axishypothalamus-pituitary-adrenal axis  At risk of adrenal insufficiency – in theAt risk of adrenal insufficiency – in the presence of catecholamine requirementpresence of catecholamine requirement  Fluid refractory shockFluid refractory shock  Normal BP, cold shockNormal BP, cold shock  Low BP, cold shockLow BP, cold shock  Dosage – stress doseDosage – stress dose  Hydrocortisone 150 mg/m2 ivpHydrocortisone 150 mg/m2 ivp
    • 47. New” “ Therapies in Septic ShockNew” “ Therapies in Septic Shock SteroidsSteroids Glucocorticoid function – immune responseGlucocorticoid function – immune response  Fall in circulating lymphocytesFall in circulating lymphocytes  Inhibits neutrophils migration to theInhibits neutrophils migration to the inflammatory sitesinflammatory sites  Inhibits macrophages secretionInhibits macrophages secretion  Promotes eosinophilic apoptosisPromotes eosinophilic apoptosis  Modulates cytokines productionModulates cytokines production
    • 48. New” “ Therapies in Septic ShockNew” “ Therapies in Septic Shock SteroidsSteroids Glucocorticoid function – CardiovascularGlucocorticoid function – Cardiovascular  Modulate vascular reactivity to angiotensinModulate vascular reactivity to angiotensin II and to catecholamines -Not fullyII and to catecholamines -Not fully understood mechanismunderstood mechanism  Modulate vascular permeability andModulate vascular permeability and production of NO and other vasodilatorproduction of NO and other vasodilator factorfactor INCREASE IN BLOOD PRESSUREINCREASE IN BLOOD PRESSURE
    • 49. New” “ Therapies in Septic ShockNew” “ Therapies in Septic Shock SteroidsSteroids Glucocorticoid production in stressGlucocorticoid production in stress  Maintain homeostasisMaintain homeostasis  Normalize vascular reactivityNormalize vascular reactivity  Modulate inflammatory responseModulate inflammatory response
    • 50. New” “ Therapies in Septic ShockNew” “ Therapies in Septic Shock Activated Protein C (Xigris)Activated Protein C (Xigris)  Recombinant Human Activated Protein CRecombinant Human Activated Protein C  Prevent DIC cascade with antithromboticPrevent DIC cascade with antithrombotic activity by inhibiting factors Va & VIIIaactivity by inhibiting factors Va & VIIIa  May exerts anti-inflammatory effects byMay exerts anti-inflammatory effects by inhibiting TNF and by blocking leukocytesinhibiting TNF and by blocking leukocytes adhesionsadhesions  Side effectsSide effects  BleedingBleeding  Pediatric trial terminated early (03/04) due toPediatric trial terminated early (03/04) due to no benefit to known risk of bleedingno benefit to known risk of bleeding

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