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Shock (Read)

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    Shock (Read) Shock (Read) Presentation Transcript

    • SHOCK
    • Question #1 Sepsis
      • 28 yo man with diffuse petechial rash diagnosed with menigococcemia
      • LP are compatible with bacterial meningitis
      • Given IV penicillin and his CXR is normal
      • T: 39 P: 120 RR: 20 MAP: 68 on NE
      • FiO2 50% and Peep 5 SaO2 = 100%
    • Question #1: Shock
      • In past 6 hours he has received 3 L NS
      • Urine Output has decreased to 0.25 ml/kg
      • WBC: 22,000 Plat: 40,000
      • Which of the following interventions is the most appropriate at this time?
        • Transfuse Platelets
        • Increase NE to achieve MAP > 75 mmHG
        • Switch from NE to DA
        • Administer 1000 ml bolus NS
        • Administer furosemide
    • Question #1
      • Correct answer : D
      • Give 1000 ml fluid bolus
        • Despite the 3 l already he is oxygenating reasonably well and there is still evidence of organ hypoperfusion
        • Only need to keep Plat >50 K if active bleeding or procedure planned
        • No evidence that DA better than NE
    • Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock Critical Care Medicine 2004 :32(3) 858-873
    • Surviving Sepsis A: Initial Resuscitation
      • 1: Should begin as soon as syndrome recognized. An elevated serum lactate helps to identify .
        • During first 6 hours the goals should include :
          • CVP 8-12mm Hg ( 12-15 mmHg on vent)
          • MAP > 65 mm Hg
          • Urine output > 0.5ml/kg/hr
          • Central Venous or mixed venous O2 sat > 70
      • Grade B
    • Surviving Sepsis A: Initial Resuscitation
      • Resuscitation directed for the aforementioned goals within the first 6 hours of presentation improved the 28-day mortality
      • Panel judged CV and mixed venous saturation to be equivalent
      • Target a higher CVP ( 12-15 mm Hg) in mechanically ventilated patients
      • Rivers E et al.: Early goal-directed therapy in the treatment of severe sepsis and septic shock N Engl J Med 2001;345:1368-77
    • Oxygen Delivery = DO2 ( ml O2/min) O2 consumption = Vo2 mlO2/min ERc= 66% B A C E A= Normal resting B= decrease DO2 C= ERc D= Shock E = Sepsis D
    • Oxygen Delivery CaO 2 = (Hgb x SaO 2 x 1.36) +(PaO 2 x 0.003) DO 2 = CaO 2 x CO x 10 DO 2 : Oxygen Delivery Hgb : Hemoglobin CaO 2 : Oxygen Carry capacity SaO 2 : Oxyhemoglobin Saturation PaO 2 : Arterial Oxygen Tension CO : Cardiac Output
    •  
    • Physiologic forms of shock
      • Hypovolemic: Dehydration/ hemmorhagic
      • Distributive: Sepsis, adrenal Insufficiency, neurogenic, anaphylactic, liver failure
      • Cardiogenic: Ischemic or non-ischemic cardiomyopathies, negative inotropes
      • Obstructive: Pulmonary HTN, PE, Cardiac Tamponade, valvular, pregnancy
    • Cardiogenic Shock Pulm edema Shock Once filling pressure exceeds a certain level, pulmonary edema forms Once cardiac output drops to a certain level shock ensues Warm-dry Cold-dry Warm-wet Cold-Wet
    •  
    • 5 10 25 125 Normal Hemodynamic Pressure: “nickel, dime, quarter and a buck twenty five for inflation” RAP/CVP=5 RV/PAP= 25 PAOP/LA=10 LVSBP= 125
    • Right heart Catheter
    • Hemodynamic Profiles 1600 2 18 30/20 15 Cardiogenic 1600 2 6 40/20 18 Obstructive (PE/PHTN) 1200 3 4 12/6 3 Hypovolemic 600 8 4 12/6 3 Distributive Sepsis/AI 1000 5 10 25/15 5 Normal SVR CO PAOP PAP CVP Disease
    • Hemodynamic Profiles 1200 3 15 30/ 15 15 Tamponade 1200 3 6 15/10 20 RV Infarct SVR 1000 CO 5 PAOP 10 PAP 25/15 CVP 5 Disease Normal
    • Question # 7: Pulmonary Hypertension Correct Answer: A 3 12 30/ 12 30/ 10 10 Constrictive Pericarditis PPH, VOD PE 3.1 26 50/20 50/10 10 A: LV failure CO 5 PAOP/PCWP 10 PAP 25/12 RVP 25/5 CVP/RAP 5 Disease