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Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
Shock (Read)
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Shock (Read)

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  • 1. SHOCK
  • 2. 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%
  • 3. 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? (A) Transfuse Platelets (B) Increase NE to achieve MAP > 75 mmHG (C) Switch from NE to DA (D) Administer 1000 ml bolus NS (E) Administer furosemide
  • 4. 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
  • 5. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock Critical Care Medicine 2004 :32(3) 858-873
  • 6. 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
  • 7. 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
  • 8. 0 50 100 150 200 250 300 350 0 200 400 600 800 1000 1200 normal Sepsis XY (Scatter) 3 Oxygen Delivery = DO2 ( ml O2/min) O2 consumption = Vo2 mlO2/min ERc= 66% B AC E A= Normal resting B= decrease DO2 C= ERc D= Shock E = Sepsis D
  • 9. Oxygen Delivery CaO2 = (Hgb x SaO2 x 1.36) +(PaO2 x 0.003) DO2 = CaO2 x CO x 10 DO2 : Oxygen Delivery Hgb : Hemoglobin CaO2: Oxygen Carry capacity SaO2 : Oxyhemoglobin Saturation PaO2 : Arterial Oxygen Tension CO : Cardiac Output
  • 10. 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
  • 11. Cardiogenic Shock PulmPulm edemaedema ShockShock Once fillingOnce filling pressure exceeds apressure exceeds a certain level,certain level, pulmonary edemapulmonary edema formsforms Once cardiac outputOnce cardiac output drops to a certaindrops to a certain level shock ensueslevel shock ensues Warm-dryWarm-dry Cold-dryCold-dry Warm-wetWarm-wet Cold-WetCold-Wet
  • 12. 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
  • 13. Right heart CatheterRight heart Catheter
  • 14. Hemodynamic Profiles Disease CVP PAP PAOP CO SVR Normal 5 25/15 10 5 1000 Distributive Sepsis/AI 3 12/6 4 8 600 Hypovolemic 3 12/6 4 3 1200 Obstructive (PE/PHTN) 18 40/20 6 2 1600 Cardiogenic 15 30/20 18 2 1600
  • 15. Hemodynamic Profiles Disease Normal CVP 5 PAP 25/15 PAOP 10 CO 5 SVR 1000 RV Infarct 20 15/10 6 3 1200 Tamponade 15 30/15 15 3 1200
  • 16. Question # 7: Pulmonary Hypertension Correct Answer: A Disease CVP/RAP 5 RVP 25/5 PAP 25/12 PAOP/PCWP 10 CO 5 A: LV failure 10 50/10 50/20 26 3.1 PPH, VOD PE Constrictive Pericarditis 10 30/10 30/12 12 3

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