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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