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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?
      • Transfuse Platelets
      • Increase NE to achieve MAP > 75 mmHG
      • Switch from NE to DA
      • Administer 1000 ml bolus NS
      • 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. 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
  • 9. 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
  • 10.  
  • 11. 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
  • 12. 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
  • 13.  
  • 14. 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
  • 15. Right heart Catheter
  • 16. 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
  • 17. 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
  • 18. 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