Shock

1. Ward Class:
Shock
18 มีนาคม 2554

2. History
 หญิงไทยคู่ อายุ 70 ปี อาชีพค้าขาย ภูมิลาเนากรุงเทพมหานคร
ไข้สูงมา 3 วัน

3. Underlying Disease
 Hypertension
 Type 2 DM
 Chronic HCV infection with HCV cirrhosis
 Last admission (27/1/2554 - 7/2/2554)
ได้รับการวินิจฉัยว่าเป็น
1. Streptococcus Group G septicemia
(Primary bacteremia) with septic shock
2. Hepatic encephalopathy
มีนัด follow up 11/2/2554 แต่ lost to follow up

4. History
Present Illness
3 วันก่อน
 มีไข้สูงหนาวสั่น
 ปวดขาขวา ขาขวาบวมแดง
 ปฏิเสธประวัติได้รับอุบัติเหตุ
 หายใจหอบเหนื่อยเล็กน้อย
 ไม่ถ่ายเหลว ไม่มี URI symptom ไม่มีอาการปวดท้อง ไม่คลื่นไส้
อาเจียน ปัสสาวะไม่แสบขัด ไม่ปวดหลัง
 เคยใช้ยา steroid มา 2 ปี หยุดยาได้ 1 เดือน

5. History
Current Medications
omeprazole(20) 1x2 PO ac
enalapril(5) ½ x2 PO pc
lactulose 30 ml PO hs
M.tussis 15 ml PO prn for cough
paracetamol(500) 2 tab PO prn for fever q 4 h

6. ER
เวลา 14.30 น.

7. Physical Examination at ER
 Vital Sign:
T 37.4 C, P 170/min, RR 28/min
BP183/133mmHg
oxygen saturation (room air) 87%
 General appearance:
good consciousness, markedly pale, no jaundice,
pitting edema both legs
palmar erythema, spider nevi
 CVS:
engorged neck vein
normal S1& S2, S3 gallop, no murmur

8. Physical Examination at ER
 RS:
minimal crepitation at right lower lungs?
 Abdomen:
soft, bowel sound positive, no tenderness
 Extremities:
marked swelling right leg with erythematous patch

9. Problem list & Provisional DX
 Problem list?
 Provisional Dx?

10. Problem List
1. fever
2. marked swelling right leg with erythematous patch
3. minimal crepitation at right lower lungs?
4. pitting edema both legs,
engorged neck vein,
S3 gallop
5. U/D: Hypertension, Type 2 DM, HCV cirrhosis
6. History of steroid use

11. ER
 Diagnosis
Sepsis
(congestive heart failure??)

12. Managements at ER
EKG 12 leads : AF with rapid ventricular response, Right bundle branch block

13. Problem List
1. fever
2. marked swelling right leg with erythematous patch
3. minimal crepitation at right lower lungs?
4. pitting edema both legs,
engorged neck vein,
S3 gallop
5. U/D: Hypertension, Type 2 DM, HCV cirrhosis
6. History of steroid use

14. ER
 Diagnosis
Sepsis?

15. Sepsis
 Sepsis = SIRS + evidence of infection
 SIRS (2/4) (systemic inflammatory response syndrome)
1. Temperature >38ºC or <36ºC
2. HR>90/min
3. RR>20/min or PaCO2<32mmHg
4. WBC>12,000/µL or <4,000/µL or Band form>10%

16. What to do next?: Management
&Investigations?
Sepsis
1. CBC
2. Urinalysis
3. Urine culture
4. Hemoculture
5. CXR
Cirrhosis
1. Blood Chemistry
2. Coagulogram
EKG 12 leads

17. Managements at ER
 Investigations
 CBC
Hb 10.9mg/dL, Hct 35.3%, MCV 93.4fL, RDW 18.2%,
WBC 9150/µL (N 70.7%, L 22.1%, M 4.2%, Eo 2.7%, B
0.3%)
platelet 105000/µL
 Blood Chemistry
BUN 8.0 mg/dL, Creatinine 0.7 mg/dL,
Na 138 mEq/L, K 4.3 mEq/L, Cl 106 mEq/L, HCO3
20mEq/L
 Coagulogram
PT 21.1s, aPTT 30.3s

18. Managements at ER
 Investigations
 Urinalysis
pH 5.0, sp.gr 1.010
albumin –ve, sugar –ve, ketone –ve,
RBC 0-1, WBC 1-2
 Urine culture
 Hemoculture
 EKG 12 leads

19. Managements at ER
EKG 12 leads : AF with rapid ventricular response, Right bundle branch block

20. What to do next?: Treatments?
Initial
ABC?
Supportive
?
Specific:sepsis
?

21. What to do next?: Treatments?
 Pathogen?
 ATB?
1. Gram +ve cocci
2. Gram –ve organism (Cirrhosis patient)
Aeromonas hydrophila (Cirrhosis patient ,bleb)
1. ceftriaxone + clindamycin
2. piperacillin + tazobactam

22. Managements at ER
 Treatments
 On Oxygen mask with bag 10 LPM
 Piperacillin + tazobactam 4.5 mg IV stat
 NSS 1000ml IV drip rate 150ml/hr
 Retain Foley catheter

23. Hospital Course
15.05 น. เหนื่อยมากขึ้น (I/O = 70/0 ml)
 Managements
 On Endotracheal tube no. 7.5 after Etomidate&Succinyl
Choline
 CXR
Airway Breathing Circulation

24. CXR S/P intubation
 CXR: pulmonary congestion
ก่อน admit S/P intubation

26. Hospital Course
 Assessment หลัง intubation
T 37.0 C, P 170/min, RR 21/min,
BP 134/95 mmHg
Oxygen saturation (ventilator) 98%
 Managements
 Off NSS
 furosemide 40 mg IV stat >>> Urine output 400 ml
 Admit อัษฎางค์ 10 เหนือ

27. Ward
เวลา 17.25 น.

28. Physical Examination at Ward
 Vital signs
T 40.3 C, P 120/min, RR 14/min, BP 80/60mmHg
oxygen saturation(ventilator) 100%
 General appearance
E3VtM6, drowsy
not pale, no jaundice
 CVS: normal S1,S2, no murmur
 RS: normal breath sound
 Extremities: marked swelling at right leg with erythematous
patch

29. Diagnosis?
Shock?
Causes??

30. Approach to shock
ขั้นตอนที่ 1: ผู้ป่วยช็อคหรือไม่
Shock คือ ภาวะที่มีการไหลเวียนของโลหิตไปเลี้ยงส่วนต่างๆของ
ร่างกายไม่เพียงพอ(Poor tissue perfusion)
1.SBP < 90 mmHg or MAP < 60 mmHg
ร่วมกับ
2.sign of poor tissue perfusion และ organ
dysfunction เช่น ซึม สับสน มือเท้าเย็น ชีพจรเร็ว ปัสสาวะ
ลดลง

31. Approach to shock
ขั้นตอนที่ 2: ผู้ป่วยช็อคชนิดใด
1. Distributive shock
2. Hypovolemic shock
3. Cardiogenic shock
4. Obstructive shock

32. Approach to shock
Pros Cons
Septic shock • Fever
• Source of infection
• Narrow pulse
pressure
Hypovolumic shock • Narrow pulse pressure
• Volume depletion
(urine output 400 ml)
• fever
Cardiogenic shock • Narrow pulse pressure
• AF with RVR
• Mostly caused by
anterolateral MI
• Sign of heart failure

33. Approach to shock
SBP
(mmHg)
PP
(mmHg)
Capillary
refill
Lung S3
gallop
JVP(cm)
patient 80 20 N/A clear - N/A
Cardiogenic
shock
ลดลง แคบ ช้าลง crackle + เพิ่มขึ้น
Hypovolemic
shock
ลดลง แคบ ช้าลง Clear - ลดลง
Distributive
shock
ลดลง กว้าง/
ปกติ
ปกติ Clear - ลดลง
Obstructive
shock
ลดลง แคบ ช้าลง Clear - เพิ่มขึ้น

34. Approach to shock
 Causes
1. Septic shock
- source of infection
2. Hypovolumic shock
- intubation&PEEPs>>>preload↓
- furosemide
(etomidate&succinylcholine?)

35. Managements
 Shock
initial supportive specific

36. Managements
1. Initial management: ABC?
• intubation
• NPO เว้นยาA
• Oxygen therapy
• on PCV mode ventilatorB
• Fluid Resuscitation
• Monitor: record BP q 15 min,
record urine output q 1 hr
C

37. Management: Fluid therapy?

39. Managements
2. Supportive management:
Septic shock guideline

40. Septic shock
.............
Source identification
Adequate antibiotic
Surgical drainage if indicated
Intubation Mechanical ventilator
respiratory failureHemodynamic Support
volume 500-1,000 ml ½ hr
.............
intravascular volume
- JVPÝ
3-5 cmH2O above sternal angle
1.Adequate Volume invasive monitoring
CVPÖ,
PCWPè
Acceptable BP
- mean arterial pressure >65 mmHg
2.Accept BP
1. Vasopressor
- Dopamine 5-20 ug/kg/min or
- Norepinephrine 0.2-2 µg/kg/min
2. MAP < 65 mmHg vasopressor
- Hydrocortisone 50 mg IV q 6 hr
- 7
3. intravascular volume status
4. Adrenaline drip titrate dose
Organ perfusion
- urine >0.5ml/kg/hr
Yes
Yes
.............
Uncertain
No
CVP >10-15 cmH2 O
PCWP >15-18 mmHgNo
Yes
...........
No
Septic shock 2008

41. 2
1.Adequate Volume invasive monitoring
CVPÖ,
PCWPè
Acceptable BP
- mean arterial pressure >65 mmHg
2.Accept BP
1. Vasopressor
- Dopamine 5-20 ug/kg/min or
- Norepinephrine 0.2-2 µg/kg/min
2. MAP < 65 mmHg vasopressor
- Hydrocortisone 50 mg IV q 6 hr
- 7
3. intravascular volume status
4. Adrenaline drip titrate dose
Organ perfusion
- urine >0.5ml/kg/hr
- SCVO2 mixed venous O2 sat > 70 %
SCVO2 Dopamine
Norepinephrine > 10 µg/kg/min
> 10 µg/min
3.Adequate perfusion
- Hct < 30% Hct ≥ 30%
- Hct > 30% Dobutamine 5-20 µg/kg/min
Goal achieved
Frequent assessment
Yes
Yes
.............
Yes
.................
Uncertain
No
No
CVP >10-15 cmH2 O
PCWP >15-18 mmHgNo
Yes
...........
No
Ý
JVP = Jugular venous pressure,
Ö,
CVP = Central venous pressure
è
PCWP = Pulmonary capillary wedge pressure,
SCvO2 = Central venous oxygen saturation

43. Managements
3. Specific: infection
 meropenem 1g IV q 8 hr +
clindamycin 600mg IV q 8 hr
 paracetamol 500mg 1 tab po q 4-6 hr
 POCT glucose q 4 hr

44. Adequate intravascular volume
(Preload)
Adequate tissue O2
Adequate tissue perfusion
Adequate cardiac output
(Cardiac output)
Acceptable perfusion pressure
(Afterload, MAP>65 mmHg)
G
O
A
L
Proper Management?

45. Proper Management?
 Early Goal-Directed Therapy(EGDT)
 MAP > 65 mmHg
 PCWP 14-18 cmH2O
 CVP 8-12 mmHg(10-15 mmH2O) in septic shock
 Oxygen delivery: Hb>10 g/dl, ScVO2>70%,O2
saturation>92%,C.I.> 2.2 L/min/mm3
 Urine >0.5 ml/kg/h, consciousness
 Normalization of blood lactate

46. Adequate intravascular volume?
 volume 500-1000ml in ½ h >>>> (500ml in ½ h)
 adequate volume >>>> uncertain
ดังนั้นจึงใส่ central line เพื่อประเมิน CVP

47. Fluid&Vasopressor >>> BP ไม่ดีขึ้น Adrenal insufficiency
Problem 1: Fluid&Vasopressor

48. serum cortisol
access central line
5%albumin 250 ml IV drip in 30 min
hydrocortisone 100 mg IV push then
hydrocortisone 200 mg + 5%DW
250 IV drip 24 hr
cortisol level 8

49. Goal: CVP > 10-15 cmH2O False High CVP???
Problem 2: CVP

50. False high CVP
 Pulmonary vascular disease
 Pericardial disease
 Valvular disease
 Right side heart disease
 Pleural disease
 Intraabdominal condition: ascites
 Mechanical ventilator + PEEPs
 Drug: vasoactive drug
 Acidosis with Kussmual’s breathing

51. Problem 3: Colloid or
Crystalloid?

52. Fluid Therapy
การเลือกชนิดของสารน้าไม่มีหลักเกณฑ์ที่แน่นอน ให้พิจารณาตามความเหมาะสม
1. ควรเลือก crystalloids ก่อน colloids
2. ประเมินลักษณะทางคลินิกที่สาคัญ คือ visceral edema
(pulmonary edema, intestinal edema) อาจพิจารณาให้
colloids แทน
Crystalloids Colloids

53. Source identification
Adequate antibiotic
Surgical drainage if indicated
Intubation Mechanical ventilator
respiratory failureHemodynamic Support
volume 500-1,000 ml ½ hr
.............
intravascular volume
- JVPÝ
3-5 cmH2O above sternal angle
1.Adequate Volume invasive monitoring
CVPÖ,
PCWPè
Acceptable BP
- mean arterial pressure >65 mmHg
2.Accept BP
1. Vasopressor
- Dopamine 5-20 ug/kg/min or
- Norepinephrine 0.2-2 µg/kg/min
2. MAP < 65 mmHg vasopressor
- Hydrocortisone 50 mg IV q 6 hr
- 7
3. intravascular volume status
4. Adrenaline drip titrate dose
Organ perfusion
- urine >0.5ml/kg/hr
- SCVO2 mixed venous O2 sat > 70 %
SCVO2 Dopamine
Norepinephrine > 10 µg/kg/min
> 10 µg/min
- Hct < 30% Hct ≥ 30%
Yes
Yes
.............
Uncertain
No
No
CVP >10-15 cmH2 O
PCWP >15-18 mmHgNo
Yes
...........
No

54. Problem 3: Vasoactive Drug

55. Vasoactive Drugs
 Warm shock **
- Hyperdynamic septic shock
(low BP, low SVR, high CO)
- use NOREPINEPHRINE
 Cold shock
- Hypodynamic septic shock
(low BP, high SVR, low CO)
- use DOPAMINE or NE + DOBUTAMINE
dopamine: 5-15 µg/kg/min
norepinephrine: 0.1-1 µg/kg/min

56. 21.05 น.(6 hr): ย้ายไป ICU
Water intake: 3150 ml
Urine output: 300 ml

57. ICU
เวลา 22.15 น.

58. ICU
 Problem list
1. Septic Shock
2. Adrenal insufficiency
3. AF & Rapid ventricular response
4. U/D: Type 2 DM,Hypertension, Chronic HCV with
cirhosis

59. Managements at ICU
1.shock
 Fluid resuscitation
ขณะนี้ได้ IV fluid เป็น
- Gelofusine IV rate 300 ml/h
- Norepinephrine 8 mg in D5W 250 ml IV drip 20 µd/min
- Dopamine 200 mg in D5W 100 ml IV drip 20 µd/min
- 10% D/NSS 1000 ml IV rate 120 ml/h
BP 87/60 mmHg, CVP 23 cmH2O

62. Fluid Challenge test
 False high CVP >>> ไม่สามารถประเมิน volume status ได้
 Initial rate
CVP
(cmH2O)
PCWP
(mmHg)
IV fluid
infusion rate
(in 10-15 min)
<8 <10 200 ml
8-12 10-14 100 ml
>12 >14 50 ml

63. Rate Adjustment: CVP 23 >> 29 (ต่างกัน 6 cmH2O)

64. Fluid challenge
Initial CVP, PCWP
Initial IV infusion
Rate Adjustment

65. CVP >5 cmH2O
PCWP >7 mmHg
Wait for
10 min
CVP > initial > 5 cmH2O
PCWP > initial > 7 mmHg
Stop IV infusion
Vasopressor + inotrope
CVP > initial < 5 cmH2O
PCWP > initial < 7 mmHg
Respond
to fluid ?
Infusion rateStop IV infusion
Vasopressor + inotrope
No Yes

66. เจาะ ScVO2 เจาะเมื่อไหร่
Problem 4: Adequate Tissue
Perfusion?

67. Adequate intravascular volume
(Preload)
Adequate tissue O2
Adequate tissue perfusion
Adequate cardiac output
(Cardiac output)
Acceptable perfusion pressure
(Afterload, MAP>65 mmHg)
G
O
A
L
Proper Management?

68. Guideline : Haemodynamic
management
Resuscitation goals
• BP (MAP > 65 mmHg)
• CVP (8-12 mmH20)
• Urine > 0.5 ml/kg/hr
• Central venous O2 sat. > 70%, or Mixed venous > 65%
IV Fluid
Start Crystalloids 1000 ml or Colloids 300-500 ml in 30 min.
Acceptable BPVolume assessment
(CVP)
NE / Dopamine
(Epinephine if no response)
Organ perfusion
Urine > 0.5 ml/kg/hr
pH 7.35 – 7.45
Lactate, SvO2
Hydrocortisone < 300 mg/day
if no response to fluid and vasopressor Fluid challenge
Hct < 30% : PRC
Acidosis, low SvO2 : Dobutamine
Goal achieved
Frequent assessment
YESNO
Adequate
Inadequate
Reassess
Adequate
Reassess
Inadequate

69. Tissue Perfusion

70. การประเมิน macrocirculation
จะประเมินเมื่อ resuscitation จนได้ความดันโลหิตตามเป้ าหมายแล้ว
1. Urine output> 0.5 cc/kg/h
2. Consciousness
3. Bowel ileus
4. Capillary refill

71. การประเมิน microcirculation
1. Regional
 Gastric tonometry
 Sublingual capnography
2. Global
 ScVO2 > 70%
 Serum Lactate < 2, Lactate reduction>10%
ในทางคลินิก จะใช้ global assessment

72. ScVo2 51%
Lactate 5.5 mmol/L
Hct 28%

73. 1.Adequate Volume invasive monitoring
CVPÖ,
PCWPè
Acceptable BP
- mean arterial pressure >65 mmHg
2.Accept BP
1. Vasopressor
- Dopamine 5-20 ug/kg/min or
- Norepinephrine 0.2-2 µg/kg/min
2. MAP < 65 mmHg vasopressor
- Hydrocortisone 50 mg IV q 6 hr
- 7
3. intravascular volume status
4. Adrenaline drip titrate dose
Organ perfusion
- urine >0.5ml/kg/hr
- SCVO2 mixed venous O2 sat > 70 %
SCVO2 Dopamine
Norepinephrine > 10 µg/kg/min
> 10 µg/min
3.Adequate perfusion
- Hct < 30% Hct ≥ 30%
- Hct > 30% Dobutamine 5-20 µg/kg/min
Goal achieved
Frequent assessment
Yes
Yes
.............
Yes
.................
Uncertain
No
No
CVP >10-15 cmH2 O
PCWP >15-18 mmHgNo
Yes
...........
No
Ý
JVP = Jugular venous pressure,
Ö,
CVP = Central venous pressure
è
PCWP = Pulmonary capillary wedge pressure,
SCvO2 = Central venous oxygen saturation

74. Managements at ICU
Poor Tissue Perfusion (ScVO2 < 70%)
Hct < 30% (Hct 28%)
จึงให้ Pack Red Cell จน Hct > 30%

76. Managements at ICU
3.Specific Management
Infection
 Consult ศัลยศาสตร์ เพื่อวินิจฉัยแยกโรค necrotizing fasciitis
>>> ยังคิดถึงน้อย และจะประเมินเป็นระยะ
 Antibiotics
meropenem 1g IV q 8 hr + clindamycin 600mg IV q 8 hr
และรอผล Hemoculture

77. Managements at ICU
Adrenal insufficiency
 Hydrocortisone 300 mg/day IV
AF & Rapid ventricular response
 Off dopamine พบ HR ลดลงจาก 160-180 เป็น 140-150/min

78. Steroids in sepsis
 IV hydrocortisone for adult septic shock
when hypotension responds poorly to adequate fluid
resuscitation and vasopressors
 ACTH stimulation test is not recommended
 Steroid therapy may be weaned once vasopressors are no
longer required

79. Steroids in sepsis
 Hydrocortisone dose should be ≤ 300 mg/day
 Sepsis without shock: do not use corticosteroids
unless the patient’s endocrine or corticosteroid history
warrants it
Surviving Sepsis Campaign 2008