Pharmacotherapy of Shock www.freelivedoctor.com
Introduction <ul><li>Review the current view on etiology, pathophysiology and management of shock with emphasis on pharmac...
Topics of Discussion <ul><li>Pathophysiology of Shock </li></ul><ul><li>Types of Circulatory Shock </li></ul><ul><li>Manag...
Shock <ul><li>Term “choc” – French for “push” or impact was first published in 1743 by the physician LeDran </li></ul><ul>...
Determinants of Shock <ul><li>Inadequate tissue perfusion </li></ul><ul><li>Sustained loss of effective circulatory blood ...
Hemodynamic States of Shock <ul><li>Hyperdynamic State </li></ul><ul><li>Hypodynamic State </li></ul><ul><li>Related to: <...
Pathophysiology of Shock <ul><li>Shock develops with inadequate capillary perfusion by decreased Cardiac Output following ...
Mediators of Shock <ul><li>Toxins </li></ul><ul><ul><li>Endotoxins </li></ul></ul><ul><li>Oligo- and polypeptides </li></u...
Main Classes of Shock <ul><li>Hypovolemic Shock </li></ul><ul><li>Distributive Shock </li></ul><ul><li>Cardiogenic Shock <...
Hypovolemic Shock <ul><li>Hemorrhagic/Traumatic </li></ul><ul><li>Dehydrative </li></ul><ul><li>Burn </li></ul>04/21/10 ww...
Distributive Shock  <ul><li>Septic </li></ul><ul><li>Anaphylactic/ Anaphylactoid </li></ul><ul><li>Neurogenic </li></ul>04...
Obstructive Shock <ul><li>Pulmonary Embolism </li></ul><ul><li>Cardiac Tamponade </li></ul><ul><li>Pneumothorax </li></ul>...
Question 04/21/10 Which one of the folowing is the most common cause of severe Lactic acidosis (blood lactate concentratio...
Management of Shock <ul><li>Shock begins when DO2 to the cells is inadequate to meet metabolic demand </li></ul><ul><li>Th...
Pulmonary Artery Catheter Waveforms 04/21/10 Right Atrium Right Ventricle  Pulmonary Artery  PCWP   www.freelivedoctor.com
Hemodynamic Characteristics in Different Types of Shock 04/21/10 / www.freelivedoctor.com Type Preload CO PVR SVR Hemmorrh...
Question 04/21/10 The wavefrom shown in this figure was observed while attempting to advance a pulmonary arterial catheter...
Inotropic Agents and Vasodilators <ul><li>Vasoactive drugs are an important pharmacologic defense in the treatment of shoc...
Effects of Inotropic Agents and Vasodilators 04/21/10 Drug   Receptor   CO   SVR  Dose Range 0 -  (  g/kg/min) 1 www.free...
Effects of Inotropic Agents and Vasodilators 04/21/10 2 Drug   CO  SVR Dose Range (  g/kg/min) www.freelivedoctor.com Nif...
Dopamine  An endogenous precursor of norepinephrine with multiple dose-related effects <ul><li>Low Dose (0.5 - 3 mg/kg/min...
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Pharmacotherapy of shock

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Pharmacotherapy of shock

  1. 1. Pharmacotherapy of Shock www.freelivedoctor.com
  2. 2. Introduction <ul><li>Review the current view on etiology, pathophysiology and management of shock with emphasis on pharmacotherapy. </li></ul>04/21/10 www.freelivedoctor.com
  3. 3. Topics of Discussion <ul><li>Pathophysiology of Shock </li></ul><ul><li>Types of Circulatory Shock </li></ul><ul><li>Management of Shock </li></ul><ul><ul><li>Inotropic Agents </li></ul></ul><ul><ul><li>Vasodilators </li></ul></ul>04/21/10 www.freelivedoctor.com
  4. 4. Shock <ul><li>Term “choc” – French for “push” or impact was first published in 1743 by the physician LeDran </li></ul><ul><li>Belief – symptoms arose from fear or some other form of altered cerebral function </li></ul><ul><li>Crile in 1899 showed that replacement of blood volume decreased mortality experimentally </li></ul>04/21/10 www.freelivedoctor.com
  5. 5. Determinants of Shock <ul><li>Inadequate tissue perfusion </li></ul><ul><li>Sustained loss of effective circulatory blood volume </li></ul><ul><li>Breakdown of cellular metabolism and microcirculatory homeostasis </li></ul><ul><li>Hypoperfusion of peripheral tissue that leads to a diminutive transcapillary exchange function </li></ul><ul><li>Disproportion between VO 2 and DO 2 </li></ul>04/21/10 www.freelivedoctor.com
  6. 6. Hemodynamic States of Shock <ul><li>Hyperdynamic State </li></ul><ul><li>Hypodynamic State </li></ul><ul><li>Related to: </li></ul><ul><ul><li>Cardiac Output (CO) </li></ul></ul><ul><ul><li>Systemic Vascular Resistance (SVR) </li></ul></ul>04/21/10 www.freelivedoctor.com
  7. 7. Pathophysiology of Shock <ul><li>Shock develops with inadequate capillary perfusion by decreased Cardiac Output following heart attack (cardiogenic shock) or blood/volume loss (hypovolemic shock) </li></ul>04/21/10 www.freelivedoctor.com
  8. 8. Mediators of Shock <ul><li>Toxins </li></ul><ul><ul><li>Endotoxins </li></ul></ul><ul><li>Oligo- and polypeptides </li></ul><ul><ul><li>Complement Factors </li></ul></ul><ul><ul><li>Opiods </li></ul></ul><ul><ul><li>TNF, Interleukins </li></ul></ul><ul><li>Fatty Acid Derivatives </li></ul><ul><ul><li>Arachidonic acid metabolites </li></ul></ul><ul><li>Varia </li></ul><ul><ul><li>Calcium </li></ul></ul>04/21/10 www.freelivedoctor.com
  9. 9. Main Classes of Shock <ul><li>Hypovolemic Shock </li></ul><ul><li>Distributive Shock </li></ul><ul><li>Cardiogenic Shock </li></ul><ul><li>Obstructive Shock </li></ul>04/21/10 www.freelivedoctor.com
  10. 10. Hypovolemic Shock <ul><li>Hemorrhagic/Traumatic </li></ul><ul><li>Dehydrative </li></ul><ul><li>Burn </li></ul>04/21/10 www.freelivedoctor.com
  11. 11. Distributive Shock <ul><li>Septic </li></ul><ul><li>Anaphylactic/ Anaphylactoid </li></ul><ul><li>Neurogenic </li></ul>04/21/10 www.freelivedoctor.com
  12. 12. Obstructive Shock <ul><li>Pulmonary Embolism </li></ul><ul><li>Cardiac Tamponade </li></ul><ul><li>Pneumothorax </li></ul>04/21/10 www.freelivedoctor.com
  13. 13. Question 04/21/10 Which one of the folowing is the most common cause of severe Lactic acidosis (blood lactate concentration >5 mmol/L)? a. Ethanol intoxication b. Severe liver disease c. Circulatory shock d. Ischemic bowel e. Acute asthma www.freelivedoctor.com
  14. 14. Management of Shock <ul><li>Shock begins when DO2 to the cells is inadequate to meet metabolic demand </li></ul><ul><li>The major therapeutic goals in shock therefore are sufficient tissue perfusion and oxygenation </li></ul><ul><li>Early diagnosis remains a major problem </li></ul>04/21/10 www.freelivedoctor.com
  15. 15. Pulmonary Artery Catheter Waveforms 04/21/10 Right Atrium Right Ventricle Pulmonary Artery PCWP www.freelivedoctor.com
  16. 16. Hemodynamic Characteristics in Different Types of Shock 04/21/10 / www.freelivedoctor.com Type Preload CO PVR SVR Hemmorrhagic Anaphylactic Cardiogenic Septic (Hyperdynamic) Septic (Hypodynamic)
  17. 17. Question 04/21/10 The wavefrom shown in this figure was observed while attempting to advance a pulmonary arterial catheter, with the Balloon inflated, from the proximal pulmonatry artery to a “ wedged” position. Which one of the following bv Which one of the following best explains the terminal portion of the depicted waveform? a. Pulmonary hypertension b. Mitral regurgitation c. Severe left ventricular dysfunction d. Obstruction of the catheter tip e. Pericardial tamponade www.freelivedoctor.com
  18. 18. Inotropic Agents and Vasodilators <ul><li>Vasoactive drugs are an important pharmacologic defense in the treatment of shock. </li></ul><ul><li>May be required to support BP in the early stages of shock. </li></ul><ul><li>These agents may be needed to : </li></ul><ul><ul><li>Enhance CO through the use of inotropic agents </li></ul></ul><ul><ul><li>Increase SVR through the use of vasopressors </li></ul></ul>04/21/10 www.freelivedoctor.com
  19. 19. Effects of Inotropic Agents and Vasodilators 04/21/10 Drug Receptor CO SVR Dose Range 0 - (  g/kg/min) 1 www.freelivedoctor.com Epinephrine        0.02 – 0.5 Norepinephrine     0 - 0.05 – 0.5 Dopamine    DR  2 -12 Dobutamine     2 - 12 Dopexamine      DR 0 - 0.9 - 5 Vasopressin Angiotensin III 5 - 20 Amrinone PDI 5 -10
  20. 20. Effects of Inotropic Agents and Vasodilators 04/21/10 2 Drug CO SVR Dose Range (  g/kg/min) www.freelivedoctor.com Nifedipine 0 - 0.5 - 10 Nitroglycerin 0 - 3 - 5 Nitroprusside 0 - 0.5 - 5 Prostacyclin 10 - 40
  21. 21. Dopamine An endogenous precursor of norepinephrine with multiple dose-related effects <ul><li>Low Dose (0.5 - 3 mg/kg/min) </li></ul><ul><ul><li> 2 and dopaminergic (DR) effects </li></ul></ul><ul><ul><li>Enhanced blood flow to renal and splanchnic beds </li></ul></ul><ul><li>Moderate Dose (5 -10 mg/kg/min) </li></ul><ul><ul><li>Positive inotropic effects </li></ul></ul><ul><li>High Dose (>20 mg/kg/min) </li></ul><ul><ul><li> -actions (vasoconstriction) </li></ul></ul>www.freelivedoctor.com
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