Shock and MODS

1. DR DHANESH KUMAR
DNB-CTVS

2.  Profound hemodynamic and metabolic
disturbance characterized by failure of the
circulatory system to maintain adequate
perfusion of vital organs

3.  Cardiogenic (intrinsic vs compressive)
 Hypovolemic
 Distributive
◦ sepsis
◦ neurogenic (spinal shock)
◦ adrenal insufficiency
◦ anaphylaxis

5.  Arterial hypotension associated with signs of
altered tissue perfusion, visualized through
three windows of body :
 Peripheral window: skin that is cold, clammy
and blue ,pale or discolored.
 Renal window: decreased urine output
:<0.5ml/kg/h.
 Neurological window : Altered mental state
characterized by obtundation ,disorientation
and confusion.

6.  Usually not clinically apparent
 Metabolism changes from aerobic to
anaerobic.
◦ Lactic acid accumulates -must be removed by blood
and broken down by liver. usual cut-off value is
2mEq/L. but lactate level of >1.5mmol/L in patients
with septic shock are associated with increased
mortality.

7.  Clinically apparent –Neural, Hormonal
&Biochemical compensatory mechanisms
 Attempts aimed to overcome consequences
of anaerobic metabolism and maintaining
homeostasis.

8. 8
•Baroreceptors in carotid and aortic bodies activate SNS in
response to ↓ BP.
•Vasoconstriction, while blood to vital organs maintained.
•↓ blood to kidneys > activates renin– angiotensin system ↑
venous return to heart, CO, BP.
•Impaired GI motility- Risk for paralytic ileus.
•Cool, clammy skin .
Except septic patient who is warm and flushed

9.  Shunting of blood from lungs increases
physiologic dead space.
 ↓ arterial O2 levels
 Increase in rate/depth of respirations
 V/Q mismatch
 SNS stimulation increases myocardial O2
demands.
 If perfusion deficit corrected, patient recovers
with no residual sequelae .
 If deficit not corrected, patient enters
progressive stage

10.  Begins when compensatory mechanisms
fail
 Aggressive interventions to prevent
multiple organ dysfunction syndrome
(MODS)
 Hallmarks -↓ cellular perfusion & altered
capillary permeability
 Leakage of protein into interstitial
space
 ↑ systemic interstitial edema

11.  Fluid leakage affects solid organs and
peripheral tissues.
• Anasarca
 Movement of fluid from pulmonary vasculature
to interstitium(decreased blood flow to
pulm.Cap.)
 Pulmonary edema
 Bronchoconstriction
 ↓ residual capacity
 Fluid moves into alveoli
 Edema-Red. surfactant
 Worsening V/Q mismatch
 Tachypnea, Crackles
 Incr.work of breathing

12.  CO begins to fall
 Red. peripheral perfusion
 Hypotension
 Weak peripheral pulses
 Ischemia of distal extremities
 Myocardial dysfunction results in
 Dysrhythmias
 Ischemia; Myocardial infarction
 End result: complete deterioration of cardiovascular
system

13.  Liver fails to metabolize drugs and waste.
 Jaundice; Elevated enzymes
 Loss of immune function
 Risk for DIC and significant bleeding
 Mucosal barrier of GI system becomes ischemic
 Ulcers
 Bleeding
 Risk of translocation of bacteria
 Reduced ability to absorb nutrients

14.  Exacerbation of anaerobic
metabolism
 Accumulation of lactic acid
 ↑ capillary permeability
 Profound hypotension and hypoxia
 Tachycardia worsens.
 Failure of one organ system
affects others.
 Recovery unlikely

15.  Myocardial Injury or Obstruction to Flow
◦ Arrythymias
◦ valvular lesions
◦ AMI
◦ Severe CHF
◦ VSD
◦ Hypertrophic Cardiomyopathy

16.  Pulmonary Edema
 Raised JVP
 Hypotension
 weak pulses
 oliguria

17.  Pulmonary Embolism (obstructive)
 Cardiac Tamponade
 Tension Pneumothorax
 Presentation will be according to underlying
disease process.

18.  Reduced circulating blood volume with
secondary decreased cardiac output
◦ Acute hemorrhage
◦ Vomiting/Diarrhea
◦ Dehydration
◦ Burns
◦ Peritonitis/Pancreatitis

19.  Hypotensive
 collapsed neck veins
 clear lungs
 cool, cyanotic extremities
 evidence of bleeding?
◦ Anticoagulant use
◦ trauma, bruising
 oliguria

20.  Peripheral Vasodilation secondary to disruption
of cellular metabolism by the effects of
inflammatory mediators.
 Gram negative or other overwhelming
infection.
 Results in decreased Peripheral Vascular
Resistance.

21.  Febrile
 Tachycardia
 clear lungs, evidence of pneumonia
 warm extremities
 collapsed neck veins
 oliguria

22.  Response to fluids
 Echo/ECG
 CXR
 Evidence of infection

23. Etiology CO PCWP SVR
cardiogenic decreased increased increased
hypovolemic decreased decreased increased
distributive increased decreased decreased
obstructive decreased Increased increased

24.  Correct underlying disorder if possible and
then direct efforts at increasing the blood
pressure to increase oxygen delivery to the
tissues.
 Maintain a mean arterial pressure of 65mmHg
(1/3 systolic + 2/3 diastolic)
 Keep O2 sats >92%, intubate if neccesary

25.  Normal Saline should be administered
anytime a patient is hypotensive.
 If possible give colloid.
 Vasopressors specially for septic shock .
 Inotropic agents for cardiogenic shock
 Intra-aortic Balloon Pump for cardiogenic

26. Drugs Indication dose MOA Principle
action
Dopamine Hypotension 5-
10mcg/k
g/min
Beta1and
dopaminergic
Inotropic(+)
Hypotension >10mcg
/kg/min
alpha1 Vasoconstri
ction
Dobutamine Cardiogenic
shock
2.5-
25mcg/k
g/min
Selective
beta1
Inotropic(+)
Norephinephrine Hypotension 2-
4mcg/kg
/min
Alpha1and
beta1
Vasoconstri
ction
Phenylephinphrine Hypotension 40-
180mcg/
kg/min
Selective
alha1
vasoconstri
ction

27.  Attempt to correct problem and increase
cardiac output by diuresing and providing
inotropic support.
 IABP is utilized if medical therapy is
ineffective. Cardiac Catheterization if
ongoing ischemia despite maximum medical
therapy.
 Cardiogenic shock is the exception to the rule
that NS is always given for hypotension NS
will exacerbate cardiac shock.

28.  Early goal directed therapy
 Identification of source of infection
 Broad Spectrum Antibiotics
 IV fluids
 Vasopressors
 Steroids ??
 Recombinant human activated protein C (
Xygris)
 Bicarbonate if pH < 7.1

29.  Correct bleeding abnormality
 If PT or PTT elevated then FFP
 Aggressive Fluid replacement with 2 large
bore IV’s or central line.
 Pressors are last line, but commonly required.

30.  HARRISON 18TH EDITION. Page no. 1689-
1695.
 Consensus on circulatory shock and
hemodynamic monitoring. Task force of
European society of Intensive care
Medicine(Intensive care Med(2014)40:1795-
1815 DOI 10.1007/s00134-014-3525-z.
 The swan –Ganz catheter: past ,present and
future(circulation .2009:119:147-152.)