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Shock

Shock

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Published by Agung Nugroho

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Published by: Agung Nugroho on May 16, 2013
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09/22/2014

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Diagnosis and Management of Shock

SHK 1
®

Objectives
• Identify the major types of shock and principles of management
• Review fluid resuscitation and use of vasopressor and inotropic agents • Understand concepts of O2 supply and demand • Discuss the differential diagnosis of oliguria

SHK 2
®

acidosis SHK 3 ® . oliguria.Shock • Always a symptom of primary cause • Inadequate blood flow to meet tissue oxygen demand • May be associated with hypotension • Associated with signs of hypoperfusion: mental status change.

Shock Categories • Cardiogenic • Hypovolemic • Distributive • Obstructive SHK 4 ® .

decreased cardiac output • Increased systemic vascular resistance – compensatory SHK 5 ® .Cardiogenic Shock • Decreased contractility • Increased filling pressures. decreased LV stroke work.

Hypovolemic Shock • Decreased cardiac output • Decreased filling pressures • Compensatory increase in systemic vascular resistance SHK 6 ® .

and acute adrenal insufficiency SHK SHK 7 7 ® . neurogenic.Distributive Shock • Normal or increased cardiac output • Low systemic vascular resistance • Low to normal filling pressures • Sepsis. anaphylaxis.

Obstructive Shock • Decreased cardiac output • Increased systemic vascular resistance • Variable filling pressures dependent on etiology • Cardiac tamponade. tension pneumothorax. massive pulmonary embolus SHK 8 ® .

Cardiogenic Shock Management • Treat arrhythmias • Diastolic dysfunction may require increased filling pressures • Vasodilators if not hypotensive • Inotrope administration SHK 9 ® .

Cardiogenic Shock Management • Vasopressor agent needed if hypotension present to raise aortic diastolic pressure • Consultation for mechanical assist device • Preload and afterload reduction to improve hypoxemia if blood pressure adequate SHK 10 ® .

colloid • Initial crystalloid choices – Lactated Ringer’s solution – Normal saline (high chloride may produce hyperchloremic acidosis) • Match fluid given to fluid lost – Blood.Hypovolemic Shock Management • Volume resuscitation – crystalloid. colloid SHK SHK 11 11 ® . crystalloid.

Distributive Shock Therapy • Restore intravascular volume • Hypotension despite volume therapy – Inotropes and/or vasopressors • Vasopressors for MAP < 60 mm Hg • Adjunctive interventions dependent on etiology SHK 12 ® .

Obstructive Shock Treatment • Relieve obstruction – Pericardiocentesis – Tube thoracostomy – Treat pulmonary embolus • Temporary benefit from fluid or inotrope administration SHK 13 ® .

Fluid Therapy • Crystalloids – Lactated Ringer’s solution – Normal saline • Colloids – Hetastarch – Albumin – Gelatins • Packed red blood cells • Infuse to physiologic endpoints SHK SHK 14 14 ® .

Fluid Therapy • Correct hypotension first • Decrease heart rate • Correct hypoperfusion abnormalities • Monitor for deterioration of oxygenation SHK SHK 15 15 ® .

Inotropic / Vasopressor Agents • Dopamine – Low dose (2-3 g/kg/min) – mild inotrope plus renal effect – Intermediate dose (4-10 g/kg/min) – inotropic effect – High dose ( >10 g/kg/min) – vasoconstriction – Chronotropic effect SHK SHK 16 16 ® .

Inotropic Agents • Dobutamine – 5-20 g/kg/min – Inotropic and variable chronotropic effects – Decrease in systemic vascular resistance SHK SHK 17 17 ® .

Inotropic / Vasopressor Agents • Norepinephrine – 0.05 g/kg/min and titrate to effect – Inotropic and vasopressor effects – Potent vasopressor at high doses SHK SHK 18 18 ® .

1 g/kg/min and titrate – Increases myocardial O2 consumption SHK SHK 19 19 ® .Inotropic / Vasopressor Agents • Epinephrine – Both  and  actions for inotropic and vasopressor effects – 0.

Therapeutic Goals in Shock • Increase O2 delivery • Optimize O2 content of blood • Improve cardiac output and blood pressure • Match systemic O2 needs with O2 delivery • Reverse/prevent organ hypoperfusion SHK 20 ® .

Oliguria • Marker of hypoperfusion • Urine output in adults <0.5 mL/kg/hr for >2 hrs • Etiologies – Prerenal – Renal – Postrenal SHK SHK 21 21 ® .

creatinine SHK SHK 22 22 ® .Evaluation of Oliguria • History and physical examination • Laboratory evaluation – Urine sodium – Urine osmolality or specific gravity – BUN.

Evaluation of Oliguria Laboratory Test Blood Urea Nitrogen/ Creatinine Ratio Urine Specific Gravity Urine Osmolality (mOsm/L) Urinary Sodium (mEq/L) Fractional Excretion of Sodium (%) Prerenal >20 >1.020 >500 <20 <1 ATN 10–20 <1.010 <350 >40 >2 SHK 23 ® .

BUN.Therapy in Acute Renal Insufficiency • Correct underlying cause • Monitor urine output • Assure euvolemia • Diuretics not therapeutic • • • • SHK SHK 24 24 Low-dose dopamine may  urine flow Adjust dosages of other drugs Monitor electrolytes. creatinine Consider dialysis or hemofiltration ® .

Pediatric Considerations • BP not good indication of hypoperfusion • Capillary refill. before inotropes or vasopressors SHK SHK 25 25 ® . extremity temperature better signs of poor systemic perfusion • Epinephrine preferable to norepinephrine due to more chronotropic benefit • Fluid boluses of 20 mL/kg titrated to BP or total 60 mL/kg.

urine volume <2 mL/kg/hr – Older children. urine volume <1 mL/kg/hr SHK SHK 26 26 ® .Pediatric Considerations • Neonates – consider congenital obstructive left heart syndrome as cause of obstructive shock • Oliguria – <2 yrs old.

Key Points SHK 27 ® .

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