SHOCK

Robert H. Sirait, dr.,Sp An Dept. of Anesthesia FK UKI Jakarta

SHOCK
Is a mismatch betwen tissue oxygen demands and tissue oxygen supply. Is pertubation poor perfusion of vital organ because of tissue hypoxia induced by oxygen supply and demand in equeities

Shock is hypotension with hypoperfusion abnormalities

Shock is dynamic syndrome

Mismatch O2 demands and tissue O2 supply Tissue hypoxia Anareobic matabolism at microcelluler level

Tissue damage Death

Delivery of Oxygen
DO2 : CO x CaO2 x 10 CaO2:{(Hb x 1,34 x SaO2)+(PaO2 x 0,0031)} Note CO : Cardiac output CaO2 : Oxygen Arterial content

Oxygen delivery can be increased by : a. increasing cardiac output b. Increasing hemoglobin concentration or c. Increasing oxyhemoglobin concentration.
Clinical interventions to decrease oxygen demand : a. Intubation (to support the work of breathing) b. Sedation c. Analgesia and d. Treatment fever

General criteria of shock

a. Systolic arterial BP < 80 mmHg or a reduction > 40 mmHg b. Oliguria c. Metabolic acidosis d. Poor tissue perfusion Cinical manisfestation of organ hypoperfusion a. Mental status changes b. Oliguria c. Lactic acidosis

Classification of Shock
A. Cardiogenic shock Myocardial dysfunction : forward blood flow inadequate B. Hypovolemic shock Intravascular volume is depleted as a result of hemorrhage, vomiting, diarrhea or third space loss. C. Distributive shock The most common is septic shock. The other forms: anaphylactic shock, acute adrenal insufficiency and neurogenic shock D. Obstructive shock Cardiac tamponade represents extracardiac obstructive shock. The other forms: tension pneumothorax and massive pulmonary embolus

Hemorrhage Classification
Class Variable Blood loss (%) EBV SBP (mmHg) Pulse (x/mt)

I
<15 >110 <100

II
15 30 >100 >100

III
30 40 <90 >120

IV
>40 <90 >140

RR (x/mt)
CNS

16

16 20

21 26

>26
Lethargic

Anxious Agitated Confused

Notes : Class I. No shock, mild tachycardia. II. Moderate shock, tachycardia, SBP, DBP, sluggish capillary refill, table tilt test +. III. Severe shock; the skin: cold, clammy, and pallid; SBP 30 40 %, DBP 15 20 %; vasoconstriction: tachypnea, hypoxemia, tissue hypoperfusion, and anaerobic metabolism; oliguria. IV. Propound shock, blood pressure no palpable, peripheral pulses loss.

Infection inflamatory response to the presence of microorganism or the invasion of normally sterile host tissue by organisms. Bacteraemia The presence of variable bacteria in the blood.

Systemic inflamatory response syndrome (SIRS) The SIR to a variety of severe clinical insults. The respon in manifested by two or more of the following conditions : - Temperature > 38o C or < 36o C - Heart rate > 90 x/mt - RR > 20 x/mt or PaO2 < 4,3 kPa (< 3,2 Torr) - White blood cell count > 12.000 cells/mm3, or >10 % immature (band) forms Sepsis Defined as SIRS as a result of infection.

Severe Sepsis Sepsis that is associated with organ dysfunction, hypoperfusion, or hypotension. Septic Shock Sepsis with hypotension, despite adequate fluid resuscitation, a long with the presence of perfusion abnormalities.

Multiple organ dysfunction (MOF) syndrome Presence of alterated organ function in an acutely ill patient such that homeostasis can not be maintained without intervention.

Haemodynamic Profiles of Shock

Type of shock Cardiogenic shock Hypovolemic shock Distributive shock PAO Pressure or N or N Cardiac Output , N or SVR

Obstructive shock C. tamponade P. embolus

Basic Principles of Management Shock

1. Increase oxygen delivery to the tissue 2. Incresing cardiac output and blood pressure with combination: a. Fluid resuscitation b. Increasing cardiac contractility with inotropes c. Raising SVR with vasopressors

A. Cardiogenic Shock
The primary goal to improve myocardial function: a. Inotropes such as dobutamine (BP N,) b. Vasopressor such as NE, high dose dopamine (BP )

Dopamine, doses : 2-3 g/kgBB/mt has modest inotropic and chronotropic effects (acts on the dopaminergic receptor in the kidney) 4-10 g/kgBB/mt has primarily inotropic effects 10 g/kgBB/mt has significant agonist effect related vasoconstriction 25 g/kgBB/mt no advantage over NE Dobutamine Is a adrenergic agonist Doses of 5-20 /kg/BB/mt is a potent inotropes increase CO

Norepinephrine (NE) Is a potent adrenergic vasopressor agent. Also has adrenergic, inotropic, and chronotropic effects. Dose ranges start at 0,05 g/kgBB/mt titrated to desired effects

Epinephrine (E) Has both and adrenergic effects Potent inotrope and chronotrope Increase in myocrdial oxygen consumption Dose ranges start at 0,1 g/kgBB/mt titrated to desired effects

B. Hypovolemic Shock
The primary goal : restoration of intravascular volume, either crystalloid or colloid fluids, blood. Targeted : to reestablish normal blood pressure, pulse and organ perfusion (adequate urine output)

C. Distributive Shock
The initial approach is : 1. Restoration and maintenance of adequate intravascular volume 2. Infection : appropiate antibiotic 3. Remains hypotensive despite adequate fluid resuscitation : inotropes and or vasopressors

Anaphylactic shock : Epinephrine sc and volume resuscitation Adrenal insufficiency: Volume therapy, corticosteroid iv and vasopressor Neurogenic shock: Cervical or thoracic spinal cord injury. Characterized: hypotension, bradycardia, flaccid paralysis, loss of extremity reflexes, and priapism Treatment for hypotension: Volume resuscitation, vasopressors, and atropine for bradycardia.

Severe Brain Injury (trias Cushing classic signs). The initial management : controlling ICP, maintaining cerebral oxygen delivery with ; a. Supplemental O2 b. Intubation c. Hyperventilation d. Elevation of head e. Limitation : excess free water and volume resuscitation f. Osmotic diuretic g. Cardiopulmonary support h. Blood transfusions i. CT scan of head j. Prompt craniotomy (when necessary)

D. Obstructive Shock
Relief of the caused obstruction Cardiac tamponade Signs : Trias Becks syndrome+pulsus paradoksus Treatment : Pericardiocentesis (puncture PX tip of left scapula, angel 45 o with longest needle). Tension pneumothoraks Thoracocentesis (puncture IC II mid clavicula lines with large needle).