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

II

III

IV

Blood loss (%)

EBV

<15

15 30

30 40

>40

SBP (mmHg)

>110

>100

<90

<90

Pulse (x/mt)

<100

>100

>120

>140

16

16 20

21 26

>26

RR (x/mt)
CNS

Anxious Agitated Confused Lethargic

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/mm 3, 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

PAO
Pressure

Cardiogenic
shock
Hypovolemic

shock
Distributive shock or N
Obstructive shock
C. tamponade
P. embolus
or N

Cardiac
Output

SVR

, N or

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).