Initial Treatment of Shock in ER

Erwin Siregar RS Jantung dan Pembuluh Darah Harapan Kita

Type of Shock
• Hypovolemic shock :
– Haemorrhage – Dehydration

• Septic shock • Cardiogenic shock • Neurogenic shock

The 2nd National Symposium on Emergencies, August 28th, 2005

Hypovolemic shock
• Initial resuscitation important
– FLUID – Drugs – Monitoring

The 2nd National Symposium on Emergencies, August 28th, 2005

Body Fluids
• Water comprises about 60 % total body weight • Extracellular fluid (20 % tbwt)
– – – – Interstitial (15 % tbwt) Intravascular (5 % tbwt) Transcellular (CSF, aqueous humour etc) Intracellular fluid (40 % tbwt)

The 2nd National Symposium on Emergencies, August 28th, 2005

Distribution of Fluid
• 70 kg man (57 % water) • Total 42 liters
– Extracellular 14 liters (20 % of mass)
• Interstitial fluid ~ 11.2 liters • Intravenous (plasma) ~ 2.8 liters

– Intracellular 28 liters (40 % of mass)
• Red blood cells ~ 2 liters

The 2nd National Symposium on Emergencies, August 28th, 2005

Type of Fluids
• Crystalloid • Colloid :
– Isotonic colloid – Hypertonic colloid

• Hypertonic saline

The 2nd National Symposium on Emergencies, August 28th, 2005

Crystalloids
• True solutions • Freely distributed across semi permeable membranes • Plasma expansion < infused volume • Rapidly excreted • Expansion ECF : PV ~ 4 : 1 • Limited duration of effect (+ 90 min)
The 2nd National Symposium on Emergencies, August 28th, 2005

• Crystalloids
– – – – – – Extracellular space expanders Limited plasma volume expansion Maintain urine output Reduce plasma oncotic pressure Range of electrolyte content CHEAP

The 2nd National Symposium on Emergencies, August 28th, 2005

Isotonic Colloids
• • • • • Suspension of large particles Generally limited to vascular compartment Volume for volume plasma expansion Excretion determined by molecular size Osmotic effect dependent on number of particles • Duration of effect 2-12 hours

The 2nd National Symposium on Emergencies, August 28th, 2005

Hypertonic colloid/ solutions
• Expansion of intravascular space • Contraction of ECF

The 2nd National Symposium on Emergencies, August 28th, 2005

Crystalloid vs Colloid ?
Colloid advantages • Intravascular space expanders • Volume for volume expansion • Rapid resuscitations • Maintain oncotic pressure • Less tissue edema • Less pulmonary edema Colloid disadvantages • Coagulation problem • Variable electrolyte content • Variable half life • Adverse reactions • EXPENSIVE !!!

The 2nd National Symposium on Emergencies, August 28th, 2005

Crystalloid vs Colloid ?
Early 1990 • Place of colloids firmly established • Role of crystalloids being challenged: increased tissue oedema equated to increased lung oedema increased brain oedema • “The end of crystalloid era”
Twigley & Hilma, Anaesthesia, 1985
The 2nd National Symposium on Emergencies, August 28th, 2005

So what went wrong ???
As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patient types can be justified outside the context of randomized controlled trials
Cochrane Database Review, 2000
The 2nd National Symposium on Emergencies, August 28th, 2005

How good are the crystalloids ?

The 2nd National Symposium on Emergencies, August 28th, 2005

Is normal saline NORMAL ??
• Is 0.9 % saline isotonic ?
– Normal plasma osmolality 280-290 mOsm/l – 0.9 % saline = 154 x 2 = 308 mOsm/l

• Is it physiological ?
– pH = 6.35 – Chloride load can cause acidosis

• ABNORMAL SALINE ???
The 2nd National Symposium on Emergencies, August 28th, 2005

Ringer’s vs Saline
• No real difference in most situations • Sodium and acid load from saline • Lactate’s in Ringer only important in the presence of liver failure • Ringer’s low in sodium and osmolality (275 mOsm/L)

The 2nd National Symposium on Emergencies, August 28th, 2005

Key Point on Crystalloids
• Large volume are frequently required • Large volume of abnormal solutions may produce abnormality • Some evidence of brain edema • Saline :
– Hypernatremia and acidosis

• Ringer’s
– Hyponatremia and alkalosis
The 2nd National Symposium on Emergencies, August 28th, 2005

Hypertonic Salines (7.5 %)
• High osmolality (2400 mOsm/l) • Small volume resuscitation • Reduces cerebral no-reflow in CPR
– Fischer M, Resusctitaion, 1996

• Decreases brain water in head injury
– Sheik AA, Crit Care Med, 1996

• Effective for a limited period only
– Favre Schweiz, Med Wochenschnr, 1996

• Reversed trauma-induced immunosuppresion
– Coimbra R, J Surg Res, 1996
The 2nd National Symposium on Emergencies, August 28th, 2005

Colloids
• • • • Plasma protein fractions Gelatins Dextrans Starches

The 2nd National Symposium on Emergencies, August 28th, 2005

Plasma Derived Colloids
• Plasma (FFP, cryoprecipitate)
– Coagulations problem only

• Albumin • Plasma protein fractions /SHS

The 2nd National Symposium on Emergencies, August 28th, 2005

Albumin
• • • • Expensive No evidence of benefit Some evidence of harm ANZICS SAFE study :
– 7000 patients randomized to Alb or NS
– Increased mortality with albumin ( p< 0.05) in trauma (more intracerebral bleeding)

The 2nd National Symposium on Emergencies, August 28th, 2005

Gelatins
• Moderate molecular weight
28-35 kDa

• Short duration of actions
2 – 4 hrs

• Minimal coagulation disturbances • Significant allergic risk
Haemacel > Gelofusin

The 2nd National Symposium on Emergencies, August 28th, 2005

Dextran
• • • • MW 40 – 70 kDa Prolonged duration of effect Improved microcirculation Significant impairment of coagulation • Small anaphylactoid risk • Some risk of renal dysfunction
The 2nd National Symposium on Emergencies, August 28th, 2005

Starches
• Range of molecular weight 70-450 kDa determines properties • Long to very long duration • May improve microcirculation and endothelial function • Moderate to small coagulation effect • Minimal anaphylactoid risk
The 2nd National Symposium on Emergencies, August 28th, 2005

Colloid, summary
• Gelatins,
– Short term volume effect – Minimal effect on coagulation – No dose limitation

• Dextrans,
– – – – Medium term volume effect Significant coagulant inhibition Renal effect with Dex40 Limit 15 ml/kg/24 hr

• HES
– Medium to long term volume effect – Minimal to moderate coagulation effect – Limit 33 ml/kg/24hr (6%) or 20 ml (10 %)

The 2nd National Symposium on Emergencies, August 28th, 2005

Fluid Balance Consequences in Early Shock
• Mobilization of ECF • Hemodilution of plasma
– ? Coagulation effect – Gradual fall in Hb

• Maintenance of vascular space at the expense of the ECF

The 2nd National Symposium on Emergencies, August 28th, 2005

Late shock
• • • • • Capillary leak Loss of plasma volume Tissue edema Organ edema (lung, kidney) Multiple Organ Failure

The 2nd National Symposium on Emergencies, August 28th, 2005

OBJECTIVES
• Early, complete restoration of tissue oxygenation • Minimal biochemical disturbances • Preservation of renal function • Avoidance of transfusion complications

The 2nd National Symposium on Emergencies, August 28th, 2005

Fluid Choices
• Well-balanced resuscitation fluid resembling extracellular fluid • Rapid volume expansion of intravascular space • Sustained expansion • No sugar

The 2nd National Symposium on Emergencies, August 28th, 2005

Problems with BLOOD
• Disease • Biochemical abnormalities :
– – – – Hypernatremia Acidosis Hyperkalaemia Hypocalcaemia

• Delayed effects :
– Metabolic alkalosis – Hypokalaemia – Immunomodulation

The 2nd National Symposium on Emergencies, August 28th, 2005

Blood
• • • • Limit transfusions Transfusion threshold < 7 g/dL Maintenance leve 7-9 g/dL Older patients and those with ischemic heart disease may need higher Hb

The 2nd National Symposium on Emergencies, August 28th, 2005

Timing of Resuscitation
• Do not delay transfer for resuscitation • Priority is arrest of hemorrhage • Commence aggressive resuscitation once control of bleeding is imminent

Pepe et al, Emerg Med Clin North Am, 1998

The 2nd National Symposium on Emergencies, August 28th, 2005

Timing of Resuscitation
• • • • Controlled fluid resuscitation Balance hypoperfusion vs bleeding risk Anemia than hypovolemia Not yet proven that colloids reduce mortality in trauma patients • In SIRS, HES may reduce capillary leak • HS solutions may benefit head injuries • Hemoglobin-based oxygen carriers may be useful in future
Nolan, Resuscitation, 2001
The 2nd National Symposium on Emergencies, August 28th, 2005

Selection of Fluids
• Early aggressive crystalloid therapy (2-3 liters RL, 0.9 % saline) • Colloids if needed :
– Short duration colloid if volume requirement is temporary – Long acting colloid otherwise

• Red blood cells if Hct < 25 • FFP, cryoprecipitate only for coagulation problems
The 2nd National Symposium on Emergencies, August 28th, 2005

DRUGS
• Inotropes :
– Dobutamine – Dopamine – Adrenaline

• Vasopressors
– – – – Noradrenaline Adrenaline Vasopressin Phenylephrine

The 2nd National Symposium on Emergencies, August 28th, 2005

MONITORING
• Non invasive
– – – – – NIBP Urine output HR Capillary filling Pulse oxymetry

• Invasive
– Arterial line – CVP – PA pressure (Swan Ganz catheter)
The 2nd National Symposium on Emergencies, August 28th, 2005

DOBUTAMIN
• Agonis β-1 yang poten • Kontraktilitas miokard ↑ • Heart Rate sedikit ↑ • Efek vasodilatasi ringan : inodilator • Memperbaiki perfusi splanknikus
The 2nd National Symposium on Emergencies, August 28th, 2005

Dopamin
• Dosis kecil – sedang ( sampai 7 µg/kgBB/mnt ) βadrenergik • Dosis besar α- adrenoreseptor ↑ vasokonstriksi Dopamin : inotropik + vasokonstriktor • Kerugian :
– – – – Takikardia : iskemia miokard ; hati-hati Dapat menyebabkan “steal effect” pada GI tract Dapat mengganggu fungsi “pituitary gland” & tiroid Dapat mempunyai efek immunosupresif

The 2nd National Symposium on Emergencies, August 28th, 2005

NORADRENALIN (VASCON®)

• Neurotransmitter postsynaps adrenergic • Stimulasi α-1 dan β-1 adrenoreseptor • Dosis rendah : efek β • Vasokonstriksi dan MAP ↑
The 2nd National Symposium on Emergencies, August 28th, 2005

ADRENALIN
• Mempunyai aktivitas β-1, β-2, dan α-1 yang poten • Pada sepsis MAP ↑ oleh karena CO ↑ (stroke volume ↑) • Kerugian : – Kebutuhan O2 miokard ↑ – Laktat serum ↑

The 2nd National Symposium on Emergencies, August 28th, 2005

VASOPRESIN (ADH)

• Dapat dipakai sebagai vasokonstriktor bila vaso konstriktor katekolamin tidak berhasil • Mengurangi perfusi splanknikus
The 2nd National Symposium on Emergencies, August 28th, 2005

FENILEFRIN
• α-1 agonis murni • Sebagai vasokonstriktor tidak menyebabkan takikardia • Sering dipakai di anestesi dan ICU untuk mengatasi dilatasi

The 2nd National Symposium on Emergencies, August 28th, 2005

SEKALI LAGI !!
Persisten hipotensi, tambahkan vasopresin Pasien Hipotensif Tentukan Target MAP

Resusitasi Cairan

Target PCWP ≥15mmHg

Persisten Hipotensi Tambah Noradrenalin

MAP N, oliguria, CO↓, Tambah dobutamin, dopamin

The 2nd National Symposium on Emergencies, August 28th, 2005

Conclusion
• Initial treatment in ER ,is Critical and very important to avoid further complications (organs, etc) • Knowledge of presenting shock is of paramount importance • Familiar with characteristics of various resuscitation fluids
– Blood is used if absolutely necessary

• Knowledge of inotropes and vasopressors • Ability to use invasive monitors an advantage
The 2nd National Symposium on Emergencies, August 28th, 2005

The 2nd National Symposium on Emergencies, August 28th, 2005

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