Amanda Schoettmer, PharmD, PGY1 Pharmacy Resident

Shock & ARDS

April 2022

Definitions

 Systemic vascular resistance (SVR): circulatory pressure

 Inotropy: force of myocardial contractions
 Chronotropy: changes in heart rate
 Mean arterial pressure (MAP): indicates end-organ perfusion; =[2(DBP) + SBP] / 3
 Cardiac output (CO): volume of blood pumped from each ventricle per minute

Septic Shock Cardiogenic Hypovolemic

Fluid resuscitation
IMMEDIATELY with 30
mL/kg IV crystalloid
Control source of
Fluid resuscitation (if no
bleeding/fluid loss and
signs or symptoms of
replace circulating blood
volume overload)
volume

Appropriate IV broad-
spectrum antibitotics
Dobutamine Crystalloid fluids (NS, LR)
within the first hour of
severe sepsis onset

Blood transfusion when

blood loss exceeds 30%
Norepinephrine or
Norepinephrine of total blood volume
dopamine
and/or if unresponsive to
2L of crystalloid fluids

Phenylephrine,
Dopamine
epinephrine, vasopressin

Dobutamine if low CO
and elevated cardiac
filling pressures

Corticosteroids if
refractory despite early
resuscitation and
aggressive vasopressor
support
Amanda Schoettmer, PharmD, PGY1 Pharmacy Resident
Shock & ARDS
April 2022

Types of Shock and Recommended Treatment

Receptor Profile and Agonist Effects

α-1 β-1 β-2 Dopamine

Vasculature Myocardium Pulmonary Vascular & Kidney
↑ Constriction ↑ Chronotropy ↑ Bronchodilation ↑ Dilation
↑ SVR/MAP ↑ Inotropy ↓ SVR/MAP

Vasopressors

α-1 β-1 β-2 Dopamine SVR/MAP CO/HR

Activity Activity Activity activity
Epinephrine
≤0.05 mcg/kg/min + +++ ++ - ↔ ↑
>0.05 mcg/kg/min +++ ++ + - ↑ ↑
Norepinephrine +++ ++ - - ↑ ↔
Dopamine
2-5 mcg/kg/min - + - +++ ↔ ↑
5-10 mcg/kg/min + +++ ++ +++ ↑ ↑
>10 mcg/kg/min +++ +++ + ++ ↑ ↔/↓
Dobutamine +++ +++ + - ↓/↔ ↑
Phenylephrine +++ - - - ↑ ↔/↓
Vasopressin - - - - ↑ ↔

Usual Dose Common Uses

Epinephrine 2 – 30 mcg/min Vasodilatory shock, cardiac arrest, cardiogenic shock
Norepinephrine 2 – 80 mcg/min Vasodilatory shock (usually drug of choice for sepsis), cardiogenic shock
Dopamine 2.5 – 20 Vasodilatory shock, cardiogenic shock, bradycardia
mcg/min
Dobutamine 2.5 – 20 Acute decompensated heart failure, low CO state, cardiogenic shock,
mcg/min bradycardia
Phenylephrine 100 – 400 Vasodilatory shock, shock due to hypotension
mcg/min
Vasopressin 0.04 units/min Vasodilatory shock, cardiogenic shock, cardiac arrest
Amanda Schoettmer, PharmD, PGY1 Pharmacy Resident
Shock & ARDS
April 2022

Acute Respiratory Distress Syndrome (ARDS)

Definition

Timing Within 1 week of a known clinical insult or new/worsening respiratory symptoms

Chest Imaging Bilateral opacities – not fully explained by effusions, lobar/lung collapse, or nodules
Origin of pulmonary edema Respiratory failure not fully explained by cardiac failure or fluid overload
Oxygenation Mild: PaO2/FIO2 >200 mmHg but ≤ 300 mmHg with PEEP or CPAP 5 cm ≥ H2O

Moderate: PaO2/FIO2 >100 mmHg but ≤ 200 mmHg with PEEP ≥ 5 cm H2O

Severe: PaO2/FIO2 ≤100 mmHg with PEEP ≥ 5 cm H2O

Treatment

Mechanical Neuromuscular Systemic

Prone Positioning
Ventilation Blockers Corticosteroids
ALL patients Cisatracurium in Methylprednisolone 1 >12 hours per day in
Consider high PEEP in select patients with mg/kg/day (early severe ARDS
patients wtih moderate to severe onset, within 7 days)
moderate to severe ARDS or 2 mg/kg/day (late
ARDS onset, after 7 days)
Moderate to severe
ARDS

References

1. Banavasi H, Nguyen P, Osman H, Soubani AO. Management of ARDS – what works and what does not. Am J Med
Sci. 2021;362(1):13-23.
2. Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Executive summary: Surviving
Sepsis Campaign: international guidelines for the management of sepsis and septic shock 2021. Crit Care Med.
2021;49(11):1974-82.
3. Kislitsina ON, Rich JD, Wilcox JE, Pham DT, Churyla A, Vorovich EB, et al. Shock – classification and
pathophysiological principles of therapeutics. Curr Cardiol Rev. 2019;15(2):102-13.
4. Moranville MP, Mieure KD, Santayana EM. Evaluation and management of shock states: hypovolemic,
distributive, and cardiogenic shock. J Pharm Pract. 2011;24(1):44-60.