rudy manalu

rudy manalu
• Shock is a life threatening situation due to poor perfusion with impaired cellular
metabolism, manifested in turn by serious pathophysiological abnormalities. (Bailey and
love)
• Shock is a term used to describe the clinical syndrome that develops when there is
critical impairment of tissue perfusion due to some form of acute circulatory failure.
(Davidson’s)
• Shock may defined as inadequate delivery of oxygenation and nutrients to maintain
normal tissue and cellular function. (Schwartz’s)
• The state in which profound and widespread reduction of effective tissue perfusion lead
first to reversible, and then if prolonged, to irreversible cellular injury. (Kumar and
Parrillo, 1995)
rudy manalu
A circulatory imbalance between oxygen supply and
oxygen demand at the cellular level and is also called
circulatory shock. (Harsh Mohan)

rudy manalu
 Traditional clinical signs :
Altered mental status
85 Tachycardia
Hypotension 40
Oliguria

• Mottled and
clammy skin
• Weak peripheral
pulses
rudy manalu
 Shock
Main Problem ?

Heart doesn’t Change in

work fluid status Low fluid Obstruction

Cardiogenic Distributive Hypovolemic Obstructive

Shock Shock Shock Shock

rudy manalu
 Classification of Shock

Shock Type Primary physiologic derangement Common Etiologies

Low preload Trauma
Hypovolemic (due to reduced intravascular volume) Severe hemorrahge
Severe diarrhea
Acute MCI
Cardiogenic Low contractility Severe CHF exacerbation
Myocarditis
Distributive Sepsis
(a.k.a. vasodilatory) Low SVR Anaphylaxis
Spinal cord trauma
Low preload Massive PE
Obstructive (due to mechanical obstruction of venous Pericardial tamponade
Tension pneumothorax
return to the LV)
rudy manalu
rudy manalu
rudy manalu
rudy manalu
rudy manalu
R
E
S
U
S
C
I
T
A
T
I
O
N
rudy manalu
 Resuscitation

S is the process
H
Resuscitation O of treating
C shock
K in an attempt
to restore
normal
physiology

rudy manalu
 Resuscitation

is the process
of treating
shock
Intravenous fluid resuscitation ? in an attempt
to restore
normal
physiology

rudy manalu
Pulse & Blood
Pressure Normal

PUMP

rudy manalu
 Cardiogenic Shock
Blood
Pressure
drops

PUMP
FAILS

rudy manalu
 Cardiogenic Shock
Blood
Pressure
drops

PUMP
FAILS

IV fluid worsen
overload

rudy manalu
 Goal of Treatment

ABCDE
• Airway
• Control Work of Breathing
• Optimize Circulation
• Assuring Adequate Oxygen Delivery
• Achieve End Points of Resuscitation

rudy manalu
 • Achieve End Points of Resuscitation
Endpoints :
- The final stage of a period of process
- The point in a titration at which a reaction is complete.
Importance of Endpoints :
- Endpoints are to be improved as guides for appropriate
resuscitation
- Prevents over-resuscitation, which is associated with increased
mortality
- Goal of resuscitation is to maximize survival and minimize
morbidity rudy manalu
 • Achieve End Points of Resuscitation

Traditional endpoints of resuscitation:

- Restoration of normal clinical perfusion parameters -

mentation, Capillary refill time (CRT), heart rate (HR),
peripheral pulse quality, temperature.

- Blood pressure

- Urine output rudy manalu

MACROCIRCULATION

MICROCIRCULATION

rudy manalu
 • Achieve End Points of Resuscitation

Resuscitation endpoints can be divided into

two groups :

- Macrocirculation
- Microcirculation

rudy manalu
 Measure the microcirculation
Are there microcirculation

Organ Dysfunction
alterations ? Endpoints of resuscitation
Yes
Treatment of microcirculation Macrocirculation :
Hypoperfusion - Hemodynamic
Measure the macrocirculation
Vasodilators ? - Global DO2 parameters
No
Treatment of macrocirculation Tissue hypoxia without vasoconstriction
RBC transfusion/Hb solutions ?
Microcirculation :
Fluid therapy ?
No - Lactate
Vasopressors ?
Organ and cell injury without
- pHi
hypoperfusion. - (a-v)CO2
Inotropes ? Anti inflammatories/Cytoprotective
strategies ? - SvO2
- Base deficit
rudy manalu
 Macrocirculation : DO2
- Hemodynamic CO CaO2
- Global DO2 parameters

Stroke Heart Rate

Hemoglobin Oxygen
Volume
Concentration Saturation

Preload

DO2 = CO x CaO2
Afterload
DO2 = CO x{(Hgb x 1.34 x SaO2) + (PaO2 x 0.003)}

Contractility
rudy manalu
Microcirculation :
- Lactate
- pHi
- (a-v)CO2
- SvO2
- Base deficit

rudy manalu
Microcirculation :
- Lactate
- pHi
- (a-v)CO2
- SvO2
- Base deficit

rudy manalu
Microcirculation :
- Lactate
- pHi
- (a-v)CO2
- SvO2
- Base deficit

rudy manalu
Clinical Practice Guideline:
Endpoints of Resuscitation

Tisherman, Samuel A.; Barie, Philip;

Bokhari, Faran; Bonadies, John;
Daley, Brian; Diebel, Lawrence;
Eachempati, Soumitra R.; Kurek,
Stanley; Luchette, Fred; Carlos
Puyana, Juan; Schreiber, Martin;
Simon, Ronald
Journal of Trauma and Acute Care
Surgery57(4):898-912, October
2004.
doi:
10.1097/01.TA.0000133577.25793.
E5

rudy manalu
rudy manalu
rudy manalu
rudy manalu
rudy manalu
• Targeted End Points of Resuscitation in shock patients
Endpoint Value Units
CI 3.5-5.5 L/min/m2

DO2 >600 mL/min/m2

VO2 >150 mL/min/m2

SBP 80-100 mmHg

MAP 60-80 mmHg
Base deficit -2-2 mEql/L
Lactate 1 ± 0.5 Mmol/L Haskins SC. The balloon –tipped, multilumen,
Thermodilution catheter.
SvO2 >70 % 5th International Veterinary Emergency and Critical
Care Symposium, San Antonio, TX, 1996, 85p.
ScvO2 >65 %

pHi >7.32 rudy manalu

• Achieve End Points of Resuscitation

Septic Shock

rudy manalu
 Shock
Main Problem ?

Heart doesn’t Change in

work fluid status Low fluid Obstruction

Cardiogenic Distributive Hypovolemic Obstructive

Shock Shock Shock Shock
Underlying Problem ?

Abnormal Loss of Sympathetic Anaphylaxis

Inflammation response tone

Septic Shock Neurogenic Shock Anaphylactic Shock

rudy manalu
(Septic Shock)

rudy manalu
 as a subset of sepsis in which underlying circulatory
Septic Shock and cellular metabolism abnormalities are profound
enough to substantially increase mortality.

Lactate Hypotension

rudy manalu
Septic Shock

rudy manalu
 Septic Shock
ABCDE
• Airway
• Control work of Breathing
• Optimize Circulation
• Assuring Adequate Oxygen Delivery
• Achieve End Points of Resuscitation

rudy manalu
 Septic Shock
Management

HEMODYNAMIC INFECTION DETECTION

STABILIZATION & CONTROL

Blood Lactate Blood cultures

IV fluids Vasoactive agent ? Antibiotics Source control ?

rudy manalu
 Septic Shock
Intravenous fluid resuscitation ?

Capillary
Vasoplegia
leak

SEPTIC SHOCK
Vasodilatory

Distributive
(maldistribution)

No volume loss !!!

rudy manalu
 S
E
P
T
I
C

S
H
O
C
K
rudy manalu
 Monitoring fluid management
R O S E
RESUSCITATION OPTIMIZATION STABILIZATION EVACUATION

Minimum monitoring :
➢ Blood Pressure SBP MAP MAP MAP
➢ Heart Rate + + + +
➢ Capillary Refill + + + +
➢ Lactate + + + +
➢ Urine Output - + + +
➢ Fluid Balance - + + +
Optimum monitoring
➢ CVP - ±/? - -
➢ ScvO2 - + - -
➢ Fluid responsiveness - + - -
➢ Cardiac Output - + - -
(PPV,SPV,SVV)
Br J Anaesth. 2014 Nov;113(5):740-7
N Engl J Med 2013;369:1726-34 rudy manalu
rudy manalu
rudy manalu
rudy manalu
Sepsis improvement program:
- Sepsis screening
- Education
- Measurement of sepsis bundle performance + patient outcomes
- Action

Meta-analysis (50 studies): These programs were associated with better adherence
to sepsis bundles along with a reduction in mortality
(OR 0,66: 95 % CI 0,61 - 0,72)
rudy manalu
• q-SOFA - 3 variables to predict death + prolonged ICU stay in patients with known or
suspected sepsis.

• Q-SOFA not an ideal screening tools for sepsis

• Only 24 % of infected patients had a q-SOFA score 2 or 3

• These patients accounted for 70 % of poor outcomes

rudy manalu
• The association of lactate level with mortality in patients with suspected infection
and sepsis is well established.

• The lactate cutoffs determining an elevated level ranged from 1.6-2.5 mmol/L,
although diagnostic characteristic were similar regardless of the cutoff

• Sensitive range from 66-83%, with specificities ranging from 80-85%.

• However, lactate alone is neither sensitive nor specific enough to role-in or role –out
the diagnosis on its own.

rudy manalu
• Timely, effective fluid resuscitation is crucial for the stabilization of sepsis-induced
tissue hypoperfusion in sepsis and septic shock.

• Previous guidelines recommend innitiating appropriate resuscitation upon

recognition of sepsis or septic shock and having a low threshold for commencing it in
those patients where sepsis is not proven but is suspected.

• Although the evidence stems from observational studies, this recommendation is

considered a best practice and there are now new data suggesting that a change is
needed.

rudy manalu
• No prospective interventional studies that compare the different volumes for initial
resuscitation.

rudy manalu
Dynamic Measures:

• Passive leg raising (PLR) + cardiac output (CO) measurement

• Stroke volume (SV)
• Stroke volume variation (SVV)

Better diagnostic accuracy at predicting fluid responsiveness

rudy manalu
Adjunct measure of perfusion / guidance of fluid resus:

• Dynamic measures over static measures

- Meta-analysis : Dynamic assessment to guide fluid therapy was associated with:

- mortality (RR 0.59; 95% CI 0.42 - 0.83)
- ICU length of stay (MD-1.16 days; 95 % CI – 1.97 to -0,36)
- duration of mechanical ventilation (-2.98h; 95 % CI -5.08 to 0.89)

rudy manalu
• Reducing lactate levels.

rudy manalu
• When advanced hemodynamic monitoring is not available, alternative measures of
organ perfusion may be used to evaluate the effectiveness and safety of volume
administration .

• Temperature of the extremities, skin mottling and capillary refill time (CRT) have
been validated and shown to be reproducible signs of tissue perfusion.

rudy manalu
rudy manalu
 • Unchanged from 2016 guidelines.

• Increasing MAP therefore usually results in increased driver of venous return and CO.
• Previous SSC guidelines recommended targeting a MAP o greater than 65 mmHg for
initial resuscitation.

• The recommendation was based principally on a RCT in septic shock comparing

patients were given vasopressors to target a MAP of 65-70 mmHg, versus a target 80-
85 mmHg. This study found no difference in mortality.

rudy manalu
 Summary
• Shock is defined as acute circulatory failure with inadequate or
inappropriately distributed tissue perfusion resulting in generalized
cellular hypoxia.

• Septic shock is another form of distributive shock.

• The aim of resuscitation is to prevent shock worsening and to

restore the circulation to level that meets the body’s tissue oxygen
requirements.

rudy manalu
 Summary

• End points of resuscitation: goal of resuscitation is to maximize

survival and minimize morbidity.

• Resuscitation endpoints can be divided into two groups, macro

circulation and microcirculation.

rudy manalu
 Summary
• Septic Shock:

- treatment and resuscitation begin immediately (recommendation)

- at least 30 mL/kg IV crystalloid fluid should be given within the
first 3 hours of resuscitation (suggestion)
- using dynamic measures to guide fluid resuscitation (suggestion)
- measuring blood lactate for adults suspected of having sepsis
(suggestion)
- guiding resuscitation to decrease serum lactate (suggestion)
- using capillary refill time to guide resuscitation as an adjunct to
other measures of perfusion (suggestion)
- target mean arterial pressure of 65 mmHg (recommendation)
rudy manalu
rudy manalu