Basics of shock + Most common cause of death in a surgical patien shock oe i. Cardiac output — Amount of blood pumped out From heart. ii. Peripheral arterial resistance — oxygen consumed in periphery and blood will flow through veins & veins also exhibit v Blood returning to heart v Sample of returning blood taken v Mixed venous oxygen saturation (MVOs) measured v Normal value - 50-70% - MVOS - % of oxygen in returning blood. —Hemorrhagic shock vs Septic shock 00:04:16 Hemorvha, ic shock Septic shock * Decreases blood volume * CO > Decreases ¢ Peripheral arterial resistance v Vasoconstriction Vv Cold peripheries * Oxygen consumption is high © Venous resistance is low « MVOS - 7O% @NEET PG 2034 Types of shock * Hypovolemic shock (Hemorrhagic shock) * Cardiogenic shock * Neurogenic * Anaphylactic shock (Distributive shock) * Septic stock (Distributive shock)Features | Hemorrhagic Cardiogenic iim PR if vA SBP + t co 1 1 eet 1 Cold peripheries | Features Neurogenic Anaphylactic Septic PR 4 tt f SBP 4 4 4) co 1 4 t PVR \ 4 1 Peripheral vasodilatation > warm peripheries Compensated shock > in which the body adapts * Kidney Lung fadequate blood supply Brain * Blood flow to skin, muscles and GIT are compromised * Tachycardia * Cold peripheriesDécompensated shock * Human can tolerate up to 15% blood loss © Blood loss is more > decrease BP Increase PR Results in organ failure (MODS) - ARDS ~ Acute renal failure ~ Liver failure ~ Coagulopathy Resuscitation parameters Oo: " s Parameters monitored : - Urine output - cvP - Sr. Lactate * Urine output 19:20 ~ Best clinical monitor to know adequate resuscitation ~ Best clinical indicator of tissue perfusion ~ Best clinical parameter * CVP ~ Best to calculate drug dosage and fluid input ~ Not accurate for cardiogenic and septic shock * Sr. lactate ~ Best lab value to know tissue perfusion v <2 mmol/L — good resuscitation ?Smwmol/L- bad resuscitationEnd point of resuscitation can be found out by 2.Systemic perfusion > by measuring ~ s. lactate Base deficit Mvos 2.GIT perfusion > by Measuring gastric mucosal pH (assess mucosal flow) Gut tonometry Sublingual capnometry Laser flow doplometry 3.Brain perfusion > near infrared spectroscopy 4.Muscle perfusion > near infrared spectroscopy Indexes to monitor * Shock index: - HR > 0.9 — Decompensated shock SBP Example: 40 =1 9O * Modified shock index (MSI) = HR/ MAP 1 (best) Most sensitive index MAP = SP 2 (DP) 3 Low MSI ~ Hyperdynamic state High MSI — hypodynamic state > bad * ROPE = PR » 3 > Decompensated shock 4 PP P. Rate over pulse pressure evaluationHemorrhagic shock 00:31:33 S Can be divided ‘into 4 classes based on percentage of blood loss * Class ~| — 0-15%, <750m| > compensated shock ~ Il — 15-30%, 750-1500 ml = Ill = 30-40%, 1500-2000 wl = Il — >40%, >2000 ml * Class | > example blood donation Class t Class tt Class WM Class IV % Blood loss |O-15% 15-30% 30-40% 240% CNS Slight Anxiety Mild Confused anxiety | increase | confusion _| lethargic comatosed PR¢é100/mi |100/min | 100-120 | 120-140 / | >140/min nute ute / ainute — | rainute ute SBP N N + Ww PP(SBP- |N + 4 1 DBP) RR N t t t V.o »Z0ral/ho | 20-30 <20ral/hour | Anuria ur mi/hour Base deficit |Oto-2 |-2to-6 |-6to-10 |>-10Green - 2G > GOml/min * Color of cannulas = 16 G - grey - rapid infusion - 200ml/minutes - 18 G - green - adults — 7Oml/minutes - 26 G - pink — adults - 26 G - blue - pediatric - 26 G — yellow — neonatal * 24G — orange canula -270 ml/minute © Maximum fluid can be infused — grey (20OmI/minute) Septic shock 00:57:58 + Sepsis > SIRS + Known source of infection © Septic shock > sepsis + hypotension SIRS * Defined by 2 or more of the following Love — leucocyte count: - WBC < 4000 (or) » 12000 T - temperature: P - <35%c (or) »32°¢ H - HR: - >90/minutes R = RR: ~ >20/minutes PaCo2 < 32 mm Hg * >.2 organ failed - MODS SOFA ~ sequential organ failure assessment QSOFA — quick sequential organ failure assessment © qSOFA -R-RR > 22/ minutes -2-C -confused state -1 - B -SBP <200mMMHG ~ 1 - Score 22: - increase mortality by 10% Surviving sepsis guidelines O1:04:50 “= IV Aids rs ~ Vasopressors > nor adrenaline ct 3 hours of admission @ hours of admission v v 2.Sr. lactate 2.MAP > 6SmmHg 2.Blood c/s before (Fluid > vasopressors) antibiotics 2.CVP: - 8-12 mmHg 3.Broad spectrum 3.MVOS: - 65% antibiotics 4.SVC 02: - 70% 4.20mI/kg of Saturation crystalloid for bf hypotension Remeasure * lactate $: lactate stminol/t Good resuscitation: - < 2mwmol/L Bad resuscitation: - >smmol/L" Metabolic response to trauma and surgery 01:10:40 Ebb and flow model Myjvsy 7 ham, Says | weeks + + + Ebb Flow Recoveny phase phase Ebb phase: - < 24 hours Maintenance of blood volume Catecholamines Vv Preserve energy store « Physiological - Decrease BMR - Decrease temperature ~ Decrease 02 consumption ~ Increase Co2 - Increase HR - Increase Gluconeogenesis ~ Increase WBC ~ Vasoconstriction * Hormones ~ Catecholamines ~ Cortisol ~ Aldosterone.Flow phase > 3-10 days v Catabolic phase * Physiological ~ increase BMR ~ increase temperature ~ inerease 02 consumption ~ Increase urinary N2 excretion Negative nitrogen balance - Increase acute phase proteins v = Increase GRP - Increase Fibrinogen © Hormones ~ lnsulin - Glucagon - Cortisol - Catecholamines -Ik-2 ‘ithe -IL-6 ‘ - TNF X« - Insulin resistance + > uncontrolled hyperglycemia Anabolic phase > 10-60 days positive nitrogen balance Hormones — v Growth hormone IGFDonors YAmount of blood donated in one sitting - 450ml * A person can donate blood for 3 times in a year. * Blood is stored in a bag with preservative CPD : 2-3 Weeks SAG- Mannitol 5 Weeks * Blood given by donor is screened for infection v -HIVI& tt - HBV - HCV - Syphilis © In India, we screen for malaria. * In western countries, we screen for Creutzfeldt Jacob disease. Storage 00:03:16 * Blood is stored in fridge at 2-6°C. =Components 00:04:30 * Whole blood is deficient of platelets * In 24¢hrs, WBC and platelets become nonfunctional * Components 2.Packed RBC > Hematocrit: 50-70% > 330 wil > Used in patients in CCF > Increases Hb/dl > Increases 3% of hematocrit > Lack coagulation factors 2.FFP (Fresh Frozen Plasma) > Rich in coagulation factors 2,7,9,10 > Factor & decreases > used to reverse coagulopathy - Warfarin toxicity - Obstructive jaundice (Increases PT) > Stored at -40°C for 2 years > 250 wl > ABO matching done > Rh compatible is not needed > When Rh positive is given to Rh negative > RA{D) immunoglobulin should be given 3.Cryoprecipitate: Increases factor & and Fibrinogen > Mainly used for hemophilia patients