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
I II III IV

Blood loss (%) <15 15 – 30 30 – 40 >40

EBV
SBP (mmHg) >110 >100 <90 <90

Pulse (x/mt) <100 >100 >120 >140

RR (x/mt) 16 16 – 20 21 – 26 >26

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/mm3, 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 Cardiac SVR
Pressure Output
Cardiogenic ↑ ↓ ↑
shock
Hypovolemic ↓ ↓ ↑
shock
Distributive shock ↓ or N ↑, N or ↓ ↓

Obstructive shock
C. tamponade ↑ ↓ ↑
P. embolus ↓ or N ↓ ↑
 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 µg/kgBB/mt has modest inotropic and
chronotropic effects (acts on the dopaminergic
receptor in the kidney)
4-10 µg/kgBB/mt has primarily inotropic effects
≥ 10 µg/kgBB/mt has significant α agonist effect →
related vasoconstriction
≥ 25 µg/kgBB/mt no advantage over NE

Dobutamine
Is a ß adrenergic agonist
Doses of 5-20 µ/kg/BB/mt is a potent inotropes →
increase CO
Norepinephrine (NE)
Is a potent α adrenergic vasopressor agent.
Also has ß adrenergic, inotropic, and
chronotropic effects.
Dose ranges start at 0,05 µg/kgBB/mt → titrated
to desired effects

Epinephrine (E)
Has both α and ß adrenergic effects
Potent inotrope and chronotrope
Increase in myocrdial oxygen consumption
Dose ranges start at 0,1 µg/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 Beck’s 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).