Ward Class:

Shock

18 มีนาคม 2554

History

หญิงไทยคู ่อาย ุ70 ปี อาชีพค้าขาย ภมูิล าเนากรุงเทพมหานคร

ไข้สูงมา 3 วัน

Underlying Disease

Hypertension

Type 2 DM

Chronic HCV infection with HCV cirrhosis

Last admission (27/1/2554 - 7/2/2554)

ได้รับการวินิจฉยัวา่เป็น

1. Streptococcus Group G septicemia

(Primary bacteremia) with septic shock

2. Hepatic encephalopathy

มีนดั follow up 11/2/2554 แต ่lost to follow up

History

Present Illness

3 วนัก่อน

มีไข้สงูหนาวสัน่ ปวดขาขวา ขาขวาบวมแดง ปฏิเสธประวตัิได้รับอบุตัิเหตุ หายใจหอบเหน่ือยเลก็น้อย ไม่ถ่ายเหลว ไม่มี URI symptom ไม่มีอาการปวดท้อง ไม่คลื่นไส้อาเจียน ปัสสาวะไม่แสบขดั ไม่ปวดหลงั เคยใช้ยา steroid มา 2 ปี หยดุยาได้ 1 เดือน

History

Current Medications

omeprazole(20) 1x2 PO ac

enalapril(5) ½ x2 PO pc

lactulose 30 ml PO hs

M.tussis 15 ml PO prn for cough

paracetamol(500) 2 tab PO prn for fever q 4 h

ER

เวลา 14.30 น.

Physical Examination at ER

Vital Sign:T 37.4 C, P 170/min, RR 28/min BP183/133mmHgoxygen saturation (room air) 87%

General appearance:

good consciousness, markedly pale, no jaundice,

pitting edema both legs

palmar erythema, spider nevi

CVS:

engorged neck vein

normal S1& S2, S3 gallop, no murmur

Physical Examination at ER

RS:

minimal crepitation at right lower lungs?

Abdomen:

soft, bowel sound positive, no tenderness

Extremities:

marked swelling right leg with erythematous patch

Problem list & Provisional DX

Problem list?

Provisional Dx?

Problem List

1. fever

2. marked swelling right leg with erythematous patch

3. minimal crepitation at right lower lungs?

4. pitting edema both legs,

engorged neck vein,

S3 gallop

5. U/D: Hypertension, Type 2 DM, HCV cirrhosis

6. History of steroid use

ER

Diagnosis

Sepsis

(congestive heart failure??)

Managements at ER

EKG 12 leads : AF with rapid ventricular response, Right bundle branch block

Problem List

1. fever

2. marked swelling right leg with erythematous patch

3. minimal crepitation at right lower lungs?

4. pitting edema both legs,

engorged neck vein,

S3 gallop

5. U/D: Hypertension, Type 2 DM, HCV cirrhosis

6. History of steroid use

ER

Diagnosis

Sepsis?

Sepsis

Sepsis = SIRS + evidence of infection

SIRS (2/4) (systemic inflammatory response syndrome)

1. Temperature >38ºC or <36ºC

2. HR>90/min

3. RR>20/min or PaCO2<32mmHg

4. WBC>12,000/µL or <4,000/µL or Band form>10%

What to do next?: Management

&Investigations?

Sepsis

1. CBC

2. Urinalysis

3. Urine culture

4. Hemoculture

5. CXR

Cirrhosis

1. Blood Chemistry

2. Coagulogram

EKG 12 leads

Managements at ER

Investigations CBC

Hb 10.9mg/dL, Hct 35.3%, MCV 93.4fL, RDW 18.2%, WBC 9150/µL (N 70.7%, L 22.1%, M 4.2%, Eo 2.7%, B

0.3%)

platelet 105000/µL

Blood Chemistry

BUN 8.0 mg/dL, Creatinine 0.7 mg/dL,

Na 138 mEq/L, K 4.3 mEq/L, Cl 106 mEq/L, HCO3 20mEq/L

Coagulogram

PT 21.1s, aPTT 30.3s

Managements at ER

Investigations

Urinalysis

pH 5.0, sp.gr 1.010

albumin –ve, sugar –ve, ketone –ve,

RBC 0-1, WBC 1-2

Urine culture

Hemoculture

EKG 12 leads

Managements at ER

EKG 12 leads : AF with rapid ventricular response, Right bundle branch block

What to do next?: Treatments?

Initial

ABC?Supportive

?Specific:sepsis

?

What to do next?: Treatments?

Pathogen?

ATB?

1. Gram +ve cocci

2. Gram –ve organism (Cirrhosis patient)

Aeromonas hydrophila (Cirrhosis patient ,bleb)

1. ceftriaxone + clindamycin

2. piperacillin + tazobactam

Managements at ER

Treatments

On Oxygen mask with bag 10 LPM

Piperacillin + tazobactam 4.5 mg IV stat

NSS 1000ml IV drip rate 150ml/hr

Retain Foley catheter

Hospital Course

15.05 น. เหน่ือยมากขึน้ (I/O = 70/0 ml)

Managements

On Endotracheal tube no. 7.5 after Etomidate&Succinyl

Choline

CXR

Airway Breathing Circulation

CXR S/P intubation

CXR: pulmonary congestion

ก่อน admit S/P intubation

Hospital Course

Assessment หลงั intubation

T 37.0 C, P 170/min, RR 21/min,

BP 134/95 mmHg

Oxygen saturation (ventilator) 98%

Managements

Off NSS

furosemide 40 mg IV stat >>> Urine output 400 ml

Admit อษัฎางค์ 10 เหนือ

Ward

เวลา 17.25 น.

Physical Examination at Ward

Vital signs

T 40.3 C, P 120/min, RR 14/min, BP 80/60mmHg

oxygen saturation(ventilator) 100%

General appearance

E3VtM6, drowsy

not pale, no jaundice

CVS: normal S1,S2, no murmur

RS: normal breath sound

Extremities: marked swelling at right leg with erythematous

patch

Diagnosis?

Shock?

Causes??

Approach to shock

ขัน้ตอนท่ี 1: ผูป่้วยชอ็คหรอืไม่Shock คอื ภาวะทีม่กีารไหลเวยีนของโลหติไปเลีย้งสว่นต่างๆของ

รา่งกายไมเ่พยีงพอ(Poor tissue perfusion)

1.SBP < 90 mmHg or MAP < 60 mmHg รว่มกบั

2.sign of poor tissue perfusion และ organ dysfunction เช่น ซึม สบัสน มือเท้าเยน็ ชีพจรเรว็ ปัสสาวะลดลง

Approach to shock

ขัน้ตอนท่ี 2: ผูป่้วยชอ็คชนิดใด

1. Distributive shock

2. Hypovolemic shock

3. Cardiogenic shock

4. Obstructive shock

Approach to shock

Pros Cons

Septic shock • Fever

• Source of infection

• Narrow pulse pressure

Hypovolumic shock • Narrow pulse pressure

• Volume depletion (urine output 400 ml)

• fever

Cardiogenic shock • Narrow pulse pressure

• AF with RVR

• Mostly caused by

anterolateral MI• Sign of heart failure

Approach to shock

SBP(mmHg)

PP(mmHg)

Capillary refill

Lung S3 gallop

JVP(cm)

patient 80 20 N/A clear - N/A

Cardiogenicshock

ลดลง แคบ ชา้ลง crackle + เพิม่ขึน้

Hypovolemicshock

ลดลง แคบ ชา้ลง Clear - ลดลง

Distributive shock

ลดลง กวา้ง/ปกติ

ปกติ Clear - ลดลง

Obstructive shock

ลดลง แคบ ชา้ลง Clear - เพิม่ขึน้

Approach to shock

Causes

1. Septic shock

- source of infection

2. Hypovolumic shock

- intubation&PEEPs>>>preload↓

- furosemide

(etomidate&succinylcholine?)

Managements

Shock

initial supportive specific

Managements

1. Initial management: ABC?

• intubation

• NPO เว้นยาA• Oxygen therapy

• on PCV mode ventilatorB• Fluid Resuscitation

• Monitor: record BP q 15 min, record urine output q 1 hr

C

Management: Fluid therapy?

Managements

2. Supportive management:

Septic shock guideline

Septic shock .............

Source identificationAdequate antibiotic

Surgical drainage if indicated

Intubation Mechanical ventilator respiratory failure Hemodynamic Support

volume 500-1,000 ml ½ hr .............

intravascular volume

- JVPÝ 3-5 cmH2O above sternal angle

1.Adequate Volume invasive monitoring CVPÖ, PCWPè

Acceptable BP - mean arterial pressure >65 mmHg

2.Accept BP

1. Vasopressor - Dopamine 5-20 ug/kg/min or - Norepinephrine 0.2-2 µg/kg/min2. MAP < 65 mmHg vasopressor - Hydrocortisone 50 mg IV q 6 hr - 7 3. intravascular volume status 4. Adrenaline drip titrate dose

Organ perfusion - urine >0.5ml/kg/hr - SCV

O2 mixed venous O2 sat > 70 %

SCVO2 Dopamine Norepinephrine > 10 µg/kg/min > 10 µg/min

3.Adequate perfusion- Hct < 30% Hct ≥ 30%- Hct > 30% Dobutamine 5-20 µg/kg/min

Goal achieved Frequent assessment

Yes

Yes .............

Yes .................

Uncertain

No

No

CVP >10-15 cmH2 OPCWP >15-18 mmHgNo

Yes ...........

No

Ý JVP = Jugular venous pressure, Ö,

CVP = Central venous pressure è

PCWP = Pulmonary capillary wedge pressure,

SCvO2 = Central venous oxygen saturation

Septic shock 2008

Septic shock .............

Source identificationAdequate antibiotic

Surgical drainage if indicated

Intubation Mechanical ventilator respiratory failure Hemodynamic Support

volume 500-1,000 ml ½ hr .............

intravascular volume

- JVPÝ 3-5 cmH2O above sternal angle

1.Adequate Volume invasive monitoring CVPÖ, PCWPè

Acceptable BP - mean arterial pressure >65 mmHg

2.Accept BP

1. Vasopressor - Dopamine 5-20 ug/kg/min or - Norepinephrine 0.2-2 µg/kg/min2. MAP < 65 mmHg vasopressor - Hydrocortisone 50 mg IV q 6 hr - 7 3. intravascular volume status 4. Adrenaline drip titrate dose

Organ perfusion - urine >0.5ml/kg/hr - SCV

O2 mixed venous O2 sat > 70 %

SCVO2 Dopamine Norepinephrine > 10 µg/kg/min > 10 µg/min

3.Adequate perfusion- Hct < 30% Hct ≥ 30%- Hct > 30% Dobutamine 5-20 µg/kg/min

Goal achieved Frequent assessment

Yes

Yes .............

Yes .................

Uncertain

No

No

CVP >10-15 cmH2 OPCWP >15-18 mmHgNo

Yes ...........

No

Ý JVP = Jugular venous pressure, Ö,

CVP = Central venous pressure è

PCWP = Pulmonary capillary wedge pressure,

SCvO2 = Central venous oxygen saturation

Septic shock 2008

Managements

3. Specific: infection

meropenem 1g IV q 8 hr + clindamycin 600mg IV q 8 hr

paracetamol 500mg 1 tab po q 4-6 hr

POCT glucose q 4 hr

Adequate intravascular volume(Preload)

Adequate tissue O2

Adequate tissue perfusion

Adequate cardiac output(Cardiac output)

Acceptable perfusion pressure(Afterload, MAP>65 mmHg)

G

O

A

L

Proper Management?

Proper Management?

Early Goal-Directed Therapy(EGDT)

MAP > 65 mmHg

PCWP 14-18 cmH2O

CVP 8-12 mmHg(10-15 mmH2O) in septic shock

Oxygen delivery: Hb>10 g/dl, ScVO2>70%,O2

saturation>92%,C.I.> 2.2 L/min/mm3

Urine >0.5 ml/kg/h, consciousness

Normalization of blood lactate

Adequate intravascular volume?

volume 500-1000ml in ½ h >>>> (500ml in ½ h)

adequate volume >>>> uncertain

ดงันัน้จงึใส ่central line เพ่ือประเมิน CVP

Fluid&Vasopressor >>> BP ไม่ดีขึน้ Adrenal insufficiency

Problem 1: Fluid&Vasopressor

serum cortisol

access central line

5%albumin 250 ml IV drip in 30 min

hydrocortisone 100 mg IV push then

hydrocortisone 200 mg + 5%DW

250 IV drip 24 hr

cortisol level 8

Goal: CVP > 10-15 cmH2O False High CVP???

Problem 2: CVP

False high CVP

Pulmonary vascular disease

Pericardial disease

Valvular disease

Right side heart disease

Pleural disease

Intraabdominal condition: ascites

Mechanical ventilator + PEEPs

Drug: vasoactive drug

Acidosis with Kussmual’s breathing

Problem 3: Colloid or

Crystalloid?

Fluid Therapy

การเลือกชนิดของสารน า้ไมมี่หลกัเกณฑ์ท่ีแน่นอน ให้พิจารณาตามความเหมาะสม

1. ควรเลือก crystalloids ก่อน colloids

2. ประเมินลกัษณะทางคลนิิกท่ีส าคญั คือ visceral edema

(pulmonary edema, intestinal edema) อาจพิจารณาให้ colloids แทน

Crystalloids Colloids

Septic shock .............

Source identificationAdequate antibiotic

Surgical drainage if indicated

Intubation Mechanical ventilator respiratory failure Hemodynamic Support

volume 500-1,000 ml ½ hr .............

intravascular volume

- JVPÝ 3-5 cmH2O above sternal angle

1.Adequate Volume invasive monitoring CVPÖ, PCWPè

Acceptable BP - mean arterial pressure >65 mmHg

2.Accept BP

1. Vasopressor - Dopamine 5-20 ug/kg/min or - Norepinephrine 0.2-2 µg/kg/min2. MAP < 65 mmHg vasopressor - Hydrocortisone 50 mg IV q 6 hr - 7 3. intravascular volume status 4. Adrenaline drip titrate dose

Organ perfusion - urine >0.5ml/kg/hr - SCV

O2 mixed venous O2 sat > 70 %

SCVO2 Dopamine Norepinephrine > 10 µg/kg/min > 10 µg/min

3.Adequate perfusion- Hct < 30% Hct ≥ 30%- Hct > 30% Dobutamine 5-20 µg/kg/min

Goal achieved Frequent assessment

Yes

Yes .............

Yes .................

Uncertain

No

No

CVP >10-15 cmH2 OPCWP >15-18 mmHgNo

Yes ...........

No

Ý JVP = Jugular venous pressure, Ö,

CVP = Central venous pressure è

PCWP = Pulmonary capillary wedge pressure,

SCvO2 = Central venous oxygen saturation

Septic shock 2008

Problem 3: Vasoactive Drug

Vasoactive Drugs

Warm shock **

- Hyperdynamic septic shock

(low BP, low SVR, high CO)

- use NOREPINEPHRINE

Cold shock

- Hypodynamic septic shock

(low BP, high SVR, low CO)

- use DOPAMINE or NE + DOBUTAMINE

dopamine: 5-15 µg/kg/min

norepinephrine: 0.1-1 µg/kg/min

21.05 น.(6 hr): ย้ายไป ICU Water intake: 3150 mlUrine output: 300 ml

ICU

เวลา 22.15 น.

ICU

Problem list

1. Septic Shock

2. Adrenal insufficiency

3. AF & Rapid ventricular response

4. U/D: Type 2 DM,Hypertension, Chronic HCV with

cirhosis

Managements at ICU

1.shock Fluid resuscitation

ขณะนีไ้ด้ IV fluid เป็น

- Gelofusine IV rate 300 ml/h

- Norepinephrine 8 mg in D5W 250 ml IV drip 20 µd/min

- Dopamine 200 mg in D5W 100 ml IV drip 20 µd/min

- 10% D/NSS 1000 ml IV rate 120 ml/h

BP 87/60 mmHg, CVP 23 cmH2O

Fluid Challenge test

False high CVP >>> ไมส่ามารถประเมิน volume status ได้

Initial rate

CVP (cmH2O)

PCWP

(mmHg)IV fluid

infusion rate (in 10-15 min)

<8 <10 200 ml

8-12 10-14 100 ml

>12 >14 50 ml

Rate Adjustment: CVP 23 >> 29 (ตา่งกนั 6 cmH2O)

Fluid challenge

Initial CVP, PCWPInitial IV infusion

Rate Adjustment

CVP >5 cmH2O

PCWP >7 mmHg

Wait for

10 min

CVP > initial > 5 cmH2O

PCWP > initial > 7 mmHg

Stop IV infusion

Vasopressor + inotrope

CVP > initial < 5 cmH2O

PCWP > initial < 7 mmHg

Respond

to fluid ?

Infusion rateStop IV infusion

Vasopressor + inotrope

No Yes

เจาะ ScVO2 เจาะเม่ือไหร่

Problem 4: Adequate Tissue

Perfusion?

Adequate intravascular volume(Preload)

Adequate tissue O2

Adequate tissue perfusion

Adequate cardiac output(Cardiac output)

Acceptable perfusion pressure(Afterload, MAP>65 mmHg)

G

O

A

L

Proper Management?

Guideline : Haemodynamic

management

Resuscitation goals• BP (MAP > 65 mmHg)

• CVP (8-12 mmH20)• Urine > 0.5 ml/kg/hr

• Central venous O2 sat. > 70%, or Mixed venous > 65%

IV FluidStart Crystalloids 1000 ml or Colloids 300-500 ml in 30 min.

Acceptable BPVolume assessment (CVP)

NE / Dopamine(Epinephine if no response)

Organ perfusionUrine > 0.5 ml/kg/hr

pH 7.35 – 7.45

Lactate, SvO2

Hydrocortisone < 300 mg/day if no response to fluid and vasopressor Fluid challenge

Hct < 30% : PRCAcidosis, low SvO2 : Dobutamine

Goal achievedFrequent assessment

YESNO

Adequate

Inadequate

Reassess

Adequate

Reassess

Inadequate

Tissue Perfusion

การประเมนิ macrocirculation

จะประเมินเม่ือ resuscitation จนได้ความดนัโลหิตตามเป้าหมายแล้ว

1. Urine output> 0.5 cc/kg/h

2. Consciousness

3. Bowel ileus

4. Capillary refill

การประเมนิ microcirculation

1. Regional

Gastric tonometry

Sublingual capnography

2. Global

ScVO2 > 70%

Serum Lactate < 2, Lactate reduction>10%

ในทางคลนิิก จะใช้ global assessment

ScVo2 51%

Lactate 5.5 mmol/L

Hct 28%

Septic shock .............

Source identificationAdequate antibiotic

Surgical drainage if indicated

Intubation Mechanical ventilator respiratory failure Hemodynamic Support

volume 500-1,000 ml ½ hr .............

intravascular volume

- JVPÝ 3-5 cmH2O above sternal angle

1.Adequate Volume invasive monitoring CVPÖ, PCWPè

Acceptable BP - mean arterial pressure >65 mmHg

2.Accept BP

1. Vasopressor - Dopamine 5-20 ug/kg/min or - Norepinephrine 0.2-2 µg/kg/min2. MAP < 65 mmHg vasopressor - Hydrocortisone 50 mg IV q 6 hr - 7 3. intravascular volume status 4. Adrenaline drip titrate dose

Organ perfusion - urine >0.5ml/kg/hr - SCV

O2 mixed venous O2 sat > 70 %

SCVO2 Dopamine Norepinephrine > 10 µg/kg/min > 10 µg/min

3.Adequate perfusion- Hct < 30% Hct ≥ 30%- Hct > 30% Dobutamine 5-20 µg/kg/min

Goal achieved Frequent assessment

Yes

Yes .............

Yes .................

Uncertain

No

No

CVP >10-15 cmH2 OPCWP >15-18 mmHgNo

Yes ...........

No

Ý JVP = Jugular venous pressure, Ö,

CVP = Central venous pressure è

PCWP = Pulmonary capillary wedge pressure,

SCvO2 = Central venous oxygen saturation

Septic shock 2008

Managements at ICU

Poor Tissue Perfusion (ScVO2 < 70%)

Hct < 30% (Hct 28%)

จงึให้ Pack Red Cell จน Hct > 30%

Managements at ICU

3.Specific Management

Infection Consult ศลัยศาสตร์ เพ่ือวินิจฉยัแยกโรค necrotizing fasciitis

>>> ยงัคิดถึงน้อย และจะประเมินเป็นระยะ

Antibiotics

meropenem 1g IV q 8 hr + clindamycin 600mg IV q 8 hr

และรอผล Hemoculture

Managements at ICU

Adrenal insufficiency

Hydrocortisone 300 mg/day IV

AF & Rapid ventricular response Off dopamine พบ HR ลดลงจาก 160-180 เป็น 140-150/min

Steroids in sepsis

IV hydrocortisone for adult septic shockwhen hypotension responds poorly to adequate fluid

resuscitation and vasopressors

ACTH stimulation test is not recommended

Steroid therapy may be weaned once vasopressors are nolonger required

Steroids in sepsis

Hydrocortisone dose should be ≤ 300 mg/day

Sepsis without shock: do not use corticosteroids

unless the patient’s endocrine or corticosteroid history

warrants it

Surviving Sepsis Campaign 2008