Shock States Beyra Rossouw Intensive Care Unit Red Cross War Memorial Children’s Hospital

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Shock States Beyra Rossouw Intensive Care Unit Red Cross War Memorial Childrens Hospital University of Cape Town. Shock. Pathophysiology Different shock states Treatment principles. Shock is:. Reduced Tissue Perfusion Cellular Hypoxia & Energy Failure. O2 Demand. - PowerPoint PPT Presentation

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  • Shock States

    Beyra RossouwIntensive Care UnitRed Cross War Memorial Childrens Hospital University of Cape Town

  • ShockPathophysiologyDifferent shock statesTreatment principles

  • Shock is:

    Reduced Tissue Perfusion

    Cellular Hypoxia & Energy FailureO2 DeliveryO2 Demand

  • VentilationGas exchangeO2 DeliveryO2 extractionO2 consumptionATPAlveoliCell

  • Oxygen Delivery Components

    Cardiac Output

    O2 ContentO2 Contentx

  • Cardiac Output

    Heart RateStroke VolumeO2 ContentPaO2SaO2HbSynchronyPreloadAfterloadContractility

  • Oxygen Content of Blood =(O2 carried by Hb) + (O2 in solution) = (1.34 x Hb x Sats x 0.01) + (0.023 x PaO2)O2O2

  • Shock StatesCapillary leak & Vasculopathy DistributiveClotCardiogenicObstructiveDissociativeHypovolemicAdapted from JL Vincent, ESICM 25 Years of Progress & Innovation

  • Distributive ShockSeptic ShockAnaphylaticNeurogenicHypovolemic ShockHemorrhageBurnsGIT lossCardiogenic MyocarditisArrythmiaSepticCongenital lesionsValvular lesions

  • GlucosePyruvic Acid Lactic Acid Acetyl Co-A KrebsCycleCO2H+38x ATP2x ATPAnaerobicAerobicFatty Acids Amino AcidsO2

  • Lactate, BP & Mortality in Sepsis

    Howell MD et al. ICM 2007; 33: 18921899

  • Stages of shock

    CompensatedDecompO2 deliveryATP Supply =ATP DemandATP Supply

  • O2 deliverySeptic shockHypovolaemic Cardiogenic Obstructive

    Timing of decompensationJL Vincent, De Backer . Oxygen Delivery Controversy ICM 2004;30:1990

  • Hemodynamic Response to ShockHeart rateBlood pressureCardiac outputCompensatedShockDecompensatedShockJ Carcillio. Fluid Resuscitation of Hypovolemic Shock. ICM 2006;32:958

  • Key Issues In ShockFalling BP = LATE sign.Pallor, tachycardia, slow CFT, restlessness = Shock until proven otherwise.BP is NOT same as perfusion.

    De Baker CCM 2006 34 :403-408Normal Septic shock with normal BP

  • Hemodynamic ProfilesM Pinsky. Functional hemodynamic Monitoring. Current Opinion Critical Care 2007;13:318

    Capillary flowArterial constrictionCardiac outputHypovolemic

    Cardiogenic

    Septic Cold

    Septic Warm

  • Key Issues Recognize & Treat during compensatory shock phaseMortality increase 2-fold for every hour in treatment delay. Han, Carcillo. Pediatrics 2003;112:793-799

  • Multisystem effect of shockResp: Resp failure, ARDSRenal: ATN, acute renal failureCNS: infarcts & bleedingLiver: centrilobular necrosisGIT: bleeds, necrosis, ileus, bacterial translocation Haemat: DIC, vasculopathy, capillary leak

    Robbins & Cotran Pathologic Basis of Disease: 2005

  • Novel strategies for the treatment of sepsis. Riedemann Nature Medicine 2003

  • Shock states coexist

    Changing hemodynamics

    Individualize treatment

  • Treatment principles1. Increase O2 delivery2. Reduce O2 demandFeverTachycardiaTachypneaAnxiety & restlessnessPainSeizures & shivering

    O2 deliveryO2 demand

  • Resuscitation PrioritiesIncrease O2 deliveryV: Ventilate & Oxygenate.I: Infuse: Fluids, fluids, fluidsElectrolytesBlood- Hb >10P: Pump Function: InotropesRhythm controlElectrolytes & glucoseE: Etiology: - Treat the cause.

  • FLUID, FLUID, FLUIDRegardless of etiology - fluid bolus x3 5ml/kg cardiac10ml/kg trauma 20ml/kg sepsisDelayed fluid resuscitation mortality. Rivers NEJM 2001, Han Pediatrics 2003Reassess liver & lungs.Septic shock may need up to 200ml/kg. No evidence one is fluid superior. Finfer NEJM 2004

  • Permissive Hypotension forUncontrolled HemorrhageRoberts et al Lancet 2001Re-bleedingHaemodilutionCoagulation disordersAggressive Volume LoadingAnaemiaHypothermiaSBPIncrease Mechanic effect on vascular clot

  • NORADRENALINEADRENALINEDOPAMINEADRENALINEDOBUTAMINE1Inotropes in fluid resistance NORADRENALINEDOPAMINEPediatric Cardiac Intensive Care . Chang & WernovskyStroke volume, HRVasoconstriction

  • B1B2 DA+++++++

  • More expensive than dopamineUse to contractility when BP stableDrug of choice for cardiacs & PHTAge specific sensitivityPeripheral IV

    B1B2+++++

  • Low dose (< 0.3mcg/kg/min) effect - ContractilityHigh dose effect - BPIdeally via central lineSide effectsRenal dysfunction, gut ischaemia Glucose Lactate & metabolic acidosisMyocardial necrosis

    B1 B2 ++++++++

  • Resuscitation endpointsNo difference between peripheral & central pulsesWarm skin, CFT < 2secNormal BP for ageDecreasing lactate & BEImproving mental stateUO >1ml/kg/hTrend of improvementPeters ICM 2008;34

  • Common errors:Failure to recognize severity. Early recognition & RxRegular reassess

    Ventilation delayed till arrest Prioritise A & B

    Crash intubationPlan & prepare intubationMyocardial depressant drugs for intubation.Slow administration.KetamineFentanylEtomidate

  • Common errors:No secure IV accessWasting time on IV accessIO needle after 90 sec.

    Inadequate fluidFluidx3Pushed inReassess liver & lungs Rx increase O2 demandCooling Sedation & pain controlSeizure controlDelayed antibiotics Antibiotics within 1 hour

  • Not improvingCoexisting cause of shockChanging hemodynamicsCardiogenic shock ? EchoNeonate & cardiacs ? Pulm HTNeonante ? prostinAdrenal insufficiency ? SteroidsTension pneumothoraxElectrolytes & glucose

    Reassess ABCs & secondary survey

  • Take home messageEarly recognition.Prioritise A, B, Cs.Dont Ever Forget Glucose & elects.Fluid, Fluid, Fluid. Reassess frequently & individualize.Early antibiotics.Look for coexisting etiologies.

  • Get The Basics Right All The Time?

  • Shock states

    SimilaritiesDifferencesReduced tissue perfusionEtiologyCellular energy failure &Multi-organ failureCoexisting etiologyHistopathology changesChanging hemodynamicsInflammatory response (SIRS)Etiologic specific Rx

    Impaired immune response Resuscitation to improve tissue perfusion

  • Drug of choice forWarm shockMyocardial contractility not severely impairedCentral line

    B1B2 +0 ++++

    *This figure illustrates typical changes in heart rate, blood pressure and cardiac output as a child moves from compensated to decompensated (ie, hypotensive) shock. Note the tachycardia without hypotension in compensated shock. Hypotension is not shock. Shock starts before before hypotension.Normal haemodynamics can still have reduced perfusion.*Aim to balance o2 demand & o2 delivery*Vipe regardless of etiology. *Hypovolemic shock most common shock syndrome in kids. Wont help to squeeze an empty tank. Fill up the tank then squeeze with inotropes.**Know what you are aiming for.No singal parameter universally defines shock & resus. Trending more NB.*

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