Shock StatesBeyra Rossouw

Intensive Care UnitRed Cross War Memorial Children’s Hospital

University of Cape Town

ShockPathophysiologyDifferent shock statesTreatment principles

Shock is:

Reduced Tissue Perfusion

Cellular Hypoxia & Energy Failure

O2 Delivery

↑O2 Demand

Ventilation

Gas exchange

O2 Delivery

O2 extraction

O2 consumption

ATP

Alveoli

Cell

Oxygen Delivery Components

Cardiac OutputO2 Content

O2 Content x

Cardiac Output

Heart Rate Stroke Volume

O2 Content

PaO2 SaO2 Hb

Synchrony

Preload Afterload Contractility

Oxygen Content of Blood

ArterialInflow (Q)

capillary

O2

O2

O2

O2

O2 O2

O2

VenousOutflow (Q)

Cell

(Adapted from the ICU Book by P. Marino)

=(O2 carried by Hb) + (O2 in solution)

= (1.34 x Hb x Sats x 0.01) + (0.023 x PaO2) O2

O2

Shock States

Capillary leak & Vasculopathy

Distributive

Clot

Cardiogenic Obstructive

Dissociative

Hypovolemic

Adapted from JL Vincent, ESICM 25 Years of Progress & Innovation

Reduced Tissue Perfusion & Energy Failure

Distributive Shock

Septic ShockAnaphylaticNeurogenic

Hypovolemic Shock

HemorrhageBurnsGIT loss

Cardiogenic

Myocarditis

Arrythmia

Septic

Congenital lesions

Valvular lesions

Glucose

Pyruvic Acid

Lactic Acid

Acetyl Co-A

Krebs

CycleCO2

H+

38x ATP

2x ATP

Anaerobic

Aerobic

Fatty Acids Amino Acids O2

Lactate, BP & Mortality in Sepsis

Howell MD et al. ICM 2007; 33: 1892–1899

Stages of shock

CompensatedDecomp

O2 delivery

ATP Supply =ATP Demand

ATP Supply <<ATP Demand

Anaerobic metabolism

Cell death

Membrane leak

Redistribution of blood flow

Vasoconstriction tachycardia

Irreversible

O2 delivery

Septic shockHypovolaemic Cardiogenic Obstructive

Timing of decompensation

JL Vincent, De Backer . Oxygen Delivery Controversy ICM 2004;30:1990

Hemodynamic Response to Shock

Heart rate

Blood pressure

Cardiac output

CompensatedShock

DecompensatedShock

J 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 :403-408

Normal Septic shock with normal BP

Hemodynamic Profiles

Capillary flow

Arterial constriction

Cardiac output

Hypovolemic

Cardiogenic

Septic Cold

Septic Warm

M Pinsky. Functional hemodynamic Monitoring. Current Opinion Critical Care 2007;13:318

Key Issues

Recognize & Treat during compensatory shock phase

Mortality 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 delivery

2. Reduce O2 demand

• Fever

• Tachycardia

• Tachypnea

• Anxiety & restlessness

• Pain

• Seizures & shiveringO2 delivery O2 demand

Resuscitation PrioritiesIncrease O2 delivery

V: Ventilate & Oxygenate.I: Infuse:

Fluids, fluids, fluids Electrolytes Blood- Hb >10

P: ↑Pump Function: Inotropes Rhythm control Electrolytes & glucose

E: Etiology: - Treat the cause.

FLUID, FLUID, FLUIDRegardless of etiology - fluid bolus x3

5ml/kg cardiac10ml/kg trauma 20ml/kg sepsis

Delayed fluid resuscitation ↑ mortality. Rivers NEJM 2001, Han Pediatrics 2003

Reassess liver & lungs.Septic shock may need up to 200ml/kg. No evidence one is fluid superior.

Finfer NEJM 2004

Permissive Hypotension forUncontrolled Hemorrhage

Roberts et al Lancet 2001

Re-bleedin

g

Haemodilution

Coagulation disorders

Aggressive Volume Loading

AnaemiaHypothermi

a

SBPIncrease

Mechanic effect on vascular clot

NORADRENALINE

ADRENALINE

DOPAMINE

ADRENALINE

DOBUTAMINE

1

Inotropes in fluid resistance

NORADRENALINE

DOPAMINE

Pediatric Cardiac Intensive Care . Chang & Wernovsky

↑Stroke volume, ↑ HRVasoconstriction

B1 B2 DA

++ + ++ ++

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

B1 B2

+++ + +

Low dose (< 0.3mcg/kg/min) effect - Contractility

High dose effect - BPIdeally via central lineSide effects

Renal dysfunction, gut ischaemia Glucose Lactate & metabolic acidosis Myocardial necrosisB1 B2

+++ ++ +++

Resuscitation endpointsNo difference between peripheral & central

pulsesWarm skin, CFT < 2secNormal BP for ageDecreasing lactate & BEImproving mental stateUO >1ml/kg/h

Trend of improvementPeters ICM 2008;34

Common errors:Failure to recognize severity. Early recognition & Rx

Regular reassess

Ventilation delayed till arrest Prioritise A & B

Crash intubation Plan & prepare intubation

Myocardial depressant drugs for intubation.

Slow administration.•Ketamine•Fentanyl•Etomidate

Common errors:

•No secure IV access•Wasting time on IV access

IO needle after 90 sec.

Inadequate fluid •Fluidx3•Pushed in•Reassess liver & lungs

Rx increase O2 demand •Cooling •Sedation & pain control•Seizure control

Delayed antibiotics Antibiotics within 1 hour

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

Reassess ABC’s & secondary survey

Take home message1. Early recognition.2. Prioritise A, B, C’s.3. Don’t Ever Forget Glucose & elects.4. Fluid, Fluid, Fluid. 5. Reassess frequently & individualize.6. Early antibiotics.7. Look for coexisting etiologies.

Get The Basics Right All The Time

?

Shock statesSimilarities Differences

Reduced tissue perfusion Etiology

Cellular energy failure &Multi-organ failure

Coexisting etiology

Histopathology changes

Changing hemodynamics

Inflammatory response (SIRS)

Etiologic specific Rx

Impaired immune response

Resuscitation to improve tissue perfusion

Drug of choice forWarm shockMyocardial contractility not severely impaired

Central line

B1 B2

+ 0 ++++