Shock

1. Shock
Dr.Indubala Maurya MD,DNB
Assistant Professor
Dept of Aanesthesia & Critical Care
MGMCRI

2. Introduction
 Shock can be defined as a state of inadequate
or inappropriate tissue perfusion resulting in
abnormal cellular metabolism.
 Shock is associated with anaerobic metabolism,
oxygen debt and tissue acidosis.

3.  Combination of hemodynamic parameters:
 MAP< 60
 SBP<90
 Clinical feature
 Abnormal lab value ( lactate > 4 mmol/L)

4. Types of shock
 Hypovolemic shock
 Distributive Shock
 Cardiogenic Shock

5. Hypovolemic shock
 Hypovolemic shock is related to decreased intravascular
volume, secondary to loss of:
 Blood (e.g. trauma)---- > Hemorrhagic shock
 Plasma (e.g. burns)
 Water and electrolytes (e.g. vomiting, diarrhoea).

6. Hypovolemic shock
 Clinical feature :

7. Hypovolemic shock
Management :
 Establish vascular access ; large bore cannula , Send
sample for Hb
 Start fluid resuscitation depending on clinical
presentation -----with crystalloid/Blood product
 Hb > 9gm% ----> continue Fluid therapy
 Hb < 9gm% --- > PRBC, correct coagulation abnormality
 Search for source of bleeding : compression of visible
vascular injury, exposure and control of internal bleeding,
embolisation ,banding

8. Measure CVP and MAP
 CVP < 8 --------> continue Fluid therapy
 CVP > 8 and MAP < 60 -----> Administer Vasopressor ( NE,DA)
 CVP > 8 and MAP > 60 ------> Resuscitation complete
 Others
 Airway control
 Plt/FFP
 Activated factor VII
 Calcium/magnesium supplement
 Rewarming
 Antibiotics
 look for other cause of shock

9. Distributive shock
e.g.
 Septic shock
 Anaphylactic shock

10. Septic shock
Surviving sepsis campaign 2012
Sepsis is defined as the presence of infection together with systemic
manifestations of infection.
Severe sepsis is defined as sepsis plus sepsis-induced organ
dysfunction or tissue hypo perfusion.
Sepsis-induced hypotension is defined as a systolic blood pressure
(SBP) < 90 mm Hg or mean arterial pressure (MAP) < 70 mm Hg or a SBP
decrease > 40 mm Hg or less than two standard deviations below normal
for age in the absence of other causes of hypotension

11. Septic shock
 Clinical feature
SBP< 90
MAP < 70
Feature of severe sepsis :
 Fever Hypothermia ,tachy,Tachypnea,Altered mental
status, Leukocytosis ,Leukopenia.
 With one or more organ involvement ( lung ,liver ,kidney )

12. Septic shock
Management
Goals during the first 6 hrs of resuscitation:
a) Central venous pressure 8–12 mm Hg
b) Mean arterial pressure (MAP) ≥ 65 mm Hg
c) Urine output ≥ 0.5 mL/kg/hr
d) Central venous (superior vena cava) or mixed venous
oxygen saturation 70% or 65%, respectively

13.  CVP < 8  continue fluid resuscitation
 CVP > 8
MAP < 65  add vasopressure
MAP > 65
 ScvO2 < 70 %
 Add dobutamine
 Transfuse if Hb < 7
 ScvO2 > 70 %  achieved all goals

14. •Fluid Therapy of Severe Sepsis:
• Crystalloids as the initial fluid of choice in the resuscitation
•Vasopressors
• Norepinephrine as the first choice vasopressor
•Inotropic Therapy
• Dobutamine infusion
• myocardial dysfunction as suggested by elevated cardiac
filling pressures and low cardiac output.
• ongoing signs of hypoperfusion, despite achieving adequate
intravascular volume and adequate MAP
•Blood Product Administration
• Red blood cell transfusion if Hb <7.0 g/dL
• Platelets prophylactically when counts are <10,000/mm3 in the
absence of apparent bleeding

15. Diagnosis :
• Cultures as clinically appropriate before antimicrobial therapy
• imaging
•Antimicrobial Therapy
• Administration of effective broad spectrum intravenous
antimicrobials within the first hour of recognition of septic shock.
• Not more than 5 days, De-escalate antibiotic therapy.
• Duration of therapy typically 7–10 days
•Source Control
• eg: abscess drainage
•Mechanical Ventilation of Sepsis-Induced ARDS

16. Anaphylactic shock
 Anaphylaxis :
 life threating clinical manifestation
 IgE mediated hypersensitivity
 Mast cell and basophil degranulation
 Anphylactoid rxn:
 Not IgE mediated

17. Anaphylactic shock
 Causes
 Anaphylaxis :
 Food( Nuts,egg etc)
 Antibiotics,vaccines blood n blood products,latex
 Anaphylactoid rxn
 NSAID
 Opiates
 Gamma globulin
 antisera

18. Anaphylactic shock
 Clinical manifestations :
 Eyes: conjuctival erthyrema, periorbital odema
 Skin: pruritus flushing urticaria angioedema
 CVS: hypotension, Tachy (Brady if severe), cardiac
arrest
 Resp: Dyspnea,wheezing,pulmonary odema
 GIT : Nausea/vomiting,Diarrohea, Abdo pain

19. Anaphylactic shock
 Suspected impending respiratory collapse ---->
intubate
 IM epinephrine 0.3-0.5 mg to ant/ lat thigh
 For severe symptoms poor response
 Iv bolus epinephrine 0.1-0.2 mg
 If hypotensive start fliud therapy
 if no response to above
 start iv epi infusion
 Aggressive fluid therapy
 Pt on beta blocker ----> Glucagon

20.  Treat all patients with Histamine 1,2 blocker
Diphenhydramine (H1)
Ranitidine (H2)

21. Cardiogenic shock
 Cardiogenic shock is related to ‘pump’
failure from many possible causes
 myocardial infarct ( common)
 valve dysfunction
 papillae rupture
 arrhythmias
 tamponade
 pulmonary embolus

22. Cardiogenic shock
 Clinical feature
SBP< 90
Sign of low cardiac output ( oliguria,poor
mental status , pulmonary odema )
 Adequate intravascular volume ( PAOP > 15
mmhg)

23. Cardiogenic shock
 Initial evaluation & rapid stabilization
 Immediate ECG:
 Look for evidence of AMI (ST ele , LBBB)
 Supplemental O2/mech vent
 BP support
 Dopamine
 Nor epi
Need CVP,Intra arterial blood pressure monitoring

24. Cardiogenic shock
 Patient with positive ECG finding :
 Immediate reperfusion therapy :
 Thrombolytic therapy
 Cardiac catheterization
 Negative ECG finding :
 Rule out mechanical cause of CS ( ECHO)
 Cardiac monitoring ( confirm cardiac etiology )
 Continued medical support (vasopressure, inotropic)

25. Cardiogenic shock
 In case of refractory cardiac shock
 Left venticular assist device
 Transplant
 Cradiac temponade :
 Beck’s triad ( raised jvp,muffled hreart sound,hypotension)
 Presence of pulsus paradox( insp fall in SBP>10)
 Echo finding
 Consider Subxiphoid Pericardiocentesis

26. Thank you