02. Dr. Robert Sp.an - Shock

8/12/2019 02. Dr. Robert Sp.an - Shock

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SHOCKRobert H. Sirait, dr.,Sp An

Dept. of Anesthesia FK UKIJakarta


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SHOCK

Is a mismatch betwen tissue oxygendemands and tissue oxygen supply.

Is pertubation poor perfusion of vital organbecause of tissue hypoxia induced byoxygen supply and demand in equeities

Shock is hypotension with hypoperfusionabnormalities


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MismatchO 2 demands and tissue O 2 supply

Tissue hypoxia

Anareobic matabolismat microcelluler level

Tissue damage

Death

Shock is dynamic syndrome


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Delivery of Oxygen

DO 2 : CO x CaO 2 x 10

CaO 2:{(Hb x 1,34 x SaO 2)+(PaO 2 x 0,0031)}

Note

CO : Cardiac outputCaO 2 : Oxygen Arterial content


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Oxygen delivery can be increased by :a. increasing cardiac outputb. Increasing hemoglobin concentration orc. Increasing oxyhemoglobin concentration.

Clinical interventions to decrease oxygen demand :a. Intubation (to support the work of breathing)b. Sedationc. Analgesia andd. Treatment fever


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General criteria of shock

a. Systolic arterial BP < 80 mmHg or a reduction >40 mmHg

b. Oliguria

c. Metabolic acidosisd. Poor tissue perfusion

Cinical manisfestation of organ hypoperfusiona. Mental status changesb. Oliguriac. Lactic acidosis


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Classification of ShockA. Cardiogenic shock

Myocardial dysfunction : forward blood flowinadequate

B. Hypovolemic shockIntravascular volume is depleted as a result ofhemorrhage, vomiting, diarrhea or third space loss.

C. Distributive shockThe most common is septic shock. The other forms:anaphylactic shock, acute adrenal insufficiency andneurogenic shock

D. Obstructive shockCardiac tamponade represents extracardiacobstructive shock. The other forms: tension

pneumothorax and massive pulmonary embolus


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Infectioninflamatory response to the presence ofmicroorganism or the invasion of normally

sterile host tissue by organisms.

Bacteraemia

The presence of variable bacteria in the blood.


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Systemic inflamatory response syndrome (SIRS)The SIR to a variety of severe clinical insults.The respon in manifested by two or more of thefollowing conditions :- Temperature > 38 o C or < 36 o C- Heart rate > 90 x/mt

- RR > 20 x/mt or PaO 2 < 4,3 kPa (< 3,2 Torr)- White blood cell count > 12.000 cells/mm 3, or >10% immature (band) forms

SepsisDefined as SIRS as a result of infection.


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Severe Sepsis

Sepsis that is associated with organdysfunction, hypoperfusion, or hypotension.

Septic ShockSepsis with hypotension, despite adequatefluid resuscitation, a long with the presence ofperfusion abnormalities.

Multiple organ dysfunction (MOF) syndromePresence of alterated organ function in anacutely ill patient such that homeostasis can

not be maintained without intervention.


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Haemodynamic Profiles of Shock

Type of shock PAOPressure

CardiacOutput

SVR

Cardiogenicshock

Hypovolemicshock

Distributive shock or N , N or

Obstructive shockC. tamponadeP. embolus

or N


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Basic Principles of ManagementShock

1. Increase oxygen delivery to the tissue2. Incresing cardiac output and blood

pressure with combination:a. Fluid resuscitationb. Increasing cardiac contractility with

inotropesc. Raising SVR with vasopressors


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A. Cardiogenic Shock

The primary goal to improve myocardialfunction:

a. Inotropes such as dobutamine (BP N, ) b. Vasopressor such as NE, high dose

dopamine (BP )


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Dopamine, doses :2-3 g/kgBB/mt has modest inotropic andchronotropic effects (acts on the dopaminergicreceptor in the kidney)4-10 g/kgBB/mt has primarily inotropic effects 10 g/kgBB/mt has significant agonist effect related vasoconstriction 25 g/kgBB/mt no advantage over NE

Dobutamine

Is a adrenergic agonistDoses of 5-20 /kg/BB/mt is a potent inotropes increase CO


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Norepinephrine (NE)

Is a potent adrenergic vasopressor agent. Also has adrenergic, inotropic, andchronotropic effects.Dose ranges start at 0,05 g/kgBB/mt titratedto desired effects

Epinephrine (E)Has both and adrenergic effectsPotent inotrope and chronotropeIncrease in myocrdial oxygen consumptionDose ranges start at 0,1 g/kgBB/mt titrated todesired effects


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B. Hypovolemic Shock

The primary goal : restoration ofintravascular volume, either crystalloid orcolloid fluids, blood.

Targeted : to reestablish normal bloodpressure, pulse and organ perfusion(adequate urine output)


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C. Distributive Shock

The initial approach is :1. Restoration and maintenance of

adequate intravascular volume2. Infection : appropiate antibiotic3. Remains hypotensive despite adequate

fluid resuscitation : inotropes and orvasopressors


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Anaphylactic shock :Epinephrine sc and volume resuscitation

Adrenal insufficiency:Volume therapy, corticosteroid iv andvasopressor

Neurogenic shock:Cervical or thoracic spinal cord injury.Characterized: hypotension, bradycardia, flaccidparalysis, loss of extremity reflexes, and priapism

Treatment for hypotension:Volume resuscitation, vasopressors, andatropine for bradycardia.


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Severe Brain Injury (trias Cushing classic signs).The initial management : controlling ICP, maintainingcerebral oxygen delivery with ;a. Supplemental O 2b. Intubationc. Hyperventilation

d. Elevation of heade. Limitation : excess free water and volumeresuscitationf. Osmotic diureticg. Cardiopulmonary supporth. Blood transfusionsi. CT scan of head

j. Prompt craniotomy (when necessary)


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D. Obstructive ShockRelief of the caused obstructionCardiac tamponade Signs : Trias Becks syndrome+pulsus paradoksus Treatment :Pericardiocentesis (puncture PX tip of leftscapula, angel 45 o with longest needle).

Tension pneumothoraksThoracocentesis (puncture IC II mid clavicula lineswith large needle).

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02. Dr. Robert Sp.an - Shock