Initial Treatment of Shock in ER2

Initial Treatment of Shock in ER

Erwin Siregar

RS Jantung dan Pembuluh Darah

Harapan Kita

Type of Shock

• Hypovolemic shock:– Haemorrhage

– Dehydration

• Septic shock

The 2nd National Symposium on Emergencies, August 28th, 2005

• Cardiogenic shock

• Neurogenic shock

Hypovolemic shock

• Initial resuscitation important

– FLUID

– Drugs


– Monitoring

Body Fluids

• Water comprises about 60 % total body weight

• Extracellular fluid (20 % tbwt)


• Extracellular fluid (20 % tbwt)– Interstitial (15 % tbwt)

– Intravascular (5 % tbwt)

– Transcellular (CSF, aqueous humour etc)

– Intracellular fluid (40 % tbwt)

Distribution of Fluid

• 70 kg man (57 % water)

• Total 42 liters– Extracellular 14 liters (20 % of mass)

• Interstitial fluid ~ 11.2 liters

• Intravenous (plasma) ~ 2.8 liters


• Intravenous (plasma) ~ 2.8 liters

– Intracellular 28 liters (40 % of mass)• Red blood cells ~ 2 liters

Type of Fluids

• Crystalloid

• Colloid :– Isotonic colloid

– Hypertonic colloid


– Hypertonic colloid

• Hypertonic saline

Crystalloids

• True solutions

• Freely distributed across semi permeable membranes

• Plasma expansion < infused volume


• Plasma expansion < infused volume

• Rapidly excreted

• Expansion ECF : PV ~ 4 : 1

• Limited duration of effect (+90 min)

• Crystalloids– Extracellular space expanders

– Limited plasma volume expansion

– Maintain urine output


– Maintain urine output

– Reduce plasma oncotic pressure

– Range of electrolyte content

– CHEAP

Isotonic Colloids

• Suspension of large particles

• Generally limited to vascular compartment

• Volume for volume plasma expansion

• Excretion determined by molecular size


• Excretion determined by molecular size

• Osmotic effect dependent on number of particles

• Duration of effect 2-12 hours

Hypertonic colloid/ solutions

• Expansion of intravascular space

• Contraction of ECF


Crystalloid vs Colloid ?

Colloid advantages

• Intravascular space expanders

• Volume for volume expansion

Colloid disadvantages

• Coagulation problem

• Variable electrolyte content

• Variable half life


expansion

• Rapid resuscitations

• Maintain oncotic pressure

• Less tissue edema

• Less pulmonary edema

• Variable half life

• Adverse reactions

• EXPENSIVE !!!

Early 1990

• Place of colloids firmly established

• Role of crystalloids being challenged: increased tissue oedema equated to

Crystalloid vs Colloid ?


increased tissue oedema equated to increased lung oedemaincreased brain oedema

• “The end of crystalloid era”

Twigley & Hilma, Anaesthesia, 1985

So what went wrong ???

As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued


it is hard to see how their continued use in these patient types can be justified outside the context of randomized controlled trials

Cochrane Database Review, 2000

How good are the crystalloids ?


Is normal saline NORMAL ??

• Is 0.9 % saline isotonic ?– Normal plasma osmolality 280-290

mOsm/l– 0.9 % saline = 154 x 2 = 308 mOsm/l

• Is it physiological ?


• Is it physiological ?– pH = 6.35– Chloride load can cause acidosis

• ABNORMAL SALINE ???

Ringer’s vs Saline

• No real difference in most situations

• Sodium and acid load from saline

• Lactate’s in Ringer only important in the presence of liver failure


the presence of liver failure

• Ringer’s low in sodium and osmolality (275 mOsm/L)

Key Point on Crystalloids

• Large volume are frequently required

• Large volume of abnormal solutions may produce abnormality

• Some evidence of brain edema


• Some evidence of brain edema

• Saline :– Hypernatremia and acidosis

• Ringer’s– Hyponatremia and alkalosis

Hypertonic Salines (7.5 %)

• High osmolality (2400 mOsm/l)• Small volume resuscitation• Reduces cerebral no-reflow in CPR

– Fischer M, Resusctitaion, 1996• Decreases brain water in head injury


• Decreases brain water in head injury– Sheik AA, Crit Care Med, 1996

• Effective for a limited period only– Favre Schweiz, Med Wochenschnr, 1996

• Reversed trauma-induced immunosuppresion– Coimbra R, J Surg Res, 1996

Colloids

• Plasma protein fractions

• Gelatins

• Dextrans

• Starches


• Starches

Plasma Derived Colloids

• Plasma (FFP, cryoprecipitate)– Coagulations problem only

• Albumin

• Plasma protein fractions /SHS


• Plasma protein fractions /SHS

Albumin

• Expensive

• No evidence of benefit

• Some evidence of harm

• ANZICS SAFE study :


• ANZICS SAFE study :– 7000 patients randomized to Alb or NS

– Increased mortality with albumin ( p< 0.05) in trauma (more intracerebral bleeding)

Gelatins

• Moderate molecular weight28-35 kDa

• Short duration of actions2 – 4 hrs


2 – 4 hrs

• Minimal coagulation disturbances

• Significant allergic riskHaemacel > Gelofusin

Dextran

• MW 40 – 70 kDa

• Prolonged duration of effect

• Improved microcirculation

• Significant impairment of


• Significant impairment of coagulation

• Small anaphylactoid risk

• Some risk of renal dysfunction

Starches

• Range of molecular weight70-450 kDadetermines properties

• Long to very long duration


• Long to very long duration

• May improve microcirculation and endothelial function

• Moderate to small coagulation effect

• Minimal anaphylactoid risk

Colloid, summary

• Gelatins,– Short term volume effect– Minimal effect on coagulation– No dose limitation

• Dextrans,– Medium term volume effect


– Medium term volume effect– Significant coagulant inhibition– Renal effect with Dex40– Limit 15 ml/kg/24 hr

• HES– Medium to long term volume effect– Minimal to moderate coagulation effect– Limit 33 ml/kg/24hr (6%) or 20 ml (10 %)

Fluid Balance Consequences in Early Shock

• Mobilization of ECF

• Hemodilution of plasma– ? Coagulation effect

– Gradual fall in Hb


– Gradual fall in Hb

• Maintenance of vascular space at the expense of the ECF

Late shock

• Capillary leak

• Loss of plasma volume

• Tissue edema

• Organ edema (lung, kidney)


• Organ edema (lung, kidney)

• Multiple Organ Failure

OBJECTIVES

• Early, complete restoration of tissue oxygenation

• Minimal biochemical disturbances

• Preservation of renal function


• Preservation of renal function

• Avoidance of transfusion complications

Fluid Choices

• Well-balanced resuscitation fluid resembling extracellular fluid

• Rapid volume expansion of intravascular space


intravascular space

• Sustained expansion

• No sugar

Problems with BLOOD

• Disease• Biochemical abnormalities :

– Hypernatremia– Acidosis– Hyperkalaemia


– Hyperkalaemia– Hypocalcaemia

• Delayed effects :– Metabolic alkalosis– Hypokalaemia– Immunomodulation

Blood

• Limit transfusions

• Transfusion threshold < 7 g/dL

• Maintenance leve 7-9 g/dL

• Older patients and those with


• Older patients and those with ischemic heart disease may need higher Hb

Timing of Resuscitation

• Do not delay transfer for resuscitation

• Priority is arrest of hemorrhage

• Commence aggressive resuscitation once control of bleeding is imminent


once control of bleeding is imminent

Pepe et al, Emerg Med Clin North Am, 1998

• Controlled fluid resuscitation• Balance hypoperfusion vs bleeding risk• Anemia than hypovolemia• Not yet proven that colloids reduce

mortality in trauma patients

Timing of Resuscitation


mortality in trauma patients• In SIRS, HES may reduce capillary leak• HS solutions may benefit head injuries• Hemoglobin-based oxygen carriers may be

useful in future

Nolan, Resuscitation, 2001

Selection of Fluids

• Early aggressive crystalloid therapy (2-3 liters RL, 0.9 % saline)

• Colloids if needed :– Short duration colloid if volume


– Short duration colloid if volume requirement is temporary

– Long acting colloid otherwise

• Red blood cells if Hct < 25• FFP, cryoprecipitate only for

coagulation problems

DRUGS

• Inotropes :– Dobutamine

– Dopamine

– Adrenaline

• Vasopressors


• Vasopressors– Noradrenaline

– Adrenaline

– Vasopressin

– Phenylephrine

MONITORING

• Non invasive– NIBP– Urine output– HR– Capillary filling


– Capillary filling – Pulse oxymetry

• Invasive– Arterial line– CVP– PA pressure (Swan

Ganz catheter)

DOBUTAMINDOBUTAMIN

• Agonis β-1 yang poten

• Kontraktilitas miokard ↑• Heart Rate sedikit ↑


• Heart Rate sedikit ↑• Efek vasodilatasi ringan :

inodilator

• Memperbaiki perfusi splanknikus

Dopamin

• Dosis kecil – sedang ( sampai 7 µg/kgBB/mnt ) β-adrenergik

• Dosis besar α- adrenoreseptor ↑ � vasokonstriksi

Dopamin : inotropik + vasokonstriktor


• Kerugian :– Takikardia : iskemia miokard ; hati-hati– Dapat menyebabkan “steal effect” pada GI tract– Dapat mengganggu fungsi “pituitary gland” & tiroid– Dapat mempunyai efek immunosupresif

NORADRENALIN NORADRENALIN (VASCON(VASCON®®))

• Neurotransmitter postsynaps adrenergic


adrenergic

• Stimulasi α-1 dan β-1 adrenoreseptor

• Dosis rendah : efek β

• Vasokonstriksi dan MAP ↑

ADRENALINADRENALIN

• Mempunyai aktivitas β-1, β-2, dan α-1 yang poten

• Pada sepsis MAP ↑ oleh karena CO ↑ (stroke volume ↑)


• Kerugian :

–Kebutuhan O2 miokard ↑–Laktat serum ↑

VASOPRESIN (ADH)VASOPRESIN (ADH)

• Dapat dipakai sebagai vasokonstriktor bila vaso


vasokonstriktor bila vaso konstriktor katekolamin tidak berhasil

• Mengurangi perfusi splanknikus

FENILEFRINFENILEFRIN

• α-1 agonis murni

• Sebagai vasokonstriktor tidak menyebabkan takikardia


menyebabkan takikardia

• Sering dipakai di anestesi dan ICU untuk mengatasi dilatasi

SEKALI LAGI !!SEKALI LAGI !!

Pasien HipotensifTentukan

ResusitasiTarget PCWP Persisten Hipotensi

Persisten hipotensi, tambahkan vasopresin


TentukanTarget MAP

ResusitasiCairan

PCWP≥15mmHg

Persisten HipotensiTambah Noradrenalin

MAP N, oliguria, CO↓, Tambah dobutamin,

dopamin

Conclusion

• Initial treatment in ER ,is Critical and very important to avoid further complications (organs, etc)

• Knowledge of presenting shock is of paramount importance

• Familiar with characteristics of various


• Familiar with characteristics of various resuscitation fluids – Blood is used if absolutely necessary

• Knowledge of inotropes and vasopressors• Ability to use invasive monitors an

advantage


Documents

Initial Treatment of Shock in ER2