Download - 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).