ionotropes in shock

8/11/2019 ionotropes in shock

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D. P. Laporta MD

SMBD-JGH

Dept of Adult Critical Care


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SHOCK -OUTLINE

DEFINITION

CAUSESEFFECTS OF INEFFECTIVE

TREATMENT

ASSESSMENT

CLINICAL APPROACH


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CASE


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SHOCK -

DEFINITION CAUSES

EFFECTS OF INEFFECTIVE TREATMENT

ASSESSMENT CLINICAL APPROACH


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A profound disturbance of the circulationand metabolism, leading to

inadequate perfusion of vital organs,

necessary to maintain homeostasis

DEFINITION


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SHOCK -

DEFINITION

CAUSES


ASSESSMENT

CLINICAL APPROACH


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HYPOPERFUSED STATES

RV LV

Arterial(resistance)

Venous(capacitance)

PVR

EF End-Diastolic Volume

SVR


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HypovolemicBP 60/30

HR 140/min

CVP 0

Lactate 10


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CardiogenicBP 70/50

HR 130/min

CVP 18

Lactate 12


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ObstructiveBP 70/50

HR 140/min

CVP 15

Lactate 12

VTED

OAD

DLD


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DistributiveBP 70/40

HR 140/min

CVP 5

Lactate 12


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SHOCK -

DEFINITION

CAUSES

EFFECTS OF INEFFECTIVE

TREATMENT ASSESSMENT

MEASUREMENT

CLINICAL APPROACH


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MISERY !!!

MODSMODS PO2/FiO2 ratio

Serum creatinine

Platelet count

Glasgow coma score

Serum bilirubin

Pressure-adjusted heart rate

(hr x CVP/MAP)

INFECTION


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SHOCK -

DEFINITION

CAUSES


ASSESSMENT

MEASUREMENT

CLINICAL APPROACH


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SHOCK: asssessment

Class 1&2 vs 3&4

needs blood or crystalloid ?


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S bli l t


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hypercarbia is a universal indicator of critical ly reduced

tissue perfusion.

Sublingual capnometry:

A new noninvasive measurement for diagnosis and

quantitation of severity of circulatory shock

Max Harry Weil MD, PhD, FCCM - CCM 1999


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S bli l t


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Sublingual capnometry:

A new noninvasive measurement for diagnosis and

quantitation of severity of circulatory shock


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SHOCK -

DEFINITION

CAUSES

EFFECTS OF IEFFECTIVE TREATMENT

MEASUREMENT

CLINICAL APPROACH

SHOCK: an EMERGENCY !!!


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SHOCK: an EMERGENCY !!!

GOAL:

RAPIDLY RESTORE TISSUE PERFUSION

Recognize it !!!

Immediate stabilization: ABC

. SHOTGUN approach

ICU & Surgical consultation

Treat the cause

M t i iti


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Management prioritiesin hypoperfused states

Priority # Physiology to

improve

Intervention Parameter to target PAC

targets

Avoid

1 Volume Fluids CVP 10-15 DO2 Low Sao2

See CXR

2 Pressure Vasopressor SBP 100 or within 20-25

torr

MBP 80 of patient's Nl

Low SV, DO2

High HR,

Resistances

3 Flow Inotrope Signs of perfusion DO2 Low BP, SV,

Resistances

BP potency: Dopamine...NEVasopressin/Phenylephrine


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ionotropes in shock

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