SHOCK IN SHOCK IN CRITICAL ILLNESSCRITICAL ILLNESS

Vikas Kesarwani MD FCCPVikas Kesarwani MD FCCP

Consultant, Pulmonary & Critical Care,Consultant, Pulmonary & Critical Care,Himalayan Institute of Medical Sciences,Himalayan Institute of Medical Sciences,

HIHT University,HIHT University,Dehradun.Dehradun.

2626thth Feb 2011 Feb 2011

Dictionary definition of ShockDictionary definition of Shock

► 1. a sudden and violent1. a sudden and violent blow or impact; collision, disturbanceblow or impact; collision, disturbance or or commotioncommotion of the mind, emotions, or sensibilitiesof the mind, emotions, or sensibilities

► 2. the physiological effect produced by the passage of an electric 2. the physiological effect produced by the passage of an electric current through the body.current through the body. 3. shocks, Informal3. shocks, Informal . . shock absorbersshock absorbers, especially in the suspension , especially in the suspension of an automobile. of an automobile. 4. 4. Pathology Pathology . a collapse of circulatory function, . a collapse of circulatory function, caused by severe injury, blood loss, or disease, and caused by severe injury, blood loss, or disease, and characterized by pallor, sweating, weak pulse, and characterized by pallor, sweating, weak pulse, and very low blood pressure.very low blood pressure.

––verb (used with object) 8. to strike or jar with intense surprise, horror, verb (used with object) 8. to strike or jar with intense surprise, horror, disgust, etc.: He enjoyed shocking people. disgust, etc.: He enjoyed shocking people.

► 9. to strike against violently.9. to strike against violently. ► 10. to give an10. to give an electric shockelectric shock to. to.

Origin: 1555–65; French choc  armed encounter, noun derivative of choquer  to clash (in battle). Germanic; compare Dutch schokken  to shake, jolt, jerk

DefinitionDefinition►Kumar and Parrillo (1995)Kumar and Parrillo (1995)

- “The state in which - “The state in which profound profound andand widespreadwidespread reduction of effective tissue reduction of effective tissue perfusionperfusion leads leads first to reversiblefirst to reversible, and , and then then if prolonged, to irreversible cellular if prolonged, to irreversible cellular injuryinjury.”.”

►Clinically manifested byClinically manifested by Hemodynamic disturbances.Hemodynamic disturbances. Tissue Hypoxia.Tissue Hypoxia. Organ dysfunctionOrgan dysfunction. .

Case ScenarioCase Scenario

► 45 yr old male. Teetotaller 45 yr old male. Teetotaller ► BG: T2DM, HTN for 10 yrs. On OHA and BG: T2DM, HTN for 10 yrs. On OHA and

antihypertensive medication. antihypertensive medication. ► H/o H/o

Cough, Expectoration, Fever - 5 days.Cough, Expectoration, Fever - 5 days.Delirious & Not passed urine since last 24 Delirious & Not passed urine since last 24 hours. hours.

► HR 121/min, BP 90/50, HR 121/min, BP 90/50, RR 28/min, SpO2 85% on RA. RR 28/min, SpO2 85% on RA.

Case Scenario Case Scenario ► 45 yr old male. 45 yr old male. ► BG: T2DM, HTN for 10 yrs. On OHA and antihypertensive medication. BG: T2DM, HTN for 10 yrs. On OHA and antihypertensive medication. ► H/o H/o

Cough,Expectoration, Fever 5 days.Cough,Expectoration, Fever 5 days.Dilirious, Not passed urine since last 24 hours. Dilirious, Not passed urine since last 24 hours.

►Hemodynamic disturbance:Hemodynamic disturbance: HR HR 121/min, BP 90/50, 121/min, BP 90/50, Tissue Hypoxia:Tissue Hypoxia: SpO2 85% on RA. SpO2 85% on RA. Dilirious.Dilirious.Organ Dysfunction:Organ Dysfunction: Anuric, dilirious. Anuric, dilirious.

DefinitionDefinition►Kumar and Parrillo (1995) Kumar and Parrillo (1995)

- “The state in which profound and - “The state in which profound and widespreadwidespread reduction of effective reduction of effective tissue perfusiontissue perfusion leads first to leads first to reversible, and then if prolonged, to reversible, and then if prolonged, to irreversible cellular injury.”irreversible cellular injury.”

►Clinically manifested byClinically manifested by Hemodynamic disturbances.Hemodynamic disturbances. Tissue Hypoxia.Tissue Hypoxia. Organ dysfunction. Organ dysfunction.

Tissue PerfusionTissue Perfusion3 components3 components

PumpPump

ContainerContainer

FluidFluid

► Cardiogenic shock –Cardiogenic shock – due to due to cardiac pump failurecardiac pump failure ;loss of myocardial contractility ;loss of myocardial contractility/ functional myocardium or structural/mechanical/ functional myocardium or structural/mechanicalfailure of the cardiac anatomy and characterized byfailure of the cardiac anatomy and characterized by elevations of diastolic filling pressures and volumeselevations of diastolic filling pressures and volumes

► Hypovolemic shockHypovolemic shock – –↓ ↓ circulating blood volumecirculating blood volume in relation to the total in relation to the total

vascular capacity and characterized by vascular capacity and characterized by a a reduction of diastolic filling pressures.reduction of diastolic filling pressures.

► Distributive shock –Distributive shock –caused by caused by loss of vasomotor controlloss of vasomotor control resulting in resulting in arteriolar/venular dilatationarteriolar/venular dilatation and characterized and characterized (after fluid resuscitation) by (after fluid resuscitation) by increased increased cardiac output and cardiac output and decreased SVR. decreased SVR.

Extra-cardiac obstructive shock –Extra-cardiac obstructive shock – due to due to obstruction to flow in the cardiovascular circuitobstruction to flow in the cardiovascular circuit and and characterized by either characterized by either impairment of diastolic filling or impairment of diastolic filling or excessive afterloadexcessive afterload

ClassificationClassification

Distributive ShockDistributive Shock►Results from a severe decrease in SVRResults from a severe decrease in SVR

Vasodilation reduces both preload & Vasodilation reduces both preload & afterloadafterload

May be associated with increased COMay be associated with increased CO►Etiologic categoriesEtiologic categories

-Septicemia-Septicemia Neurogenic / spinalNeurogenic / spinal Systemic inflammation(SIRS) Systemic inflammation(SIRS)

– pancreatitis, burns.– pancreatitis, burns. Anaphylaxis and anaphylactoid reactionsAnaphylaxis and anaphylactoid reactions

Toxin reactions – drugs, transfusion.Toxin reactions – drugs, transfusion.

The Sepsis ContinuumThe Sepsis Continuum

SIRS = systemic inflammatory response syndrome

SevereSepsisSIRS

Septic

Shock

Refractory Septic Shock

SEPSIS

ACCP: American college of chest physician.SCCM: Society of critical care medicine

What is SIRS?What is SIRS?Systemic level of Systemic level of acute acute inflammationinflammation, that may or may not , that may or may not be due to infection. be due to infection.

Requires 2 of the following 4 features to be Requires 2 of the following 4 features to be present:present:►Temp >38.3° or <36.0° CTemp >38.3° or <36.0° C►Tachypnea (RR>20 or PaCO2 <32 mmHg)Tachypnea (RR>20 or PaCO2 <32 mmHg)►Tachycardia (HR>100, Tachycardia (HR>100, in the absence of intrinsic heart in the absence of intrinsic heart disease)disease)

►WBC > 10,000/mmWBC > 10,000/mm33 or <4,000/mm or <4,000/mm33 or or >10% band forms on differential>10% band forms on differential

Definitions Definitions (ACCP/SCCM)(ACCP/SCCM)

SepsisSepsis• >>2 2 SIRSSIRS Criteria. Criteria.• Either a culture-Either a culture-provenproven infectioninfection or an or an

infection identified by visual inspectioninfection identified by visual inspection

ACCP: American college of chest physician.SCCM: Society of critical care medicine

Sepsis: Grade ISepsis: Grade I•Severe Sepsis: Severe Sepsis:

SSepsisepsis ++ at least one of the following at least one of the following signs of signs of organ hypoperfusion or organ hypoperfusion or dysfunctiondysfunction..

• • Mottled skin, Capillary refillingMottled skin, Capillary refilling>>3sec.3sec. •  • Urine output <0.5 mL/kg/Hr. or requiring Dialysis.Urine output <0.5 mL/kg/Hr. or requiring Dialysis. •  • Lactate >2 mmol/L.Lactate >2 mmol/L. •  • Altered sensorium. Altered sensorium.  •  • Platelet count <100,000/mLPlatelet count <100,000/mL •  • Disseminated intravascular coagulation(DIC)Disseminated intravascular coagulation(DIC) •  • Acute lung injury or acute respiratory distress syndrome Acute lung injury or acute respiratory distress syndrome

(ARDS)(ARDS) •  • Cardiac dysfunction.Cardiac dysfunction.

Send the patient to higher centre or to a friend Doctor who can manage any further deterioration.

• Septic ShockSeptic Shock:: severe sepsissevere sepsis ++ one one or both of the following:or both of the following:

1. Mean 1. Mean BP<60mmHgBP<60mmHg. . (<80 in Hypertensive pt.) (<80 in Hypertensive pt.)

after Adequate fluid resuscitation. after Adequate fluid resuscitation.

2. Requires 2. Requires dopamine dopamine >5 mcg/kg/min, or >5 mcg/kg/min, or norepinephrinenorepinephrine <0.25 mcg/kg/min, or  <0.25 mcg/kg/min, or epinephrineepinephrine <0.25 mcg/kg/min  <0.25 mcg/kg/min despite despite adequate fluid resuscitation.adequate fluid resuscitation.

Sepsis: grade IISepsis: grade II

Adequate fluid resuscitation : infusion of 20 to 30 mL/kg of starch, infusion of 40 to 60 mL/kg of saline solution, or a measured pulmonary capillary wedge pressure (PCWP) of 12 to 20 mmHg.

• Refractory Septic ShockRefractory Septic Shock:: To maintain To maintain MMean BP >60ean BP >60 mmHg mmHg (or >80 (or >80

mmHg if the patient has baseline hypertension)mmHg if the patient has baseline hypertension) requires dopamine >15requires dopamine >15 mcg/kg/min, mcg/kg/min, norepinephrine >0.25norepinephrine >0.25 mcg/kg/min, or mcg/kg/min, or epinephrine >0.25epinephrine >0.25 mcg/kg/min mcg/kg/min despite adequate fluid resuscitation. despite adequate fluid resuscitation.

Sepsis: grade IIISepsis: grade III

Adequate fluid resuscitation : infusion of 20 to 30 mL/kg of starch, infusion of 40 to 60 mL/kg of saline solution, or a measured pulmonary capillary wedge pressure (PCWP) of 12 to 20 mmHg.

The Sepsis ContinuumThe Sepsis Continuum

SIRS = systemic inflammatory response syndrome

SevereSepsis

SIRS Septic

Shock

Refractory Septic Shock

SEPSIS

ACCP: American college of chest physician.SCCM: Society of critical care medicine

A clinical response A clinical response arising from a arising from a nonspecific insult, nonspecific insult, with with 2 of the 2 of the following:following: T >38T >38ooC or <36C or <36ooCC HR >100 beats/minHR >100 beats/min RR >20/minRR >20/min WBC >12,000/mmWBC >12,000/mm33

or <4,000/mmor <4,000/mm33 or or >10% bands>10% bands

Sepsis + organ hypo-perfusion or dysfunction

SIRS + confirmed infection.

Septic shock+High Inotropes.

Severe Sepsis + BP<60mmHg.after fluid resuscitationor Low Inotrope

SEPSIS

Relationship Between Sepsis Relationship Between Sepsis and SIRSand SIRS

TRAUMA

BURNS

PANCREATITIS

SIRSINFECTION

BACTEREMIA

Fungemia

Parasitemia

viremia

PrognosisPrognosisOverall mortality Overall mortality from SIRS/sepsis in the from SIRS/sepsis in the U.S. isU.S. is approximately 20%. approximately 20%. Mortality is roughly linearly related Mortality is roughly linearly related to the number of organ failures.to the number of organ failures. Each additional organ failure raising the Each additional organ failure raising the mortality rate by 15%.mortality rate by 15%.

HypothermiaHypothermia is one of the worst is one of the worst prognostic signs. prognostic signs. Patients presenting with Patients presenting with SIRS and hypothermia have an overall SIRS and hypothermia have an overall mortality of ~80%.mortality of ~80%.

Sepsis: PathophysiologySepsis: Pathophysiology

Pro-inflammatory Pro-inflammatory MediatorsMediators

• Bacterial EndotoxinBacterial Endotoxin• TNF-TNF-αα• Interleukin-1Interleukin-1• Interleukin-6Interleukin-6• Interleukin-8Interleukin-8• Platelet Activating Platelet Activating

Factor (PAF)Factor (PAF)• Interferon-GammaInterferon-Gamma• ProstaglandinsProstaglandins• LeukotrienesLeukotrienes• Nitric OxideNitric Oxide

Mediators of Septic Mediators of Septic ResponseResponse

Anti-Anti-inflammatory inflammatory MediatorsMediators

• Interleukin-10Interleukin-10• PGE2PGE2• Protein CProtein C• Interleukin-6Interleukin-6• Interleukin-4Interleukin-4• Interleukin-12Interleukin-12• LipoxinsLipoxins• GM-CSFGM-CSF• TGFTGF• IL-1RAIL-1RA

Cohen, Nature: 2002 420:885

Management: Septic ShockManagement: Septic Shock

Starting from common Starting from common ground…ground…

►Appropriate supportive careAppropriate supportive care ABCs ABCs (CAB if patient has arrested)(CAB if patient has arrested) FluidsFluids Vasopressors/inotropesVasopressors/inotropes Organ support (ventilation, dialysis, Organ support (ventilation, dialysis,

etc.)etc.)►Appropriate empiric and adjusted Appropriate empiric and adjusted

antibioticsantibiotics►Source identification & control.Source identification & control.►Steroids, Glycemic control, Steroids, Glycemic control,

Nutrition, Activated protein C.Nutrition, Activated protein C.

CVP: central venous pressure

MAP: mean arterial pressure

ScvO2: central venous oxygen saturation

Early Goal-Early Goal-Directed TherapyDirected Therapy

NEJM 2001;345:1368-77.

What to do if you don’t have What to do if you don’t have facility for CVP measurement ?facility for CVP measurement ?

-20ml/Kg fluid bolus every 30--20ml/Kg fluid bolus every 30-60minutes. (NS or Colloid)60minutes. (NS or Colloid)

Poor Man’s CVP assessment & Poor Man’s CVP assessment & Guided fluid: Guided fluid: Passive leg raising (PLR) Passive leg raising (PLR) increasing increasing preload.preload.

Watch HR trendWatch HR trend↓HR= Give more.↓HR= Give more.↑HR= Stop giving.↑HR= Stop giving.(other reasons for tachycardia/bradycardia ruled out)(other reasons for tachycardia/bradycardia ruled out)

What to do if you don’t have What to do if you don’t have facility for CVP measurement ?facility for CVP measurement ?Poor Man’s CVP assessment & Guided Poor Man’s CVP assessment & Guided

fluid:fluid: Passive leg raising (PLR)Passive leg raising (PLR)

Poor Man’s Cardiac output:Poor Man’s Cardiac output: U/OU/O> > 0.5ml/kg/hr.0.5ml/kg/hr.

►Spo2 ~95-97% (NOT 100%)Spo2 ~95-97% (NOT 100%)►HRHR►U/OU/O►Neurological state.Neurological state.

Treatment: Treatment: (Vasopressors)(Vasopressors)

►Noradrenaline, Adrenaline, Noradrenaline, Adrenaline, Vasopressin.Vasopressin. (after volume resuscitation). (after volume resuscitation).

►? Dopamine & Dobutamine. ? Dopamine & Dobutamine. ► A goal MAP =60-65mmHg,A goal MAP =60-65mmHg,► Urine output, mental status, and skin Urine output, mental status, and skin

perfusionperfusion are better variables to use in are better variables to use in monitoring monitoring adequate perfusion then BP adequate perfusion then BP alonealone..

TreatmentTreatmentAntibioticsAntibiotics ► Consider Consider possiblepossible organisms organisms at at

suspected/confirmed suspected/confirmed sitesite of the infection. of the infection.► Obtain cultures, give empirical antibiotics Obtain cultures, give empirical antibiotics quicklyquickly

and at and at appropriate dose.appropriate dose.► De-escalateDe-escalate ones organism identified. ones organism identified.

Mechanical VentilationMechanical Ventilation► Do not delayDo not delay mechanical ventilation if indicated. mechanical ventilation if indicated.

Know your intubation criteria. Know your intubation criteria.► Low tidal volume ventilation for ARDSLow tidal volume ventilation for ARDS► Nearly all patientsNearly all patients with septic shock require with septic shock require oxygenoxygen, ,

and and 80%(80%(approx.) require approx.) require mechanical ventilation.mechanical ventilation.

Give your patients Give your patients ONE FAST ONE FAST HUGHUG everyday in HDU & ICU everyday in HDU & ICU

► OO: Oral care.: Oral care.► NN: Nose care.: Nose care.► EE: Ear care. : Ear care.

► FF: Feeding : Feeding (adequate (adequate calories.)calories.)

► AA: Analgesia : Analgesia (Check)(Check)

► SS: sedation : sedation (Check)(Check)

► TT: : ThromboprophylaxisThromboprophylaxis

► HH: Head raised : Head raised 4545degreedegree

► UU: Ulcer prophylaxis. : Ulcer prophylaxis. ► GG: Glucose control. : Glucose control.

Crit Care Med 2005 Vol. 33, No. 6

Evidence-Based Sepsis Evidence-Based Sepsis GuidelinesGuidelines

Components:Components:

• Early Goal-Directed TherapyEarly Goal-Directed Therapy• Steroid ReplacementSteroid Replacement• Recombinant Activated Protein CRecombinant Activated Protein C• Glycemic ControlGlycemic Control• Nutritional SupportNutritional Support• Adjuncts: Stress Ulcer Prophylaxis, Adjuncts: Stress Ulcer Prophylaxis, DVT Prophylaxis, Transfusion, DVT Prophylaxis, Transfusion, Sedation, Analgesia, Organ Sedation, Analgesia, Organ ReplacementReplacement

Evidence based Summary of Sepsis Evidence based Summary of Sepsis GuidelinesGuidelines

InitiativeInitiative GradeGrade DVT prophylaxisDVT prophylaxis with low dose heparins with low dose heparins or mechanical devicesor mechanical devices

AA

Stress ulcer prophylaxisStress ulcer prophylaxis, preferably , preferably with Hwith H2 2 blockersblockers

AA

Do not use > 300 mg/day Do not use > 300 mg/day hydrocortisonehydrocortisone

AA

Weaning protocolWeaning protocol with spontaneous with spontaneous breathing trialsbreathing trials

AA

Do not increase cardiac index to Do not increase cardiac index to supranormalsupranormal

AA

Early initial resuscitation to goalsEarly initial resuscitation to goals BB Red blood cell transfusion/dobutamineRed blood cell transfusion/dobutamine

to goalsto goalsBB

InitiativeInitiative GradeGrade Do not useDo not use low dose low dose dopamine dopamine for renal for renal protectionprotection

BB

rh Activated Protein Crh Activated Protein C [drotrecogin alfa [drotrecogin alfa (activated)] in patients with high risk of (activated)] in patients with high risk of death death

BB

RBC transfusionRBC transfusion if hemoglobin <7 g/dL if hemoglobin <7 g/dL BB Do not use erythropoietinDo not use erythropoietin for sepsisfor sepsis caused caused anemiaanemia

BB

Avoid high tidal volumesAvoid high tidal volumes and plateau and plateau pressures in ALI/ARDSpressures in ALI/ARDS

BB

Continuous vs. intermittentContinuous vs. intermittent renal renal replacement replacement considered equivalentconsidered equivalent for for acute renal failureacute renal failure

BB

Evidence based Summary of Sepsis Evidence based Summary of Sepsis GuidelinesGuidelines

InitiativeInitiative GradeGrade Sedation protocolsSedation protocols with goal and with goal and assessment scaleassessment scale

BB

Daily interruptionDaily interruption if continuous i.v. if continuous i.v. sedation sedation

BB

Use Use colloids or crystalloidscolloids or crystalloids CC CorticosteroidsCorticosteroids for 7 days for 7 days in septic shockin septic shock patients on vasopressorspatients on vasopressors

CC

Permissive hypercapniaPermissive hypercapnia to minimize to minimize plateau pressures and tidal volumesplateau pressures and tidal volumes

CC

Do not use bicarbonate if pH ≥7.15Do not use bicarbonate if pH ≥7.15 in in hypoperfusion lactic acidemiahypoperfusion lactic acidemia

CC

Semirecumbent positioning to avoid VAPSemirecumbent positioning to avoid VAP (head of bed at 45-degrees)(head of bed at 45-degrees)

CC

Evidence based Summary of Sepsis Evidence based Summary of Sepsis GuidelinesGuidelines

►Fluid resuscitation, goal-directedFluid resuscitation, goal-directed►Appropriate cultures prior to Appropriate cultures prior to

antibiotic administration (but do not antibiotic administration (but do not delay) and source control ASAP. delay) and source control ASAP.

►Use of vasopressors/inotropes when Use of vasopressors/inotropes when fluid resuscitation optimized.fluid resuscitation optimized.

►Low tidal volumes (6cc/kg) for Low tidal volumes (6cc/kg) for mechanical ventilation in ARDS.mechanical ventilation in ARDS.

Take home messageTake home message

►Stress ulcer and DVT prophylaxisStress ulcer and DVT prophylaxis►De-escalate antibiotic.De-escalate antibiotic.►Prevent VAP: 45 degree Prevent VAP: 45 degree

elevationelevation►Facilitate early discontinuation Facilitate early discontinuation

of mechanical ventilation: of mechanical ventilation: sedation interruption, early SBTsedation interruption, early SBT

Take home message (Cont’d)Take home message (Cont’d)Prevent ComplicationPrevent Complication

"First Do No Harm"