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Shock, Sepsis, and Hemodynamic support

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1
Type of shock -- normal / high CO/SVO2
distributive
2
Type of shock -- high CVP
cardiogenic and obstructive
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Type of shock -- ECHO normal
distributive
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Type of shock -- ECHO --> small chambers and normal / high contractility
hypovolemic
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Type of shock -- ECHO --> large ventricles + poor contractility
cardiogenic
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Type of shock -- dec afterload (SVR)
distributive
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Type of shock -- dec preload (CVP)
hypovolemic
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Type of shock -- dec CO
cardiogenic and obstructive
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Causes of cardiogenic shock
MI, LV failure, valvular disease, arrhythmias
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Only type of shock that requires central venous monitoring
cardiogenic
pulmonary artery catheter
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Cardiogenic -- dx
- SBP <80-90 or MAP drop 30 mmHg
- reduction in CO
- adequate filling pressure
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Cardiogenic -- use ____ to dx and guide therapy
pulmonary artery catheter
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Cardiogenic -- ToC
dobutamine (inotropic!)
- milrinone = 2nd line
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Cardiogenic -- tx
dobutamine inotrope!
+/- NEPI or DA for vasopressor
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Hypovolemic shock -- can lead to ___
multiple system organ failure
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Hypovolemic shock -- 3 things that can happen
lactic acidosis
coagulopathy
hypothermia
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Hypovolemic shock -- (2) most common causes of hemorrhage
PUD
trauma
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Hypovolemic shock -- meds for initial hemodynamic support
none!
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Hypovolemic shock -- prehospital care
- identify hemorrhage, physical bleed control, large volume parenteral admin, prevent hypothermia, get patient to facility ASAP
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Hypovolemic shock -- hospital care
- definitive ID of source of dx of shock, large vol. parenteral and HD support, stop bleed, possible reversal of anticoag, massive transfusion protocols
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Hypovolemic shock -- massive transfusion protocol consists of (4)
RBC
PLT
plasma
cryoprecipitate
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Tranexamic acid is used in (2)
hemorrhagic shock, OB/GYN surgeries
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Obstructive shock tx
treat underlying cause
- pericardial tamponade or tension pneumothorax --> stick needle and relieve pressure

- PE --> TPA or surgery
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Distributive shock -- (3) types
anaphylaxis
neurogenic
sepsis
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Most common type of distributive shock
septic shock
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Distributive shock -- systemic vaso_____ --> initial _____ afterload and eventually affects preload
vasodilation
decreased
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Type of distributive shock not associated with CNS dysfxn / infection
anaphylaxis
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Anaphylaxis tx
ABC
EPI 1 mg/ml 0.3 mg IM STAT
benedryl 25-50 mg IV STAT
H2RA
albuterol inhaled
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Neurogenic shock -- due to what
spinal cord injury, CNS trauma, spinal anesthesia, CNS depression
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Neurogenic shock -- systemic vaso______ and often ____cardia
vasodilation
bradycardia
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Neurogenic shock -- tx general
restore intravascular volume
vasopressors
manage hypothermia
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Neurogenic shock -- possible vasopressors
DA
NEPI
phenylephrine
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Sepsis -- systemic _____ due to a source of ____
inflammation
infection
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Sepsis -- results in systemic vaso_____ --> ____perfusion; dec anticoag --> __________; organ dysfxn leads to inc risk of _______
vasodilation --> hypoperfusion
thrombus formation
mortality
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Sepsis -- most organisms are G(___)
(+)
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Sepsis -- if GN, ____ mortality, ___ chance of septic shock
higher mortality and 2x as likely to lead to septic shock
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Sepsis -- SIRS -- need 2 of 4 criteria
- >90 bpm
- > 20 breaths / min or pCO2 <32
- temp > 38 or < 36
- WBC >12K, <4K, or >10% bands
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Sepsis -- SIRS + ____
infection
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Severe sepsis = sepsis + _____
end organ damage
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Septic shock = severe sepsis + ______
hypotension
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Life threatening organ dysfxn caused by dysregulated host response to infection
sepsis
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Sepsis + hypotension requiring vasopressors to maintain MAP≥65 and lactate >2 mmol/L
septic shock
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Scale to determine organ dysfxn
qSOFA and SOFA
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Sepsis = 1 of 3 of qSOFA + _____
infection
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qSOFA -- need 1 of 3
≥ 22 breaths/min
altered mentation
SBP ≤100 mmHg
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Sepsis -- acute goals of tx
inc intravascular volume, inc tissue perfusion and O2 delivery, get tx ASAP for infection
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Sepsis -- long-term goals of tx
tx with de-escalation, dec ICU time, dec morbidity and mortality
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Sepsis -- early goals

- CVP
- MAP
- SCVO2
CVP 8-12 mmHg
MAP 65-90 mmHg
SCVO2 ≥70%
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Sepsis -- early goal directed therapy improves ___
mortality
50
Sepsis -- central line?
no
51
Sepsis -- resuscitation with IV ______ within first 3 hours
crystalloid
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Sepsis -- recommend treating to normalize ______ concentrations
serum lactate
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Sepsis -- how soon to start abx
ASAP within 1 hour!! every hour of delay = survival decreases by 7.6%
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Sepsis -- most common site of infection
lung
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Sepsis -- abx therapy
anti MRSA --> vanc
GN coverage --> Zosyn, cefepime
+/- anaerobic --> Zosyn, carbapenem, metronidazole
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Sepsis -- abx tx how long
7-10 days
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Sepsis -- fluid replacement -- best (2)
- balanced crystalloids
LR
plasmalyte
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Sepsis -- concern with NS
chloride content and acidosis with large amt
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Sepsis -- balanced crystalloids -- which one is most affordable
LR
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Sepsis -- balanced crystalloids -- most matched to plasma components
LR
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Sepsis -- balanced crystalloids -- most matched to plasma in osmolality and tonicity
plasmalyte
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Sepsis -- vasopressors -- does not have heart effects
phenylephrine
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Sepsis -- vasopressors -- (2) helps with CO
NEPI, EPI
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Sepsis -- vasopressor with dose-dependent receptor effects
DA
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Sepsis -- vasopressor of choice for septic shock
NEPI
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Vasopressor ADRs:

- cardiac ischemia
- peripheral ischemia
cardiac: EPI
peripheral: NEPI
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Sepsis -- DA as vasopressor?
Not rec in guidelines
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Sepsis -- DA risk
tachyarrhythmias high
- only use in bradycardic pts
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Vasopressor that only has alpha activity, no central activity
phenylephrine
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Vasopressor with no alpha or ß activity
vasopressin
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Sepsis -- Vasopressin use
vasopressor as adjunct to NEPI in septic shock
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Vasopressor -- (+) strong inotrope with weak chronotropic effects
dobutamine
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Dobutamine -- net effect

- use in who
inc contractilty and cardiac muscle O2 consumption
- use in low CO or sx bradycardia
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Septic shock -- vasopressor algorithm
initiate NEPI to MAP of 65 mmHg
- if not at goal, add vasopressin
- if not at goal, add EPI
- if not at goal, add phenylephrine
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Vasopressor of choice
NEPI
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When dobutamine in septic shock
persistent hypoperfusion despite fluid resuscitaion and vasopressor use
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Septic shock -- when IV hydrocortisone
unable to achieve adequate hemodynamic stability after fluid resuscitation AND vasopressors
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Septic shock -- glucose -- tx and when to initiate
insulin when 2 consecutive BG > 180
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Septic shock -- BG goal
≤180 mg/dl

- do not want hypoBG
80
Fluid resuscitation -- balanced crystalloid dose
30 ml/kg
81
Need to check cortisol-stimulation test before hydrocortisone?
NO
82
When blood transfusion
hemoglobin <7 g/dL
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