shock gordon r. bernard, m.d
TRANSCRIPT
Shock
Gordon R. Bernard, M.D.
Division of Allergy, Pulmonary, and Critical Care Medicine
Vanderbilt University
Overall Objectives
• Understand the pathophysiology of shock
• Know the types of shock and how they differ
• Understand the therapeutic approaches to shock
Definition
• (Gross, 1882) “A manifestation of the rude unhinging of the machinery of life.”
• (Guyton, 1966) “An abnormal state of the circulation in which cardiac output is reduced enough that the tissues of the body are damaged from lack of blood flow.”
Types of Shock
• Hypovolemic• Loss of blood or plasma
• Cardiogenic• Myocardial infarction• Cardiac trauma
• Distributive• e.g., septic shock
• Obstructive• Pulmonary embolism
Arterial Resistance
• Controlled by:
• a) Arteriolar tone
• b) Precapillary sphincter» Control capillary hydrostatic pressure
• c) Postcapillary sphincter
Blood Pressure = SVR X C.O.
Factors Causing Reduced Cardiac Output
• A. Reduced venous return• Hypovolemic shock• Endotoxic shock• Anaphylactic shock• Obstruction to venous return
• B. Reduced pumping ability• Cardiogenic shock
Hemorrhagic shock
• Due to volume loss:
• Blood
• Plasma
• Fluid/electrolyte
• 10% of blood volume can be lost with minimal hemodynamic effects.
• 20% loss followed by initiation of BP reduction.
• Sympathetic activity increases.
• Vasoconstriction occurs (cerebral and coronary circulation protected).
CORRELATION OF MAGNITUDE OF VOLUME DEFICIT AND CLINICAL PRESENTATION
Approximatedeficit
Decrease in BloodVolume Degree Signs
ml %
0 – 500 0 – 10 None None
500 – 1200 10 - 25 Mild(Compromised)
Slight tachycardiaPostural blood pressure changesMild peripheral vasoconstriction
1200 – 1600 25 – 15 Moderate Thready pulse, 100-120 beats/minBlood pressure 90-100 mmHg systolicMarked vasocontrictionDiaphoresisAnxiety, restlessnessDecreased urinary output
1600-2500 16 – 60 Severe Thready pulse > 120 beats/minBlood pressure <60 mmHg systolicMarked vasocontrictionObtundationNo urinary output
Shock
Clinical Features• Sensorium
Anxiety to obtundation• Weakness or prostration• Pallor• Sweating• Tachycardia• Thready pulse• Hypotension• Tachypnea
Hypovolemic Shock
First signs are postural drop in pressure(10 mm) or increase in heart rate
Laboratory Changes
• Hematocrit - No change until dilution occurs• Blood Gas Studies:
Indicate degree of acid-base disturbance and lactic acidosis (anaerobic metabolism)
• Electrolytes and Renal Function Tests:Important baseline information
• Blood - Type and crossmatch• Urine Output - Monitor continuously
Initial:
Time Required for Blood Typing Procedures
Blood Bank Activity Time Required
Release O-negative blood (no 1 minutetesting)
Issue type specific blood (group 15 minutesand type recipient’s blood)
Carry out saline and albumin 30 minutes cross-matches
Finish complete crossmatch (regroup, 45 minutes retype, carry out saline, Coombs, and albumin crossmatches, screen recipient’s blood)
Compensatory Mechanisms
• To maintain perfusion pressure
• Sympathetic discharge• Catecholamines increase• Heart rate and contractility increased• Afferent arterioles in vascular beds constrict• Peripheral resistance• Venous capacitance vessels constricted• Increase in venous return
• Aim is to effectively perfuse coronary and carotid arteries.
• Catecholamines produce greater contraction of precapillary sphincter than postcapillary sphincter.
• Therefore, cappilary hydrostatic pressure is reduced.
• In early stages of shock this is important in pulling fluid into the intravascular space and increasing blood volume (Hct reduced).
Overall Effect:
• Constriction of arterioles and venules
• Increase in central blood volume
• Increase in cardiac output (circulates the available blood more rapidly)
• Draws interstitial fluid into intravascular space
Sympathetic Discharge
• Negative effects if sustained• Sludging of blood• Disseminated intravascular coagulation• Profound acidosis• Tissue hypoxia-cell death
• Acidosis, metabolites and hypoxia relax precapillary sphincter more than post capillary sphincter.
Late Shock
• Postcapillary sphincter resistance greater than precapillary
• Therefore, hydrostatic pressure increased
• Interstitial edema produced
Capillary Injury
• Important part of the shock process
• Maybe due to:• Increased platelet adhesiveness• Release of vasoactive materials
• Leads to further loss of plasma volume.
• Also, if in pulmonary bed may contribute to shock lung.
Shock Lung (ARDS)
• Pulmonary edema
• Alveolar hemorrhage
• Pulmonary vascular congestion
• Loss of surfactant
• Increased lymph flow
Hypovolemic Shock
• Control bleeding
• Establish and maintain airway + O2
• Assist ventilation (if necessary)
• Replace volume
• Acid-base correction
Therapy
Fluids
• Any fluid can improve perfusion, at least temporarily
• Only RBC’s carry oxygen
Two generalizations:
Fluids
• Crystalloids (electrolyte solutions)
• Colloids (large molecular weight)
• Red blood cells
Object is to refill the vascular compartment.
Choice:
Selection of Replacement Fluid
• Electrolyte solutions (crystalloids)
• Rapidly escape from intravascular space into the interstitium. Therefore, short-lived volume expansion.
Colloids (large molecules)
• Increase plasma onocotic pressure• Draw fluid into plasma space• Remain in circulation longer than crystalloids
• Raise interstitial onocotic pressure• May cause pulmonary edema
e.g. Dextran, Albumin, Hetastarch, P.P.F.
But
When they escape from circulation, e.g., through damaged capillaries:
Colloid vs Crystalloid Controversy
Choi PTL, et al. Critical Care Med 1999;27:200-10. Schierhout G, et al. BMJ 1998;316:961-4.
Lowe 1977 0.68Lucas 1978 0.07Butros 1979 2.22Virgillo 1979 1.07Moss 1981 2.43Goodwin 1983 0.27Modic 1983 1.08Rackow 1983 1.23Shires 1983 1.0Metildi 1984 0.82Sade 1985 1.83Karanko 1987 2.37Davidson 1991 1.0London 1992 0.22Pocka 1994 0.90
Overall 0.97
1 100.10.01 100
FavorsCrystalloid
FavorsColloid
Cardiogenic Shock
• Myocardial infarction
• Rhythm disturbance
Due to impaired cardiac pumping due to:
CVP Increased
Pulmonary Capillary Wedge increased
Cardiogenic Shock
• Systolic BP < 80 mm
• Cardiac Index < 2.1 liters/min/m2
• Urinary output < 20 ml/hr
• Reduced cerebral perfusion (Confusion Obtundation)
Cardiogenic Shock
• Incidence 15% of M.I.
• Mortality 70-90%
• Usually > 40% of left ventricle infarcted
Potentially Repairable Lesions
• Ruptured chordae tendinae
• Intraventricular septal defects
Cardiogenic Shock
PCWP < 18 mmHg PCWP > 18 mmHg
Expand Blood Volume Inotropic drug
Diuretic
Vasodilator
Mechanical Asst.
Dobutamine
• ß1 Stimulant
• Mainly inotropic effects
• Probably drug of choice in cardiogenic shock
Septic Shock
• Endotoxin or other mediator release• Activation of vasoactive kinins• Activation of intrinsic coagulation system
• Increasing capillary permeability• Decreased peripheral vascular resistance• Disseminated intravascular coagulation
• Mortality 40-50%
Causing
Hemodynamics:
• Peripheral resistance fails
• C.O. and HR rise (but not enough)
• BP falls
Therapy for Septic Shock
• General supportive measures
• Specific antibacterial therapy
• Corticosteroids?
• Activated protein C
Recent Randomized Studies Suggest:
High-dose steroids produce short-term improvement but no long-term effects on survival.
Treatment of Shock
Remember: problem is flow, not simply blood pressure
Aim:
To increase flow through the microcirculation
Vasoconstrictors
• Phenylephrine• Vasoconstricts• Elevates blood pressure but increases
myocardial work• Decrease cardiac output• Decrease tissue perfusion• Rarely used except in anesthesia for
management of drug induced vasodilation
1-Agonists
Dopamine
Effects Effects Dopaminergic
Low doses(1-2g/kg/min)
- - +++
Intermediate doses(2-10g/kg/min)
- ++ +++
High doses +++ +++ +++
Vasopressin in Septic Shock
• Redistributes blood flow– Away from muscle, skin, gut – To brain and heart
• High dose: coronary vasoconstriction
• Antidiuretic effect
• Inexpensive
• No proven effect on ultimate outcome
BP and Vasopressin Levels After AVP for Septic Shock
0
40
80
120
160
Baseline AVP 0.04U/min
AVP Off AVP 0.01U/min
Landry DW, et al. Circulation 1997;95:1122-5. Landry DW, et al. Crit Care Med 1997;25:1279-82.
SBP
N=10
SB
P (
mm
Hg
) o
r A
VP
leve
l (pg
/mL
)
TNFTNFIL-1, 6, 8IL-1, 6, 8
Nitric oxideNitric oxideOxidantsOxidants
BradykininBradykininThromboxaneThromboxane
ProstaglandinsProstaglandinsLeukotrienesLeukotrienes
EnzymesEnzymesComplementComplement
TNFsr IL-TNFsr IL-1ra1ra
PGE2 PGE2 IL-6 IL-IL-6 IL-
1010
Tissue FactorTissue Factor
TNFTNFIL-1IL-1IL-6IL-6IL-8IL-8
TNFTNFIL-1IL-1IL-6IL-6IL-8IL-8
VIIIaVIIIa
VaVa
TAFITAFI
PAI-1PAI-1
Inhibition of Inhibition of FibrinolysisFibrinolysis
ThrombinThrombin
APCAPC
APCAPC
APCAPC
APCAPC
APCAPC
APCAPC
APCAPC
Primary Analysis: Primary Analysis: 28-Day All-Cause Mortality28-Day All-Cause Mortality
24.7
30.8
0
5
10
15
20
25
30
35
Placebo Drotrecogin Alfa (Activated)
Mo
rtal
ity
2-sided P value 0.005Relative risk reduction 19.4%Increase in odds of survival 38.1%
N=840 N=850
Bernard GR, et al. N Engl J Med 2001;344:699-709.