Monitoring www.gims-org.com Shock Shock is a Cardiovascular Derangement. 1. Deliver Oxygen and Metabolic Substrates 2. Remove Products of Cellular Metabolism 3. Thermoregulation Definition: A physiological state characterized by a significant, systemic reduction in tissue perfusion, resulting in decreased tissue oxygen delivery and insufficient removal of cellular metabolic products, resulting in tissue injury. Classification of Shock Hypovolemic Septic/Inflammatory Cardiogenic (Intrinsic, compressive & Obstructive) Neurogenic Anaphylactic Clinical Markers of Shock K l k j Brachial systolic blood pressure: <110mmHg Sinus tachycardia: >90 beats/min Respiratory rate: <7 or >29 breaths/min Urine Output: <0.5cc/kg/hr Metabolic acidemia: [HCO3]<31mEq/L or base deficit>3mEq/L Hypoxemia: 0-50yr: <90mmHg; 51-70yr: <80mmHg; >71yo<70mmHg; Cutaneous vasoconstriction vs. vasodilation. Mental Changes: anxiousness, agitation, indifference, lethargy, obtundation Etiology & Hemodynamic Changes in Shock Etiology of shock example CVP CO SVR VO2 sat preload hypovolemic low low high low contractility cardiogenic high low high low afterload distributive Etiology & Hemodynamic Changes in Shock (Afterload) ETIOLOGY OF SHOCK EXAMPLE CVP CO SVR VO2 SAT AFTERLOAD DISTRIBUTIVE Hyperdynamic Septic Low/High High Low High Hypodynamic Septic Low/High Low High Low/High Neurogenic Low Low Low Low Anaphylactic Low Low Low Low Hypovolemic Shock Decreased preload->small ventricular end-diastolic volumes -> inadequate cardiac generation of pressure and flow Causes: -- bleeding: trauma, GI bleeding, ruptured aneurysms, hemorrhagic pancreatitis -- protracted vomiting or diarrhea -- adrenal insufficiency; diabetes insipidus -- dehydration -- third spacing: intestinal obstruction, pancreatitis, cirrhosis Hypovolemic Shock Signs & Symptoms: Hypotension, Tachycardia, MS change, Oliguria, Deminished Pulses. Markers: monitor UOP,CVP, BP, HR, Hct, MS, CO, lactic acid and PCWP Treatment: ABCs, IVF (crystalloid), Trasfusion Stem ongoing Blood Loss Patients on -blockers, w/ spinal shock & athletes may not be tachycardic Septic/Inflammatory Shock Mechanism: release of inflammatory mediators leading to 1. Disruption of the microvascular endothelium 2. Cutaneous arteriolar dilation and sequestration of blood in cutaneous venules and small veins Causes: 1. Anaphylaxis, drug, toxin reactions 2. Trauma: crush injuries, major fractures, major burns. 3. infection/sepsis: G(-/+ ) speticemia, pneumonia, peritonitis, meningitis, cholangitis, pyelonephritis, necrotic tissue, pancreatitis, wet gangrene, toxic shock syndrome, etc. Septic/Inflammatory Shock Signs: Early warm w/ vasodilation, often adequate urine output, febrile, tachypneic. Late-- vasoconstriction, hypotension, oliguria, altered mental status. Monitor/findings: Earlyhyperglycemia, respiratory alkylosis, hemoconcentration, WBC typically normal or low. Late Leukocytosis, lactic acidosis Very Late Disseminated Intravascular Coagulation & Multi-Organ System Failure. Tx : ABCs, IVF, Blood cx, ABX, Drainage (ie abscess) pressors. Cardiogenic Shock Mechanism: Intrinsic abnormality of heart -> inability to deliver blood into the vasculature with adequate power Causes: 1. Cardiomyopathies: myocardial ischemia, myocardial infarction, cardiomyopathy, myocardiditis, myocardial contusion 2. Mechanical: cardiac valvular insufficiency, papillary muscle rupture, septal defects, aortic stenosis 3. Arrythmias: bradyarrythmias (heart block), tachyarrythmias (atrial fibrillation, atrial flutter, ventricular fibrillation) 4. Obstructive disorders: PE, tension peneumothorax, pericardial tamponade, constrictive pericaditis, severe pulmonary hypertension Cardiogenic Shock Characterized by high preload (CVP) with low CO Signs/SXS: Dyspnea, rales, loud P2 gallop, low BP, oliguria Monitor/findings: CXR pulm venous congestion, elevated CVP, Low CO. Tx: CHF diuretics & vasodilators +/- pressors. LV failure pressors, decrease afterload, intraaortic ballon pump & ventricular assist device. Neurogenic Shock Causes: 1. Spinal cord injury 2. Regional anesthesia 3. Drugs 4. Neurological disorders Mechanism: Loss of autonomic innervation of the cardiovascular system (arterioles, venules, small veins, including the heart) Neurogenic Shock Characterized by loss of vascular tone & reflexes. Signs: Hypotension, Bradycardia, Accompanying Neurological deficits. Monitor/findings: hemodynamic instability, test bulbo- carvernous reflex Tx: IVF, vasoactive medications if refractory Monitoring Adjuncts in Shock Sphyngomanometry Pulse Oximeter Arterial Line Central Venous Line (Cordice, Triple Lumen, Pulmonary Artery Catheter) Pulmonary Artery Catheterization K l k j Allows for accurate and continuous hemodynamic monitoring in shock patients 1. Evaluate Fluid Resuscitation 2. Titration of Vasoactive Medications 3. Allows for Assessment of Cardiovascular Performance. 4. Monitor the Effects of Changes in Mechanical Ventilation. Pulmonary Artery Catheterization K l k j Pulmonary Artery Catheterization: cardiovascular performance K l k j Central Venous Pressure (CVP): CVP = right atrial pressure (RAP) = right-ventricular end-diastolic pressure (RVEDP) (Right Ventricular Preload) Pulmonary Capillary Wedge Pressure (PCWP) PCWP = left atrial pressure (LAP) = left-ventricular end-diastolic pressure (LVEDP) (Left Ventricular Preload) Cardiovascular Performance K l k j Cardiac Output (CO) = HR x SV (L/min) Normal CO = 4 to 8 L/min Cardiac Index (CI) = CO/BSA (L/min/m 2 ) Normal CI = 2.5-4.2 L/min/m2 Stroke Volume Index (SVI): CI/HR (ml/beat/m 2 ) Normal SVI = 40-85 ml/beat/m2 Systemic Vascular Resistance = MAP CVP / CO x 80 Normal SVR = 900-1600 dynes/sec/cm -5 Systemic Vascular Resistance Index = MAP CVP / CI x 80 Normal SVRI = 1970-2390 dynes/sec/cm-5 Pulmonary Artery Catheterization: systemic oxygen transport K l k j Oxygen Delivery (DO 2 ) [520-570 mL/min x m 2 ]: rate of oxygen transport in arterial blood DO 2 = CI x 13.4 x Hb x SaO 2 Oxygen Uptake (VO 2 ) [110-160 ml/min x m 2 ]: rate of oxygen taken up from the systemic microcirculation VO 2 = CI x 13.4 x Hb x (SaO 2 SvO 2 ) Hemodynamic Profiles K l k j PCWP CVP CO/CI SVR/I Hypovolemic Low Low Low High Cardiogenic High High Low High Inflammatory Low / N Low/N High Low Neurogenic Low Low Low Low Shock