Shock and Multisystem

Failure

Rudolf M. Tan
 Shock
• A condition in which tissue perfusion is
inadequate to deliver oxygen and nutrients to
support vital organs and cellular function
• Affects all body systems
 Classifications of Shock
• Hypovolemic
• Cardiogenic
• Septic
• Neurogenic
• Anaphylactic
– Hemolytic
• Psychogenic
Cellular Effects of Shock
Compensatory Mechanisms in Shock
 Stages of Shock:
• Compensatory
• Progressive
• Irreversible
 Compensatory Stage of Shock
• SNS causes vasoconstriction, increased HR, and
increased heart contractility.
• This maintains BP and CO.
• Body shunts blood from skin, kidneys, and GI
tract, which results in cool, clammy skin,
hypoactive bowel sounds, and decreased urine
output.
• Perfusion of tissues is inadequate.
• Acidosis occurs as a result of anaerobic
metabolism.
• Respiratory rate increases due to acidosis and
may cause a compensatory respiratory alkalosis.
• Confusion may occur.
 Progressive Stage of Shock
• Mechanisms that regulate BP can no longer
compensate, and BP and MAP decrease.
• All organs suffer from hypoperfusion.
• Vasoconstriction continues, further
compromising cellular perfusion.
• Mental status further deteriorates as a result
of decreased cerebral perfusion and hypoxia.
 Progressive Stage of Shock
• Lungs begin to fail, decreased pulmonary blood
flow causes further hypoxemia, and carbon
dioxide levels increase; alveoli collapse and
pulmonary edema occur.
• Inadequate perfusion of the heart leads to
dysrhythmias and ischemia.
• As MAP falls below 70, GFR cannot be
maintained. Acute renal failure may occur.
• Liver function, GI function, and hematologic
function are all affected.
• DIC (disseminated intravascular coagulation) may
occur as a cause or complication of shock.
 Irreversible Stage of Shock
• At this point, organ damage is so severe that the
patient does not respond to treatment and
cannot survive.
• BP remains low.
• Renal and liver functions fail.
• Anaerobic metabolism worsens acidosis.
• Multiple organ dysfunction progresses to
complete organ failure.
• The judgment that shock is irreversible is made
only in retrospect.
 For All Types of Shock
• Early identification and timely treatment
• Identify and treat the underlying cause
• The sequence of events for the different types
of shock will vary. Therefore, the management
and care of the patient will vary.
Pathophysiology of Hypovolemic Shock
Modified Trendelenburg
Pathophysiology of Cardiogenic Shock
 Circulatory Shock

• Septic shock
• Neurogenic shock
• Anaphylactic shock
Pathophysiology of Circulatory Shock
 Management of All Types of Shock
• Fluid replacement to restore intravascular
volume
• Vasoactive medications to restore vasomotor
tone and improve cardiac function
• Nutritional support to address metabolic
requirements
 Fluid Replacement
• Crystalloids: 0.9% saline, lactated Ringer’s,
hypertonic solutions (3% saline)
• Colloids: albumin, dextran (dextran may
interfere with platelet aggregation)
• Blood components for hypovolemic shock
• Complications of fluid replacement include
fluid overload and pulmonary edema.
 Vasoactive Medications
• Used when fluid therapy alone does not maintain
MAP
• Support hemodynamic status; stimulate the SNS
• Do vital signs frequently; continuous monitoring
of vital signs every 15 minutes or more often.
• Give through central line if possible. Extravasation
may cause extensive tissue damage.
• Dosages are usually titrated to patient response.
 Nutritional Therapy
• Nutritional support is needed to meet
increased metabolic and energy requirements
and prevent further catabolism due to
depletion of glycogen.
• Support with parenteral or enteral nutrition.
• GI system should be used, if possible, to
support its integrity.
• Administration of glutamine
• Administration of H2 blockers or proton pump
inhibitors
 Psychological Support of Patients and
Families
• Anxiety
• Support of coping
• Patient and family education
• Communication
• End-of-life issues
• Grief processes
Multiple Organ Dysfunction Syndrome:
MODS
• A phase of the progression of shock
• Altered organ function that requires medical
intervention to support continued organ
function
• Classified as primary or secondary
• High mortality rate; 75%
• Prevention is key.