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Tugas DR Yoma Anca
Tugas DR Yoma Anca
CARDIOGENIC
SHOCK
Fiddy Firmansyah
17-777-013
SEPTIC SHOCK
In the setting of suspected or documented
infection, septic shock is typically defined in
a clinical setting by low systolic (≤90 mm
Hg) or mean arterial blood pressure (≤65
mm Hg) accompanied by signs of
hypoperfusion (eg, oliguria, hyperlactemia,
poor peripheral perfusion, or altered mental
status).
TREATMENT OF
SEPTIC SHOCK
INITIAL RESUSCITATION
INFECTION ISSUES
Initial resuscitation
• Central venous pressure (CVP) 8-12 mm Hg
• Mean atrial pressure (MAP) ≥ 65 mm Hg
• Urine output ≥ 0.5 ml/kg/hr
• Central venous (superior vena cava) or mixed
venous oxygen saturation 70% or 65%,
respectively
• In patients with elevated lactate levels targeting
resuscitations to normazile lactate
SCREENING FOR SEPSIS AND
PERFOMACE IMPROVEMENT
Routine screening of potentially infected
seriously ill patients for severe sepsis to
allow earlier implementation of therapy
(grade 1C). Hospital–based performance
improvement efforts in severe sepsis (UG).
DIAGNOSIS
To optimize identification of causative organisms,
we recommend at least two blood cultures be
obtained before antimicrobial therapy is
administered as long as such cultures do not cause
significant delay (>45 minutes) in antimicrobial
administration, with at least one drawn
percutaneously and one drawn through each
vascular access device, unless the device was
recently (<48 hr.) inserted (Grade 1C).
ANTIMICROBIAL THERAPHY
• Administration of effective intravenous
antimicrobials within the first hour of
recognition of septic shock (grade 1B) and
severe sepsis without septic shock (grade
1C) as the goal of therapy.
SOURCE CONTROL
• No randomized-controlled data
• Don’t be satisfied with a diagnosis of
sepsis and no source.
• If a source exists and is potentially
removable, get the ball rolling.
INFECTION PREVENTION
• Selective oral decontamination and selective digestive
decontamination should be introduced and investigated
as a method to reduce the incidence of ventilator-
associated pneumonia; this infection control measure
can then be instituted in health care settings and regions
where this methodology is found to be effective (grade
2B).
• Oral chlorhexidine gluconate be used as a form of
oropharyngeal decontamination to reduce the risk of
ventilator-associated pneumonia in ICU patients with
severe sepsis (grade 2B).
FLUID THERAPY
• Crystalloids (1B)
• Albumin (2C)
• Avoid HES (1B)
VASOPRESSOR
• We recommend norepinephrine as the first
choice vasopressor (Grade 1 B).
• We suggest epinephrine (added to and
potentially substituted for norepinephrine) when
an additional agent is needed to maintain blood
pressure (Grade 2B).
• Vasopressin .03 units/min can be added to
norepinephrine with the intent of raising MAP to
target or decreasing or decreasing
norepinephrine dosage. (UG)
INOTROPIC THERAPY
• A trial of dobutamine infusion up to 20
micrograms/kg/min be administered or added to
vasopressor (if in use) in the presence of (a)
myocardial dysfunction as suggested by elevated
cardiac filling pressures and low cardiac output,
or (b) ongoing signs of hypoperfusion, despite
achieving adequate intravascular volume and
adequate MAP (grade 1C).
• Not using a strategy to increase cardiac index to
predetermined supranormal levels (grade 1B).
CORTICOSTEROIDS
• We suggest against using intravenous
hydrocortisone to treat septic shock
patients if adequate fluid resuscitation and
vasopressor therapy are able to restore
hemodynamic stability. If this is not
achievable, we suggest intravenous
hydrocortisone at a dose of 200 mg per
day.
CARDIOGENIC SHOCK
CARDIOGENIC SHOCK
The clinical definition of cardiogenic shock is
decreased cardiac output and evidence of tissue
hypoxia in the presence of adequate
intravascular volume. Cardiogenic shock is the
leading cause of death in acute myocardial
infarction (MI), with mortality rates as high as
70-90% in the absence of aggressive, highly
experienced technical care.
TREATMENT OF
CARDIOGENIC SHOCK
THERAPY/TREATMENT
• ACC Guidelines
• Diuretics
• Cardiac Catheterization
Arterial Pressure
Standby Counterpulsation
Inflation
Deflation Inflation
Systole Diastole