How to approach the patient in
shock
Payam Parvinchiha, MD
Internal Medicine Chief Resident
July 2014
Case 1, Part 1
It’s your first day on wards. You get a page
“patient’s BP is 80/40.”
•When are you going to see the patient?
•What questions do you want to ask?
•What are some orders to consider?
Learning Objectives
1. Approach to the patient with shock
Physiology
Pathophysiology
Physical exam
2. Recognize Shock
3. Differentiate b/w SIRS, Sepsis, & Septic Shock
4. Lactate levels and mortality in sepsis
5. Implement Early Goal Directed Therapy
Blood Pressure Physiology
• Mean arterial blood pressure
– MAP = CO x SVR
– MAP = 1/3 SBP + 2/3 DBP
– MAP goal is to maintain perfusion of the vital organs
– MAP goal is dependent on patient’s individual physiology
• Cardiac Output
– CO = HR x SV
Physiologic Approach: MAP= CO x SVR
– Low CO, High SVR
• Cool extremities, slow capillary refill
• Cardiogenic, Tamponade, Pulmonary Embolus,
Tension pneumothorax, and Hypovolemic shock
• Very late septic shock
– High CO, Low SVR
• Wide pulse pressure, warm extremities, normal
capillary refill
• Early septic shock, adrenal insufficiency, anaphylaxis,
neurogenic, thyroid storm, AV fistulas
Hypotension vs. Shock
• Hypotension is an abnormal vital sign
• Shock is a physiologic state defined by vital organ
hypoperfusion
• Not everyone with hypotension is in shock
• Not everyone in shock is hypotensive
• By evaluating and treating hypotension EARLY, you
can prevent progression to shock
Etiologies of Shock
CATEGORY
PHYSIOLOGY
ETIOLOGIES
Hypovolemic
Decreased venous return
Blood loss
Fluid loss
Cardiogenic
Cardiac pump failure/Low CO
Left/Right Ventricular failure
Valvular dysfunction
Arrhythmia
Distributive
Decreased SVR
(Vasodilated)
Anaphylactic (FFP)
Adrenal insufficiency
Neurogenic
Obstructive
Extra-cardiac obstruction to
blood flow
Tamponade
Pulmonary Embolus
Tension Pneumothorax
Septic
Sepsis
Case 1: Part 1
It’s your first day on wards. You get a page
“patient’s BP is 80/40.”
•When are you going to see the patient?
•What questions do you want to ask?
•What are some orders to consider?
When do you evaluate the
hypotensive patient?
Immediately
I will be there in 1 minute
Questions to ask yourself
• Is patient symptomatic – delirium, dyspnea, chest
pain, oliguria, bleeding, vomiting, diarrhea
• Why is patient in hospital
• Vitals: Temp, HR, RR, pulse ox, prior BP
• Meds: Antibiotics/Blood pressure
• Recent procedures – endoscopy, cardiac
catheterization, IR procedures, surgery
• How much IVF has been given and did they respond
Orders to consider as you head over
to see the patient
•
•
•
•
•
•
•
CBC, CMP
Lactate, troponin
Urinalysis, Urine Culture, Blood Cultures
ABG/EKG/CXR
Cortisol level/ACTH stim test
IVF/Blood Transfusion
Grab the bedside ultrasound
Case 1, Part 2
Bedside, the patient is lethargic and unable to
speak and there is no family at bedside
What constellation of physical exam signs can
help you narrow you differential diagnosis?
Helpful physical exam findings
• GEN: Delirium, confusion, lethargy, accessory muscle use
• HEENT: Dry mucous membranes
• CV: Jugular venous distension/flattening, murmurs, extra
heart sounds, irregular tachycardia?
• Lungs: Asymmetric hemi-thorax, rales or other
abnormalities
• Abdomen: Absent bowel sounds, distension, rebound
– Palpate the back, groin, and thigh
• Extremities: edema
• Skin: Pallor, cyanosis, capillary refill, warm or cold
Case 1, Part 3
•
•
•
•
•
•
•
•
•
•
•
•
Patient admitted earlier today for confusion
Vitals: 39 C, HR 130, RR 22, BP 80/40, 98% RA,
Confused
Dry mucous membranes
Symmetric, CTAB
S1 S2 regular tachycardia
Cool extremities
Abd Soft, mildly distended, nontender, few bowel sounds
CVA tenderness on Right
UA: 200 WBC and few bacteria
Urine output 10cc/hr
WBC 25,000
Definitions of SIRS/Sepsis
• Bacteremia: Positive Blood Cultures
• SIRS: 2 or more
– T <36 or >38
– HR >90
– RR >20
– WBC <4000 or >12000 or 10% bands
• SEPSIS: SIRS that has proven or suspected microbial etiology
• SEVERE SEPSIS: Sepsis induced tissue hypoperfusion with organ
dysfunction
• SEPTIC SHOCK: Sepsis with hypotension despite adequate fluid
resuscitation or vasopressors needed to maintain SBP >90 or MAP >65
What defines severe sepsis vs sepsis?
Tissue hypoperfusion
•
•
•
•
•
•
•
•
Elevated lactate
Urine output <30cc/kg – foley
Acute kidney injury
Elevated troponins
Transaminitis
Altered mental status, chest pain
Ischemic bowel
gangrene
SIRS and SEPSIS
Lactate and Mortality in Sepsis
• Optimizing Oxygen delivery to the vital
organs.
• O2 delivery = CO x 1.34 x Hb x %O2
saturation
• Serum Lactate: biochemical evidence of
suboptimal tissue O2 delivery
Serum lactate is associated with mortality in severe sepsis independent
of organ failure and shock
Figure 3. Association
between serum lactate level
and 28-day mortality,
stratified by the presence of
shock. Serum lactate
categorized as follows:
low = 0-1.9 mmol/L,
intermediate = 2-3.9
mmol/L
high = 4 mmol/L.
Critical Care Medicine. 37(5):1670-1677, May 2009.
DOI: 10.1097/CCM.0b013e31819fcf68
© 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams
& Wilkins, Inc.
2
Surviving Sepsis Campaign
• 1. Goal-oriented hemodynamic resuscitation
• 2. Cultures (Blood, Urine, CSF, etc)
– Before antibiotics if does not delay antibiotic
administration by more than 45 minutes
• 3. Antimicrobial antibiotics in the first 1 hour of recognizing
severe sepsis or septic shock
• 4. Check lactate in first 3 hours
• 5. Source control of infection
Hemodynamic Resuscitation
It’s all about optimizing Oxygen delivery to the
tissue.
MAP = CO x SVR
CO = HR x SV
O2 delivery = CO x 1.34 x Hb x %sat O2
Early Goal Directed Therapy
• Early hemodynamic resuscitation in the first 6 hours based
on CVP, MAP, ScvO2 (%), Hct
• Randomized, controlled, single-center study
• Urban center ED
• 130 assigned to early goal directed therapy
• 133 assigned to standard therapy
– Achieving these targets resulted in a 15.9% absolute
reduction in 28 day mortality
Protocol for Early Goal-Directed Therapy.
Rivers E et al. N Engl J Med 2001;345:1368-1377.
Early “Hemodynamic” Goal Directed
Therapy: The first 6 hours
• Give first 2L IVF bolus over 10 minutes, then check CVP
immediately (use pressure bags or rapid infuser)
• check measures of vital organ perfusion:
– lactate, blood pH, urine output, MAP
• Repeat 1L bolus every 10 minutes until CVP 8-12 or vital
organ perfusion is achieved
Case 1, Part 4
• Patient receives 6L of IVF, CVP 12, and BP
now 80/60, urine output 15cc/hr, lactate 5
• Patient meets criteria for septic shock
Protocol for Early Goal-Directed Therapy.
Rivers E et al. N Engl J Med 2001;345:1368-1377.
Vasopressors
Vasopressors
First line: Norepinephrine (Levophed)
Second line: Epinephrine
Third line: Vasopressin (0.04 units/min fixed dose)
Patient requires norepinephrine and epinephrine to
maintain adequate vital organ perfusion
Protocol for Early Goal-Directed Therapy
O2 delivery = CO x 1.34 x Hb x %saturation O2
Inotropes
First line: Dobutamine (max dose 20mcg/kg/min)
-myocardial dysfunction
-ongoing hypoperfusion despite adequate
intravascular volume and MAP
Corticosteroids in ICU
• Why?
– Cytokine release TNF alpha, IL-1, IL-2 via an unknown
mechanisms induces adrenal insufficiency
• When to start?
– When adequate fluid hydration and vasopressors are not
enough to restore hemodynamic stability
– Cortisol level, ACTH stim test are not needed
• Hydrocortisone 50mg IV q6
– Glucocorticoid + Mineralocorticoid effect
Protocol for Early Goal-Directed Therapy.
Rivers E et al. N Engl J Med 2001;345:1368-1377.
Protocol for Early Goal-Directed Therapy
UCI Severe Sepsis Order Set
Case 1 Review
•
•
•
•
•
•
•
•
•
•
•
SIRS criteria 39 C, HR 130, RR 22, WBC 25K
Source of infection identified
UO 15cc/hr, lactate 5
2L IVF -> BP 80/60
How much IVF do you give and how?
What do you do if MAP still inadequate for vital tissue
perfusion?
How do you assess adequate tissue perfusion?
Which vasopressors?
When do you transfuse PRBC?
When do you start steroids and which one?
What is the name of the order set if you don’t know what to
do for sepsis?
Case 1 Finale
• Transferred out of ICU 2 days later
• Patient survived
• GOOD WORK!
The key to success as an intern in the ICU:
• Hypotension is a vital sign
• Shock is a physiologic state defined by vital organ
hypoperfusion
• MAP goal is to maintain perfusion of the vital organs
– MAP = CO x SVR
– MAP = 1/3 SBP + 2/3 DBP
• 5 categories of shock: Hypovolemic, Distributive,
Cardiogenic, Obstructive, Septic
• Identify shock early in patients on the wards and ICU
• Know goal directed therapy!
Etiologies of Shock
CATEGORY
PHYSIOLOGY
ETIOLOGIES
Hypovolemic
Decreased venous return
Blood loss
Fluid loss
Cardiogenic
Cardiac pump failure/Low CO
Left/Right Ventricular failure
Valvular dysfunction
Arrhythmia
Distributive
Decreased SVR
(Vasodilated)
Anaphylactic (FFP)
Adrenal insufficiency
Neurogenic
Obstructive
Extra-cardiac obstruction to
blood flow
Tamponade
Pulmonary Embolus
Tension Pneumothorax
Septic
Sepsis
References
• Early Goal Directed Therapy in the Treatment of Severe Sepsis and Septic
Shock NEJM 345, 19. Nov 8, 2001
• Principles of Critical Care, 3rd edition. Chapter 21: Shock
• Serum lactate is associated with mortality in severe sepsis independent of
organ failure and shock. Critical Care Medicine. 37(5):1670-1677, May
2009.
• Surviving Sepsis Campaign
• Corticus trial: Corticosteroids in sepsis
• Transfusion Requirements in Crticial Care evaluated mortality and Hb 7-9
From: Medical Management of Advanced Heart Failure
JAMA. 2002;287(5):628-640. doi:10.1001/jama.287.5.628
Date of download: 7/20/2013
Copyright © 2012 American Medical
Association. All rights reserved.