Shock
States
Beyra Rossouw
Intensive Care Unit
Red Cross War Memorial Children’s Hospital
University of Cape Town
Shock
 Pathophysiology
 Different shock states
 Treatment principles
Shock is:
↑O2 Demand
O2 Delivery
Reduced Tissue Perfusion
Cellular Hypoxia & Energy Failure
Oxygen Delivery to Tissues
Ventilation
Alveoli
Gas exchange
O2 Delivery
O2 extraction
ATP
Cell
O2 consumption
Oxygen Delivery Components
O2 Content
O2 Content
x
Cardiac Output
Oxygen Delivery Components
O2 Content
Cardiac Output
Heart Rate
PaO2 SaO2
Hb
Stroke Volume
Preload Afterload Contractility
Synchrony
Oxygen Content of Blood
=(O2 carried by Hb) + (O2 in solution)
= (1.34 x Hb x Sats x 0.01) + (0.023 x PaO2)
O2
Cell
Arterial
Inflow
(Q)
O2
O2 O 2
O2 O2
capillary
O2
O2
O2
Venous
Outflow
(Q)
(Adapted from the ICU Book by P. Marino)
Shock States
Adapted from JL Vincent, ESICM 25 Years of Progress & Innovation
Cardiogenic
Dissociative
Obstructive
Clot
Capillary leak &
Vasculopathy
Distributive
Hypovolemic
Common Shock States
Distributive
Shock
Septic Shock
Anaphylatic
Neurogenic
Hypovolemic
Shock
Hemorrhage
Burns
GIT loss
Cardiogenic
Myocarditis
Arrythmia
Septic
Congenital lesions
Valvular lesions
Reduced Tissue Perfusion &
Energy Failure
Glucose
2x
ATP
Fatty
Acids
Amino
Acids
Anaerobic
Pyruvic Acid
Lactic Acid
Acetyl Co-A
Aerobic
O2
Krebs
CO2
Cycle
H+
38x
ATP
Lactate, BP & Mortality in Sepsis
Howell MD et al. ICM 2007; 33: 1892–1899
Stages of shock
O2 consumption
ATP Supply <<ATP
Demand
Anaerobic
metabolism
ATP Supply =ATP Demand
Redistribution
of blood flow
Membrane
leak
Cell
death
Irreversible
Decomp
Compensated
O2 delivery
Vasoconstriction
tachycardia
Timing of decompensation
JL Vincent, De Backer . Oxygen Delivery Controversy ICM 2004;30:1990
Hypovolaemic
Cardiogenic
Obstructive
Septic shock
O2 delivery
Hemodynamic Response to Shock
J Carcillio. Fluid Resuscitation of Hypovolemic Shock. ICM 2006;32:958
Heart
rate
Blood
pressure
Cardiac output
Compensated
Shock
Decompensated
Shock
Key Issues In Shock
 Falling BP = LATE sign.
 Pallor, tachycardia, slow CFT, restlessness
= Shock until proven otherwise.
 BP is NOT same as perfusion.
Normal
Septic shock with normal BP
De Baker CCM 2006 34 :403-408
Hemodynamic Profiles
M Pinsky. Functional hemodynamic Monitoring. Current Opinion Critical Care
2007;13:318
Capillary
flow
Hypovolemic
Cardiogenic
Septic Cold
Septic Warm
Arterial
constriction
Cardiac
output
Key Issues
Recognize & Treat during
compensatory shock phase
Mortality
increase 2-fold for every hour
in treatment delay.
Han, Carcillo. Pediatrics 2003;112:793-799
Multisystem effect of shock
 Resp: Resp failure, ARDS
 Renal: ATN, acute renal failure
 CNS: infarcts & bleeding
 Liver: centrilobular necrosis
 GIT: bleeds, necrosis, ileus, bacterial translocation
 Haemat: DIC, vasculopathy, capillary leak
Robbins & Cotran Pathologic Basis of Disease: 2005
Novel strategies for the treatment of sepsis. Riedemann
Nature Medicine 2003
Shock states coexist
Changing hemodynamics
Individualize treatment
Treatment principles
1. Increase O2 delivery
2. Reduce O2 demand
• Fever
• Tachycardia
• Tachypnea
• Anxiety & restlessness
• Pain
• Seizures & shivering
O2 delivery
O2 demand
Resuscitation Priorities
Increase O2 delivery
 V: Ventilate & Oxygenate.
 I: Infuse:



Fluids, fluids, fluids
Electrolytes
Blood- Hb >10
 P: ↑Pump Function:



Inotropes
Rhythm control
Electrolytes & glucose
 E: Etiology: - Treat the cause.
FLUID, FLUID, FLUID
 Regardless of etiology - fluid bolus x3
5ml/kg cardiac
10ml/kg trauma
20ml/kg sepsis
 Delayed fluid resuscitation ↑ mortality.
Rivers NEJM 2001, Han Pediatrics 2003
 Reassess liver & lungs.
 Septic shock may need up to 200ml/kg.
 No evidence one is fluid superior.
Finfer NEJM 2004
Permissive Hypotension for
Uncontrolled Hemorrhage
Rebleeding
Mechanic effect
on vascular clot
Anaemia
Hypothermia
Roberts et al Lancet 2001
SBP
Increase
Coagulation
disorders
Aggressive
Volume
Loading
Haemodilution
Inotropes in fluid resistance
Vasoconstriction
NORADRENALINE

↑Stroke volume, ↑ HR
1
ADRENALINE
ADRENALINE
DOBUTAMINE
DOPAMINE
DOPAMINE
NORADRENALINE
Pediatric Cardiac Intensive Care . Chang & Wernovsky
Dopamine
 Drug of choice ACCM/PALS in septic shock.
CCM 2009; 37: 2, CCM 2002; 30:6
 Low dose: DA effect -  Splanchnic vasodilatation
 Medium dose:  effect - Contractility
 High dose:  effect -  BP
 Age –specific sensitivity
 Peripheral IV
B1
++
B2
+

++
DA
++
Dobutamine
 More expensive than dopamine
 Use to contractility when BP stable
 Drug of choice for cardiacs & PHT
 Age –specific sensitivity
 Peripheral IV
B1
+++
B2
+

+
Adrenaline
 Low dose (< 0.3mcg/kg/min)  effect - Contractility
 High dose  effect -  BP
 Ideally via central line
 Side effects
 Renal dysfunction, gut ischaemia
  Glucose
  Lactate & metabolic acidosis
 Myocardial necrosis
B1
+++
B2
++

+++
Resuscitation endpoints
 No difference between peripheral & central pulses
 Warm skin, CFT < 2sec
 Normal BP for age
 Decreasing lactate & BE
 Improving mental state
 UO >1ml/kg/h
Trend of improvement
Peters ICM 2008;34
Common errors:
Failure to recognize severity.
Early recognition & Rx
Regular reassess
Ventilation delayed till arrest
Prioritise A & B
Crash intubation
Plan & prepare intubation
Myocardial depressant drugs
for intubation.
Slow administration.
•Ketamine
•Fentanyl
•Etomidate
Common errors:
•No secure IV access
•Wasting time on IV access
IO needle after 90 sec.
Inadequate fluid
•Fluidx3
•Pushed in
•Reassess liver & lungs
•Cooling
•Sedation & pain control
•Seizure control
Rx increase O2 demand
Delayed antibiotics
Antibiotics within 1 hour
Not improving








Coexisting cause of shock
Changing hemodynamics
Cardiogenic shock ? Echo
Neonate & cardiacs ? Pulm HT
Neonante ? prostin
Adrenal insufficiency ? Steroids
Tension pneumothorax
Electrolytes & glucose
Reassess ABC’s & secondary survey
Take home message
1. Early recognition.
2. Prioritise A, B, C’s.
3. Don’t Ever Forget Glucose & elects.
4. Fluid, Fluid, Fluid.
5. Reassess frequently & individualize.
6. Early antibiotics.
7. Look for coexisting etiologies.
Get The Basics Right
All The Time
?
Shock states
Similarities
Differences
Reduced tissue perfusion
Etiology
Cellular energy failure &
Multi-organ failure
Histopathology
changes
Coexisting etiology
Inflammatory response
(SIRS)
Etiologic specific Rx
Impaired immune response
Resuscitation to improve tissue
perfusion
Changing
hemodynamics
Noradrenaline
 Drug of choice for
 Warm shock
 Myocardial contractility not severely impaired
 Central line
B1
+
B2
0

++++