This document provides an overview of shock and hemodynamic monitoring using a pulmonary artery catheter. It defines shock as inadequate organ perfusion and outlines the main categories of shock: hypovolemic, cardiogenic, distributive, and obstructive. It discusses goals of fluid resuscitation in shock and reviews hemodynamic parameters measured by a pulmonary artery catheter such as cardiac output, vascular resistances, and oxygen transport variables. The document uses case studies to demonstrate how these parameters can be utilized to diagnose and guide treatment in different shock states.
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Shock
1. Shock
Scott G. Sagraves, MD, FACS
Assistant Professor
Trauma & Surgical Critical Care
Associate Director of Trauma
UHS of Eastern Carolina
2. Objectives
•
•
•
•
Define & classify shock
Outline management principles
Discuss goals of fluid resuscitation
Understand the concepts of oxygen
supply and demand in managing shock.
• Describe the physiologic effects of
vasopressors and inotropic agents
3. Goals
• Review hemodynamic techniques in the ICU
• Introduce the concept of the cardiac cycle
• Review of the pulmonary artery catheter
parameters
• Utilize the presentation to analyze clinical
cases and to feel comfortable with pa-c
parameters.
5. Hypotension
• In Adults:
– systolic BP ≤ 90 mm Hg
– mean arterial pressure ≤ 60 mm Hg
systolic BP > 40 mm Hg from the
patient’s baseline pressure
8. Pathophysiology
ATP + H2O ⇒ ADP + Pi + H+ + Energy
Acidosis results from the accumulation of acid
when during anaerobic metabolism the
creation of ATP from ADP is slowed.
H+ shift extracellularly and a metabolic acidosis
develops
9. Pathophysiology
• ATP production fails, the Na+/K+ pump
fails resulting in the inability to correct
the cell electronic potential.
• Cell swelling occurs leading to rupture
and death.
• Oxidative Phosphorylation stops &
anaerobic metabolism begins leading to
lactic acid production.
10. Why Monitor?
• Essential to understanding their disease
• Describe the patient’s physiologic
status
• Facilitates diagnosis and treatment of
shock
11. History
• 1960’s
– low BP = shock; MSOF resulted after BP
restored
• 1970’s
– Swan & Ganz - flow-directed catheter
– thermistor → cardiac output
• 1980’s
– resuscitation based on oxygen delivery,
consumption & oxygen transport balance.
17. Standard Parameters
• Measured
– Blood pressure
– Pulmonary A.
pressure
– Heart rate
– Cardiac Output
– Stroke volume
– Wedge pressure
– CVP
• Calculated
–
–
–
–
Mean BP
Mean PAP
Cardiac Index
Stroke volume
index
– SVRI
– LVSWI
– BSA
18. Why Index?
• Body habitus and size is individual
• Inter-patient variability does not allow
“normal” ranges
• “Indexing” to patient with BSA allows for
reproducible standard
19. Index Example
PATIENT A
•
•
•
•
60 yo male
50 kg
CO = 4.0 L/min
BSA = 1.86
CI = 2.4 L/min/m2
PATIENT B
•
•
•
•
60 yo male
150 kg
CO = 4.0 L/min
BSA = 2.64
CI = 1.5 L/min/m2
25. Hemodynamic Calculations
Parameter
Cardiac Index (CI)
Normal
2.8 - 4.2
Stroke Volume Index (SVI)
30 - 65
Sys Vasc Resistance Index (SVRI)
1600 - 2400
Left Vent Stroke Work Index (LVSWI) 43 - 62
26. Cardiac Index
C.I. = HR x SVI
SVI measures the amount of blood ejected by the
ventricle with each cardiac contraction.
Total blood flow = beats per minute x blood volume ejected per beat
27. Vascular Resistance Index
SYSTEMIC (SVRI)
MAP - CVP
CI
x 80
↑ SVR = vasoconstriction
↓ SVR = vasodilation
PULMONARY (PVRI)
MPAP - PAOP
CI
x 80
↑PVR = constriction
PE, hypoxia
Vascular resistance = change in pressure/blood flow
28. Stroke Work
LVSWI = (MAP-PAOP) x SVI x 0.0136
normal = 43 - 62
VSWI describe how well the ventricles
are contracting and can be used to
identify patients who have poor
cardiac function.
ventricular stroke work = ∆ pressure x vol. ejected
30. Definitions
• O2 Delivery - volume of gaseous O2
delivered to the LV/min.
• O2 Consumption - volume of gaseous
O2 which is actually used by the
tissue/min.
• O2 Demand - volume of O2 actually
needed by the tissues to function in an
aerobic manner
Demand > consumption = anaerobic metabolism
31. Rationale for Improving
O2 Delivery
Insult
Tissue Hypoxia
Demands are met
Increased Delivery
Increased Consumption
32. VO2I
Critical O2 Delivery
The critical value is
variable
& is dependent upon the
patient, disease, and the
metabolic demands of the
patient.
DO2I
33. Oxygen Calculations
• Arterial Oxygen Content
(CaO2)
• Venous Oxygen Content
(CvO2)
• Arteriovenous Oxygen
Difference (avDO2)
• Delivery (O2AVI)
• Consumption (VO2I)
Efficiency of
the
oxygenation
of blood and
the rates of
oxygen
delivery and
consumption
34. Arterial Oxygen Content
CaO2 = (1.34 x Hgb x SaO2) + (PaO2 x 0.0031)
If low, check hemoglobin or pulmonary gas
exchange
36. Oxygen Delivery (DO2I)
O2AVI = CI x CaO2 x 10
Normal values suggests that the heart
& lungs are working efficiently to
provide oxygen to the tissues.
< 400 is bad sign
37. Oxygen Consumption
VO2I = CI x (CaO2 - CvO2)
If VO2I < 100 suggest tissues are not
getting enough oxygen
40. Resuscitation Goals
• CI = 4.5 L/min/m2
• DO2I = 600 mL/min/m2
• VO2I = 170 mL/min/m2
NOT ALL PATIENTS CAN ACHIEVE THESE GOALS
Critically ill patients who can respond to their disease states by
spontaneously or artificially meeting these goals do show a
better survival.
50. Treatment - Hypovolemic
• Reverse hypovolemia vs. hemorrhage
control
• Crystalloid vs. Colloid
• PASG role?
• Pressors?
51. Resuscitation
• Transport times < 15 minutes showed
pre-hospital fluids were ineffective,
however, if transport time > 100 minutes
fluid was beneficial.
• Penetrating torso trauma benefited from
limited resuscitation prior to bleeding
control. Not applicable to BLUNT
victims.
52. Fluid Administration
•
•
•
•
1 L crystalloid ≈ 250 ml colloid
crystalloids are cheaper
blood must supplement either
FFP for coagulopathy, NOT volume
• Watch for hyperchloremic metabolic acidosis
when large volumes of NaCl are infused
• NO survival benefit with colloids
53. Role of PASG?
• Houston - Higher mortality rate in penetrating
thoracic, cardiac trauma
• No benefit in penetrating cardiac trauma
• Role undefined in rural, blunt trauma
• Splinting role
54. Cardiogenic Shock
• Cause
– defect in cardiac function
• Signs
cardiac output
PAOP
SVR
left ventricular stroke work (LVSW)
58. SIRS - Distributive Shock
• Prompt volume replacement - fill the tank
• Early antibiotic administration - treat the cause
• Inotropes - first try Dopamine
• If MAP < 60
– Dopamine = 2 - 3 µg/kg/min
– Norepinephrine = titrate (1-100 µg/min)
• R/O missed injury
59. Adrenal Crisis
Distributive Shock
• Causes
– Autoimmune adrenalitis
– Adrenal apoplexy = B hemorrhage or infarct
– heparin may predispose
• Steroids may be lifesaving in the patient
who is unresponsive to fluids, inotropic,
and vasopressor support. Which one?
66. Dobutamine
∀ β-agonist
• 5 - 20 µg/kg/min
• potent inotrope, variable chronotrope
• caution in hypotension (inadequate volume)
may precipitate tachycardia or worsen
hypotension
67. Norepinephrine
• Potent α-adrenergic vasopressor
• Some β-adrenergic, inotropic, chronotropic
• Dose 1 - 100 µg/min
• Unproven effect with low-dose dopamine to
protect renal and mesenteric flow.
68. Epinephrine
∀ α- and β-adrenergic effects
• potent inotrope and chronotrope
• dose 1 - 10 µg/min
• increases myocardial oxygen consumption
particularly in coronary heart disease
69. Amrinone
• Phosphodiesterase inhibitor, positive inotropic
and vasodilatory effects
• increased cardiac stroke output without an
increase in cardiac stroke work
• most often added with dobutamine as a second
agent
• load dose = 0.75 -1.5 mg/kg → 5 - 10 µg/kg/min
drip
• main side-effect - thrombocytopenia
73. GSW
• 24 year old male victim of a
shotgun blast to his right lower
quadrant/groin at close range.
• Hemodynamically unstable in the
field and his right lower extremity
was cool and pulseless upon
arrival to the trauma resuscitation
area.
75. Post-op
• Patient received 12 L crystalloid, 15
units of blood, 6 units of FFP, and 2 6
packs of platelets.
• HR 130, BP 96/48, T 34.7° C
• PAWP 8, CVP 6, CI 4.2, SVRI 2700,
LVSWI 42.
Diagnosis? Treatment?
81. Auto-Pedestrian Crash
• Thrown from the
rear bed of pick up
truck during a MVC
at 60 mph.
• Hemodynamically
unstable
• Pain to palpation of
the pelvis
• Hematuria with
Foley® insertion
85. Sepsis
• Fluids
• Correct the cause
• Antibiotics
• Debridement
• Vasopressors
– Phenylephrine
– Levophed
86. Initial Resuscitation
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•
•
•
•
CVP: 8- 12 mm Hg
MAP ≥ 65 mm Hg
UOP ≥ 0.5 cc/kg/hr
Mixed venous Oxygen Sat ≥ 70%
Consider:
– Transfusion to Hgb ≥ 10
– Dobutamine up to 20 µg/kg/min
87. Vasopressors
• Assure adequate fluid volume
• Administer via CVL
• Do not use dopamine for renal
protection
• Requires arterial line placement
• Vasopressin:
– Refractory shock
– Infusion rate 0.01 – 0.04 Units/min
88. Steroid Use in Sepsis
• Refractory shock 200-300 mg/day of
hydrocortisone in divided doses for
7 days
• ACTH test
• Once septic shock resolves, taper
dose
• Add fludrocortisone 50 µg po q day
89. Geriatric Trauma
• 70 year old female
• MVC while talking on
her cell phone
• ruptured diaphragm
and spleen s/p OR
• Intubated and PA-C