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Shock Syndromes I Gretchen L. Sacha, Pharm.D., FCCM, BCCCP Cleveland Clinic Cleveland, Ohio…

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Shock Syndromes I Shock Syndromes I Gretchen L. Sacha, Pharm.D., FCCM, BCCCP Cleveland Clinic Cleveland, Ohio…

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Learning Objectives 3 min

Shock Syndromes I Learning Objectives 1. Distinguish between the various shock syndromes on the basis of a patient’s clinical and hemodynamic parameters. 2. Interpret hemodynamic data from monitor…

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Shock Syndromes I determined that the patient is still fluid responsive, you would like to give another fluid bolus. Which fluid is best for the fluid bolus? A. 0.9% sodium chloride. B. 5% albumin…

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Shock Syndromes I 8. A 68-year-old woman (weight 88 kg) presents to the ED with a urinary tract infection. Her medical his- tory is significant for paroxysmal atrial fibrillation. The patient’s vit…

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Exam Content Outline 1 min

Shock Syndromes I BPS Critical Care Pharmacy Examination Content Outline This chapter covers the following sections of the Critical Care Pharmacy Examination Content Outline: 1. Domain 1: Critical Ca…

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Data Tables 3 min

Shock Syndromes I I.  INTRODUCTION A. Shock 1. Shock is a heterogeneous group of syndromes best defined as “acute circulatory failure.” This arises when the tissues receive an insufficient supply o…

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Data Tables 4 min

Shock Syndromes I Value Equation (as applicable) Normal Value Pulmonary artery diastolic pressure (PADP) 8–12 mm Hg Mean pulmonary artery pressure (mPAP) [PASP + (2 × PADP)]/3 12–15 mm Hg Pulmonary c…

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Shock Syndromes I 6. SVR (also termed total peripheral resistance) is the resistance to flow that must be overcome by the left ventricle. a. SVR is the major determinant of LV afterload. b. System…

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Shock Syndromes I 3. In general, less invasive devices are desired, but they often have limited accuracy in estimating hemodynamic parameters compared with invasive devices. 4. When further hemodyn…

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Data Tables 2 min

Shock Syndromes I Device or Category Obtainable Parameters Advantages Limitations Pulmonary artery catheter (PAC) Measured: PASP, PADP, mPAP, CVP/RAP, PCWP/ PAOP, CO, and CI by thermodilution…

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Data Tables 3 min

Shock Syndromes I Device or Category Obtainable Parameters Advantages Limitations Arterial pulse pressure wave- form analysis (FloTrac/Vigileo, PiCCOplus, PulsioFlex, LiDCO plus, PRAM-MostCare…

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Shock Syndromes I iii. Elevated lactate concentrations may be the result of increased production, decreased clearance, or both. (a) Type A lactic acidosis occurs in the setting of Do2/Vo2 mismatch…

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Shock Syndromes I 2. Regional tissue perfusion a. Microcirculatory blood flow i. The microcirculation consists of arterioles, capillaries, and venules and is where oxygen release to the tissues oc…

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Data Tables 3 min

Shock Syndromes I Patient Case 1. A 77-year-old man presents to the ED with light-headedness and fatigue. He reports increasing melena during the past 24 hours. His medical history is significant fo…

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Shock Syndromes I D. A patient’s history of present illness can help differentiate between shock states. For example, a patient presenting after motor vehicle collision likely has hypovolemic shock,…

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Shock Syndromes I 4. General goals of therapy include resolution of altered mental status and adequate urinary output (above 0.5 mL/kg of body weight per hour). However, these goals may be challengi…

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Shock Syndromes I d. The specific values of PPV and SVV used to predict fluid responsiveness vary by study, specific conditions (e.g., use of vasopressors), and assessment method or device. In a sys…

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Shock Syndromes I 10. The best dynamic marker of fluid responsiveness to use in practice is unclear. a. In the previously mentioned study, the AUC ROC for predicting fluid responsiveness was higher…

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Shock Syndromes I E. Adequate Do2 1. CO, Scvo2, and Svo2 a. Historically, CO was monitored and used as a therapeutic target in most patients with a PAC. i. Because treatment of general ICU patient…

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Shock Syndromes I V.  AGENTS USED TO TREAT SHOCK – FLUIDS AND VASOACTIVE AGENTS A. See the Fluids, Electrolytes, and Nutrition chapter for a further discussion of fluid components. B. The below desc…

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Data Tables 3 min

Shock Syndromes I Table 4. Vasoactive Pharmacology and Pharmacodynamic Effectsa DA α1 β1 β2 Other Mechanism HR CVP CO SVR PVR Vasopressors Dopamineb < 5 mcg/kg/min ++++ — or ↑ — or ↑ — or ↑ ↔ ↔ Dop…

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Shock Syndromes I 4. Inotropes exert a pharmacodynamic effect that increases CO after adequate fluid administration. a. Dobutamine is a β-agonist that improves cardiac function by improving SV and C…

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Data Tables 4 min

Shock Syndromes I b. Crystalloids vs. colloids i. The Saline versus Albumin Fluid Evaluation (SAFE) study, which enrolled almost 7000 patients with varied shock types requiring fluid resuscitation,…

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Shock Syndromes I iii. A large, double-blind, cluster randomized, double-crossover trial, the SPLIT trial, allocated four ICUs in New Zealand to either 0.9% sodium chloride (n=1025) or a balanced cr…

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Shock Syndromes I viii. Balanced crystalloid solutions may lead to hyponatremia (with lactated Ringer’s solution) or cardiotoxicity (with acetate-containing solutions) when administered in large vol…

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Shock Syndromes I ii. Participants treated had more arrhythmias with dopamine than with norepinephrine. The authors concluded that major changes to clinical practice are not needed but that selectio…

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Shock Syndromes I Patient Case Questions 4 and 5 pertain to the following case. J.B. is a 28-year-old man (weight 92 kg) who presented to the surgical ICU with shock after an appendectomy was complic…

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Shock Syndromes I B. Pathophysiology 1. Vasodilatory shock occurs because of a failure of the vascular smooth muscle cells to constrict, whether from a failure of vasoconstriction methods or the in…

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Shock Syndromes I b. The potential offending agent should be discontinued (for medication-related reactions) and potentially removed (in the setting of envenomation) for patients with immune-mediate…

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Shock Syndromes I VII.  SEPSIS A. Introduction 1. Sepsis is caused by a dysregulated host response to infection. 2. While continuing to evolve, the diagnosis of sepsis traditionally has required a…

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Shock Syndromes I C. Epidemiology and Social Determinants of Health 1. Sepsis is common, with an annual incidence in the United States above 890,000, rising by about 13% per year, and an associated…

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Shock Syndromes I Box 1. Pharmacologic-Related Surviving Sepsis Campaign Recommendations for Patients with Sepsis and Septic Shocka Initial Resuscitation 1. Sepsis and septic shock are medical emerg…

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Shock Syndromes I Box 1. Pharmacologic-Related Surviving Sepsis Campaign Recommendations for Patients with Sepsis and Septic Shocka (continued) Fluid Therapy 1. Crystalloids are recommended as first…

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Shock Syndromes I 2. Early recognition and treatment of patients with sepsis, particularly those with sepsis-induced end- organ hypoperfusion, is of utmost importance. 3. Initial resuscitation a. I…

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Shock Syndromes I (c) Australasian Resuscitation in Sepsis Evaluation (ARISE) study (1) Randomized ED patients in both academic and nonacademic centers mainly in Australia and New Zealand to either…

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Shock Syndromes I • Recent studies have evaluated approaches of restricting early fluid resuscitation in patients with septic shock. • The Crystalloid Liberal or Vasopressors Early Resuscitation in…

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Shock Syndromes I iv. Given these findings, in a low-level recommendation, the SSC suggested targeting resuscitation to decrease lactate in patients with elevated lactate concentrations as a marker…

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Shock Syndromes I e. This care bundle has been adopted by the Centers for Medicare & Medicaid Services as a quality (core) measure (SEP-1). f. The slight differences between the SSC bundle and the…

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Shock Syndromes I Patient Case 6. A 56-year-old woman with a medical history of hypertension presents to the ED with shortness of breath and cough productive of sputum. Her vital signs on admission…

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Shock Syndromes I the differences in the benefit with combination therapy according to baseline mortality risk, showed a significant benefit of combination therapy in those with a mortality risk gre…

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Shock Syndromes I iv. Procalcitonin and other biomarkers may be used to limit the duration of antimicrobial therapy and are discussed in detail in the Infectious Diseases II chapter. 8. Source cont…

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Shock Syndromes I ii. A systematic review and fixed-effect meta-analysis of albumin compared with alternative fluids for resuscitation in patients with sepsis found an association between albumin us…

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Shock Syndromes I c. Low-dose AVP (up to 0.03 units/minute) can be added to norepinephrine as the second-line adjunctive agent rather than escalating the dose of norepinephrine in patients not at go…

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Shock Syndromes I (a) A study of patients with vasodilatory shock (about 50% with septic shock) requiring high-dose norepinephrine (greater than 0.6 mcg/kg/minute) randomized patients to AVP 0.033…

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Shock Syndromes I iii. During a shortage of norepinephrine in 2011, phenylephrine was used as an alternative for patients with septic shock. Compared with normal use, in-hospital mortality was highe…

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Shock Syndromes I Patient Case 7. A 55-year-old man presents to the medical ICU with presumed urosepsis. His medical history is significant for congestive heart failure with a baseline ejection frac…

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Shock Syndromes I iv. The Activated Protein C and Corticosteroids for Human Septic Shock (APROCCHSS) trial randomized 1241 patients to hydrocortisone and fludrocortisone or placebo within 24 hours o…

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Shock Syndromes I Patient Case 8. A 62-year-old woman was admitted to the surgical ICU with presumed aspiration pneumonia. The patient has a history of insulin-dependent diabetes and hyperthyroidism…

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Shock Syndromes I iv. Although the study did not specifically evaluate the practice of transfusing blood in patients with evidence of hypoperfusion (low Scvo2 or elevated lactate concentrations) ass…

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Shock Syndromes I (e) Initiation of inhaled nitric oxide after quantitative resuscitation did not improve microcirculatory flow or lactate clearance. (f) In summary, fluid resuscitation and dobutam…

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Shock Syndromes I REFERENCES Introduction Huang YC. Monitoring oxygen delivery in the critically ill. Chest. 2005;128(5 suppl 2):554S-560S. https://doi. org/10.1378/chest.128.5_suppl_2.554s Mascha EJ…

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Shock Syndromes I shock. Crit Care Med. 2004;32(9):1825-1831. https://doi. org/10.1097/01.ccm.0000138558.16257.3f Differentiation of Shock States Cecconi M, De Backer D, Antonelli M, et al. Consensus…

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Shock Syndromes I Puskarich MA, Trzeciak S, Shapiro NI, et al. Prognostic value and agreement of achieving lactate clearance or central venous oxygen saturation goals during early sep- sis resuscita…

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Shock Syndromes I Myburgh JA, Finfer S, Bellomo R, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med. 2012;367(20):1901-1911. https://doi. org/10.1056/nejm…

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Shock Syndromes I Wood GC, Boucher AB, Johnson JL, et al. Effectiveness of pseudoephedrine as adjunctive therapy for neu- rogenic shock after acute spinal cord injury: a case series. Pharmacotherapy…

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Shock Syndromes I Med. 2017;195(7):906-911. https://doi.org/10.1164/ rccm.201604-0854oc De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of sho…

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Shock Syndromes I Kumar A, Ellis P, Arabi Y, et al. Initiation of inappropri- ate antimicrobial therapy results in a fivefold reduction of survival in human septic shock. Chest. 2009;136(5):1237- 124…

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Shock Syndromes I early septic shock. N Engl J Med. 2014;370(18):1683- 1693. https://doi.org/10.1056/nejmoa1401602 Raghunathan K, Shaw A, Nathanson B, et al. Association between the choice of IV crys…

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Shock Syndromes I vasodilatory shock: a randomized, controlled, open- label trial. Intensive Care Med. 2010;36(1):57-65. https:// doi.org/10.1007/s00134-009-1630-1 Townsend SR, Rivers E, Tefera L. Def…

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Answers & Explanations 5 min

Shock Syndromes I ANSWERS AND EXPLANATIONS TO PATIENT CASES 1. Answer: B The patient has hypovolemic shock caused by his upper GI hemorrhage and has symptoms of compromised end- organ perfusion (i.e…

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Shock Syndromes I to the new definition (Answer B is correct). Although she has an elevated lactate concentration, she does not require vasopressors to maintain a MAP above 65 mm Hg and therefore d…

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Self-Assessment 5 min

Shock Syndromes I ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS 1. Answer: C This older adult patient presents with septic shock. Shock is a syndrome of impaired Do2, leading to tissue inju…

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Shock Syndromes I 6. Answer: D The patient has features of vasodilatory shock second- ary to an immune-mediated (“anaphylactic”) reaction (low preload, a low Scvo2 [suggestive of poor Do2], and an…

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