UPMC Critical Care

Size: px
Start display at page:

Download "UPMC Critical Care"

Transcription

1 UPMC Critical Care

2 Shock and Monitoring Samuel A. Tisherman, MD, FACS, FCCM Professor Departments of CCM and Surgery University of Pittsburgh

3 Shock Anaerobic metabolism Lactic acidosis Dysoxia Activation of inflammatory cascades Inadequate DO 2 Organ system dysfunction

4 Shock Normal cardiovascular system Pathophysiology of shock Categories of shock Resuscitation Monitoring

5 Key components of CV system Intravascular volume Cardiac output Preload Heart rate Contractility Afterload

6 Key components of CV system Resistance circuit arterioles Distribution of organ flow Capillaries Leak Obstruction to flow Shunts Venous capacitance vessels Vary venous return

7 Organ blood flow Most dependent upon mean arterial pressure (MAP) Autoregulation Maintained during large variations of MAP mmhg Can be impaired - hypertension

8 Autoregulation

9 Supply and demand O 2 delivery Hemoglobin Saturation Cardiac output O 2 demand 20-60% VO 2 = DO 2 x ERO 2 ER = extraction ratio

10 O 2 supply dependency Oxygen consumption Critical DO2 Critical DO2 Dysoxia Lactic acidosis Oxygen delivery

11 Cytopathic Hypoxia Sepsis Normal oxygen delivery Impaired mitochondrial O 2 utilization Mediators Inflammatory cytokines Inhibition of pyruvate dehydrogenase Inhibition of cytochrome a,a3 by NO Irreversible inhibition of one or more mitochondrial respiratory complexes by peroxynitrite Poly(ADP-ribose) polymerase-1

12 Reperfusion Injury ATP Ischemia Hypoxanthine Reperfusion O 2 Xanthine Dehydrogenase Xanthine Oxidase Oxygen radical formation Lipid mediator release Tissue injury Endothelial cell dysfunction Neutrophil chemotaxis Microvascular changes

13 It s not the fall that gets you.

14 Organ failure Ischemic Injury Organ Damage Reperfusion injury Inflammatory mediators (TNF, NO, free radicals)

15 Classifications of shock Hypodynamic Low CO (narrow PP) No No Hypovolemia Hemorrhage Dehydration Pulmonary edema? JVD? Yes RV failure Obstructive PE Tamponade PTX Hypotension Yes Cardiogenic shock MI Valvular dz Hyperdynamic Low SVR (wide PP) Distributive shock Sepsis Neurogenic shock Adrenal insufficiency Liver failure Anaphylaxis Medications

16 Hemorrhagic shock Most common cause of hypotension in trauma patients Initial fluid should be crystalloid Transfusion Hypotensive after 2 L crystalloid (ATLS) Earlier for severe shock Uncontrolled hemorrhage Stop hemorrhage Limited fluid resuscitation

17 Cardiogenic shock Resuscitation simultaneous with revascularization Patients may need higher than normal filling pressures (poor LV compliance) Inotropes may worsen ischemia Pacing may be helpful for relative bradycardia Intra-aortic balloon pump improves coronary perfusion and decreases afterload

18 Pulmonary embolism Risk factors Hypercoagulability, stasis, trauma Presentation Respiratory Cardiovascular Diagnosis CT angio, VQ, echo, angio, d-dimer Management Anticoagulation, thrombolytic, embolectomy Prevent the next one -?filter

19 Cardiac tamponade Pentrating trauma more common than blunt Beck s triad (hypotension, distant heart sounds, JVD) obscured by hypovolemia High index of suspicion Diagnose: echo or pericardial window Treatment: Need sternotomy or thoracotomy (trauma) Pericardiocentesis (non-trauma)

20 Septic shock Decreased preload Hypovolemia (capillary leak) Increased venous capacitance Vasodilatation Cardiac dysfunction Ventricular dilatation Decreased ejection fraction Cytopathic hypoxia

21 Endstage shock Cardiac decompensation Irreversible shock Vasomotor dysfunction Terminal hypodynamic state

22 Initial management

23 Initial management Resuscitation Ventilation?intubation early Infusion Bolus to effect?blood Clear lactate Pump therapy Inotropic support Afterload reduction Vasodilatation Vasopressor support Definitive therapy Stop bleeding Circulatory assist Antibiotics and drainage/debridement

24 Monitoring

25 CVP Only elevated in disease RV dysfunction Pulmonary hypertension LV dysfunction Tamponade Hyperinflation Intravascular volume expansion Poor correlation with volume responsiveness

26 PAOP and Preload Muscle LVEDV LVEDP LAP PAOP

27 CVP and PAOP Kumar, et al. CCM, 2004.

28 Functional Hemodynamic Monitoring 2-3 heart beats later

29 Resp variation in pulse pressure Limitations: spontaneous breathing, arrhythmias. Michard and Teboul. Crit care, 2000.

30 Passive Leg Raising

31 Passive Leg Raising Monnet, et al. CCM, 2012.

32 Preload Echo Distensibility index Max-min D IVC x 100% Min D IVC Collapsibility index Max-min D IVC x 100% Max D IVC Resp variability index ΔD IVC = Max-min D IVC x 100% Mean D IVC Feissel, et al. Intensive Care Med, 2004.

33 Mixed venous oxygen - SvO2 Decrease SvO 2 Decrease DO 2 Hb, O 2 sat, cardiac output Increase O 2 demands Fever, sepsis, exercise Normal >65% Critical value ~40% Resuscitation endpoint for sepsis and cardiogenic shock Sepsis -> maldistribution of blood flow SvO 2 normal with tissue dysoxia still present

34 Oxidative Metabolism Mitochondria 2 ATP Glucose Pyruvate Acetyl CoA Lactate 2 ATP Citric acid Cycle Remember 2:38 NADH/FADH2 Electron transport chain ADP 34 ATP O 2 H 2 O

35 Base Deficit Definition Amount of base needed to normalize ph with normal PCO 2 Limitations Administration of bicarbonate Alcohol intoxication Hyperchloremic metabolic acidosis Seizures Pre-existing acidosis

36 Lactate Excess production Anaerobic metabolism Initial level and time to clearance useful Decreased metabolism (liver, kidney) Washout during reperfusion Sepsis Increase flux of alanine from muscle Decreased PDH activity Decreased hepatic clearance Dysfunctional mitochondrial respiration

37 Near Infrared Spectroscopy Measurements PO 2 PCO 2 ph O 2 saturation of hemoglobin Tissue oxyhemoglobin coupling to cytochrome a,a3 redox Mitochondrial O 2 Location Muscle Stomach Bowel Liver

38

39 Hypodynamic Low CO (narrow PP) No No Hypovolemia Hemorrhage Dehydration Fluids Blood Hemostasis Pulmonary edema? JVD? Yes RV failure Obstructive PE Tamponade PTX Fluids Inotropes Specific Tx Hypotension Yes Cardiogenic shock MI Valvular dz Inotropes IABP Revascularize Hyperdynamic Low SVR (wide PP) Distributive shock Sepsis Neurogenic shock Adrenal insufficiency Liver failure Anaphylaxis Medications Fluids Vasopressors EGDTx Treat cause Base deficit Lactate SvO 2

40 UPMC Critical Care

Irreversible shock can defined as last phase of shock where despite correcting the initial insult leading to shock and restoring circulation there is

Irreversible shock can defined as last phase of shock where despite correcting the initial insult leading to shock and restoring circulation there is R. Siebert Irreversible shock can defined as last phase of shock where despite correcting the initial insult leading to shock and restoring circulation there is a progressive decline in blood pressure

More information

SHOCK. Emergency pediatric PICU division Pediatric Department Medical Faculty, University of Sumatera Utara H. Adam Malik Hospital

SHOCK. Emergency pediatric PICU division Pediatric Department Medical Faculty, University of Sumatera Utara H. Adam Malik Hospital SHOCK Emergency pediatric PICU division Pediatric Department Medical Faculty, University of Sumatera Utara H. Adam Malik Hospital 1 Definition Shock is an acute, complex state of circulatory dysfunction

More information

Case year old female nursing home resident with a hx CAD, PUD, recent hip fracture Transferred to ED with decreased mental status BP in ED 80/50

Case year old female nursing home resident with a hx CAD, PUD, recent hip fracture Transferred to ED with decreased mental status BP in ED 80/50 Case 1 65 year old female nursing home resident with a hx CAD, PUD, recent hip fracture Transferred to ED with decreased mental status BP in ED 80/50 Case 1 65 year old female nursing home resident with

More information

ENDPOINTS OF RESUSCITATION

ENDPOINTS OF RESUSCITATION ENDPOINTS OF RESUSCITATION Fred Pieracci, MD, MPH Acute Care Surgeon Denver Health Medical Center Assistant Professor of Surgery University of Colorado Health Science Center OUTLINE Recognition and characterization

More information

Circulatory shock. Types, Etiology, Pathophysiology. Physiology of Circulation: The Vessels. 600,000 miles of vessels containing 5-6 liters of blood

Circulatory shock. Types, Etiology, Pathophysiology. Physiology of Circulation: The Vessels. 600,000 miles of vessels containing 5-6 liters of blood Circulatory shock Types, Etiology, Pathophysiology Blagoi Marinov, MD, PhD Pathophysiology Dept. Physiology of Circulation: The Vessels 600,000 miles of vessels containing 5-6 liters of blood Vessel tone

More information

Ruminations about the Past, Present, and Future

Ruminations about the Past, Present, and Future Ruminations about the Past, Present, and Future Raymond L. Fowler, MD, FACEP, DABEMS Professor and Chief Division of Emergency Medical Services Department of Emergency Medicine UT Southwestern Medical

More information

Shock Quiz! By Clare Di Bona

Shock Quiz! By Clare Di Bona Shock Quiz! By Clare Di Bona Test Question What is Mr Burns full legal name? Answer Charles Montgomery Plantagenet Schicklgruber Burns. (Season 22, episode 11) Question 1. What is the definition of shock?

More information

Use of Blood Lactate Measurements in the Critical Care Setting

Use of Blood Lactate Measurements in the Critical Care Setting Use of Blood Lactate Measurements in the Critical Care Setting John G Toffaletti, PhD Director of Blood Gas and Clinical Pediatric Labs Professor of Pathology Duke University Medical Center Chief, VAMC

More information

SHOCK. Pathophysiology

SHOCK. Pathophysiology SHOCK Dr. Ahmed Saleem FICMS TUCOM / 3rd Year / 2015 Shock is the most common and therefore the most important cause of death of surgical patients. Death may occur rapidly due to a profound state of shock,

More information

Shock and hemodynamic monitorization. Nilüfer Yalındağ Öztürk Marmara University Pendik Research and Training Hospital

Shock and hemodynamic monitorization. Nilüfer Yalındağ Öztürk Marmara University Pendik Research and Training Hospital Shock and hemodynamic monitorization Nilüfer Yalındağ Öztürk Marmara University Pendik Research and Training Hospital Shock Leading cause of morbidity and mortality Worldwide: dehydration and hypovolemic

More information

FLUIDS AND SOLUTIONS IN THE CRITICALLY ILL. Daniel De Backer Department of Intensive Care Erasme University Hospital Brussels, Belgium

FLUIDS AND SOLUTIONS IN THE CRITICALLY ILL. Daniel De Backer Department of Intensive Care Erasme University Hospital Brussels, Belgium FLUIDS AND SOLUTIONS IN THE CRITICALLY ILL Daniel De Backer Department of Intensive Care Erasme University Hospital Brussels, Belgium Why do we want to administer fluids? To correct hypovolemia? To increase

More information

Dr. F Javier Belda Dept. Anesthesiology and Critical Care Hospital Clinico Universitario Valencia (Spain) Pulsion MAB

Dr. F Javier Belda Dept. Anesthesiology and Critical Care Hospital Clinico Universitario Valencia (Spain) Pulsion MAB State of the Art Hemodynamic Monitoring III CO, preload, lung water and ScvO2 The winning combination! Dr. F Javier Belda Dept. Anesthesiology and Critical Care Hospital Clinico Universitario Valencia

More information

Hemodynamic monitoring beyond cardiac output

Hemodynamic monitoring beyond cardiac output Hemodynamic monitoring beyond cardiac output Prof Xavier MONNET Medical Intensive Care Unit Bicêtre Hospital Assistance publique Hôpitaux de Paris FRANCE Conflicts of interest Lilly GlaxoSmithKline Pulsion

More information

The Pharmacology of Hypotension: Vasopressor Choices for HIE patients. Keliana O Mara, PharmD August 4, 2018

The Pharmacology of Hypotension: Vasopressor Choices for HIE patients. Keliana O Mara, PharmD August 4, 2018 The Pharmacology of Hypotension: Vasopressor Choices for HIE patients Keliana O Mara, PharmD August 4, 2018 Objectives Review the pathophysiology of hypotension in neonates Discuss the role of vasopressors

More information

SHOCK Susanna Hilda Hutajulu, MD, PhD

SHOCK Susanna Hilda Hutajulu, MD, PhD SHOCK Susanna Hilda Hutajulu, MD, PhD Div Hematology and Medical Oncology Department of Internal Medicine Universitas Gadjah Mada Yogyakarta Outline Definition Epidemiology Physiology Classes of Shock

More information

Failure of the circulation to maintain Tissue cellular. Tissue hypoperfusion Cellular hypoxia SHOCK. Perfusion

Failure of the circulation to maintain Tissue cellular. Tissue hypoperfusion Cellular hypoxia SHOCK. Perfusion Shock SHOCK Failure of the circulation to maintain Tissue cellular Perfusion Organs Syndrome RR

More information

How and why I give IV fluid Disclosures SCA Fluids and public health 4/1/15. Andrew Shaw MB FRCA FCCM FFICM

How and why I give IV fluid Disclosures SCA Fluids and public health 4/1/15. Andrew Shaw MB FRCA FCCM FFICM How and why I give IV fluid Andrew Shaw MB FRCA FCCM FFICM Professor and Chief Cardiothoracic Anesthesiology Vanderbilt University Medical Center 2015 Disclosures Consultant for Grifols manufacturer of

More information

SHOCK AETIOLOGY OF SHOCK (1) Inadequate circulating blood volume ) Loss of Autonomic control of the vasculature (3) Impaired cardiac function

SHOCK AETIOLOGY OF SHOCK (1) Inadequate circulating blood volume ) Loss of Autonomic control of the vasculature (3) Impaired cardiac function SHOCK Shock is a condition in which the metabolic needs of the body are not met because of an inadequate cardiac output. If tissue perfusion can be restored in an expeditious fashion, cellular injury may

More information

Swans and Pressors. Vanderbilt Surgery Summer School Ricky Shinall

Swans and Pressors. Vanderbilt Surgery Summer School Ricky Shinall Swans and Pressors Vanderbilt Surgery Summer School Ricky Shinall Shock, Swans, Pressors in 15 minutes 4 Reasons for Shock 4 Swan numbers to know 7 Pressors =15 things to know 4 Reasons for Shock Not enough

More information

12/1/2009. Chapter 19: Hemorrhage. Hemorrhage and Shock Occurs when there is a disruption or leak in the vascular system Internal hemorrhage

12/1/2009. Chapter 19: Hemorrhage. Hemorrhage and Shock Occurs when there is a disruption or leak in the vascular system Internal hemorrhage Chapter 19: Hemorrhage Hemorrhage and Shock Occurs when there is a disruption or leak in the vascular system External hemorrhage Internal hemorrhage Associated with higher morbidity and mortality than

More information

Swans and Pressors. Vanderbilt Surgery Summer School Ricky Shinall

Swans and Pressors. Vanderbilt Surgery Summer School Ricky Shinall Swans and Pressors Vanderbilt Surgery Summer School Ricky Shinall SHOCK Hypotension SHOCK Hypotension SHOCK=Reduction of systemic tissue perfusion, resulting in decreased oxygen delivery to the tissues.

More information

Sepsis and Shock States

Sepsis and Shock States Sepsis and Shock States Presented By: Cynthia Webner BSN, RN, CCRN, CMC www.cardionursing.com CNEA 2009 1 INFECTION Inflammatory response to microorganisms, or Invasion of normally sterile tissues SYSTEMIC

More information

Shock Management. Seyed Tayeb Moradian MSc, Critical Care Nursing Ph.D Candidate. PDF created with pdffactory Pro trial version

Shock Management. Seyed Tayeb Moradian MSc, Critical Care Nursing Ph.D Candidate. PDF created with pdffactory Pro trial version Shock Management Seyed Tayeb Moradian MSc, Critical Care Nursing Ph.D Candidate Definition of Shock The definition of shock does not involve low blood pressure, rapid pulse or cool clammy skin - these

More information

การอบรมว ทยาศาสตร พ นฐานทางศ ลยศาสตร เร อง นพ.ส ณฐ ต โมราก ล ภาคว ชาว ส ญญ ว ทยา คณะแพทยศาสตร โรงพยาบาลรามาธ บด มหาวทยาลยมหดล

การอบรมว ทยาศาสตร พ นฐานทางศ ลยศาสตร เร อง นพ.ส ณฐ ต โมราก ล ภาคว ชาว ส ญญ ว ทยา คณะแพทยศาสตร โรงพยาบาลรามาธ บด มหาวทยาลยมหดล การอบรมว ทยาศาสตร พ นฐานทางศ ลยศาสตร เร อง นพ.ส ณฐ ต โมราก ล ภาคว ชาว ส ญญ ว ทยา คณะแพทยศาสตร โรงพยาบาลรามาธ บด มหาวทยาลยมหดล Distributive shock Severe sepsis and Septic shock Anaphylactic shock Neurogenic

More information

Written 01/09/17 Rewritten 3/29/17 for Interior Regional EMS Symposium

Written 01/09/17 Rewritten 3/29/17 for Interior Regional EMS Symposium Written 01/09/17 Rewritten 3/29/17 for Interior Regional EMS Symposium MARIA E. MANDICH MD Fairbanks Memorial Hospital Emergency Department Attending Physician Interior Region EMS Council Medical Director

More information

DO 2 > VO 2. The amount of oxygen delivered is a product of cardiac output (L/min) and the amount of oxygen in the arterial blood (ml/dl).

DO 2 > VO 2. The amount of oxygen delivered is a product of cardiac output (L/min) and the amount of oxygen in the arterial blood (ml/dl). Shock (Part 1): Review and Diagnostic Approach Jeffrey M. Todd, DVM, DACVECC University of Minnesota, St. Paul, MN Overview Shock is the clinical presentation of inadequate oxygen utilization, typically

More information

Unit 4 Problems of Cardiac Output and Tissue Perfusion

Unit 4 Problems of Cardiac Output and Tissue Perfusion Unit 4 Problems of Cardiac Output and Tissue Perfusion Lemone and Burke Ch 30-32 Objectives Review the anatomy and physiology of the cardiovascular system. Identify normal heart sounds and relate them

More information

Haemodynamic Support. (getting the blood to go round and round) philippelefevre.com

Haemodynamic Support. (getting the blood to go round and round) philippelefevre.com Haemodynamic Support (getting the blood to go round and round) philippelefevre.com Haemodynamic Support Whats wrong with your patient? What can we do about it? Volume expansion Inotropes, Chronotropes

More information

Impedance Cardiography (ICG) Application of ICG in Intensive Care and Emergency

Impedance Cardiography (ICG) Application of ICG in Intensive Care and Emergency Impedance Cardiography (ICG) Application of ICG in Intensive Care and Emergency Aim of haemodynamic monitoring in ICU and ED Detection and therapy of insufficient organ perfusion Answers to common cardiovascular

More information

-Cardiogenic: shock state resulting from impairment or failure of myocardium

-Cardiogenic: shock state resulting from impairment or failure of myocardium Shock chapter Shock -Condition in which tissue perfusion is inadequate to deliver oxygen, nutrients to support vital organs, cellular function -Affects all body systems -Classic signs of early shock: Tachycardia,tachypnea,restlessness,anxiety,

More information

Physiologic Based Management of Circulatory Shock Kuwait 2018

Physiologic Based Management of Circulatory Shock Kuwait 2018 Physiologic Based Management of Circulatory Shock Kuwait 2018 Dr. Yasser Elsayed, MD, PhD Director of the Targeted Neonatal Echocardiography, Point of Care and Hemodynamics Program Staff Neonatologist

More information

Fluids in Sepsis: How much and what type? John Fowler, MD, FACEP Kent Hospital, İzmir Eisenhower Medical Center, USA American Hospital Dubai, UAE

Fluids in Sepsis: How much and what type? John Fowler, MD, FACEP Kent Hospital, İzmir Eisenhower Medical Center, USA American Hospital Dubai, UAE Fluids in Sepsis: How much and what type? John Fowler, MD, FACEP Kent Hospital, İzmir Eisenhower Medical Center, USA American Hospital Dubai, UAE In critically ill patients: too little fluid Low preload,

More information

Disclaimer. Improving MET-based patient care using treatment algorithms. Michael R. Pinsky, MD, Dr hc. Different Environments Demand Different Rules

Disclaimer. Improving MET-based patient care using treatment algorithms. Michael R. Pinsky, MD, Dr hc. Different Environments Demand Different Rules Michael R. Pinsky, MD - June 29, 26 Improving MET-based patient care using Michael R. Pinsky, MD, Dr hc Department of Critical Care Medicine University of Pittsburgh Disclaimer Michael R. Pinsky, MD is

More information

Department of Intensive Care Medicine UNDERSTANDING CIRCULATORY FAILURE IN SEPSIS

Department of Intensive Care Medicine UNDERSTANDING CIRCULATORY FAILURE IN SEPSIS Department of Intensive Care Medicine UNDERSTANDING CIRCULATORY FAILURE IN SEPSIS UNDERSTANDING CIRCULATORY FAILURE IN SEPSIS a mismatch between tissue perfusion and metabolic demands the heart, the vasculature

More information

Introduction. Invasive Hemodynamic Monitoring. Determinants of Cardiovascular Function. Cardiovascular System. Hemodynamic Monitoring

Introduction. Invasive Hemodynamic Monitoring. Determinants of Cardiovascular Function. Cardiovascular System. Hemodynamic Monitoring Introduction Invasive Hemodynamic Monitoring Audis Bethea, Pharm.D. Assistant Professor Therapeutics IV January 21, 2004 Hemodynamic monitoring is necessary to assess and manage shock Information obtained

More information

Nothing to Disclose. Severe Pulmonary Hypertension

Nothing to Disclose. Severe Pulmonary Hypertension Severe Ronald Pearl, MD, PhD Professor and Chair Department of Anesthesiology Stanford University Rpearl@stanford.edu Nothing to Disclose 65 year old female Elective knee surgery NYHA Class 3 Aortic stenosis

More information

LeMone & Burke Ch 30-32

LeMone & Burke Ch 30-32 LeMone & Burke Ch 30-32 2 Right side- Low oxygenation Low pressure Light workload Goes toward the lungs Left side High oxygenation Thick walled high pressure Heavier workload Carries oxygenation blood

More information

SHOCK. May 12, 2011 Body and Disease

SHOCK. May 12, 2011 Body and Disease SHOCK May 12, 2011 Body and Disease Shock Definition of shock Pathophysiology Types of shock Management of shock Shock Definition? Shock What the Duke Community would have experienced if Gordon Hayward

More information

The Hemodynamic Puzzle

The Hemodynamic Puzzle The Hemodynamic Puzzle SVV NIRS O 2 ER Lactate Energy Metabolism (Oxygen Consumption) (Ml/min/m 2 ) Oxygen Debt: To Pay or Not to Pay? Full Recovery Possible Delayed Repayment of O 2 Debt Oxygen Deficit

More information

Sepsis Wave II Webinar Series. Sepsis Reassessment

Sepsis Wave II Webinar Series. Sepsis Reassessment Sepsis Wave II Webinar Series Sepsis Reassessment Presenters Nova Panebianco, MD Todd Slesinger, MD Fluid Reassessment in Sepsis Todd L. Slesinger, MD, FACEP, FCCM, FCCP, FAAEM Residency Program Director

More information

Bachelor of Chinese Medicine Shock

Bachelor of Chinese Medicine Shock BCM Year 2 Dr. Irene Ng Jan 28, 2003 9:30 am 1:00 pm Rm 004 UPB Bachelor of Chinese Medicine 2002 2003 Shock Learning objectives Be able to: know the definition of shock know the classification and causes

More information

Presented by: Indah Dwi Pratiwi

Presented by: Indah Dwi Pratiwi Presented by: Indah Dwi Pratiwi Normal Fluid Requirements Resuscitation Fluids Goals of Resuscitation Maintain normal body temperature In most cases, elevate the feet and legs above the level of the heart

More information

Pediatric emergencies (SHOCK & COMA) Dr Mubarak Abdelrahman Assistant Professor Jazan University

Pediatric emergencies (SHOCK & COMA) Dr Mubarak Abdelrahman Assistant Professor Jazan University Pediatric emergencies (SHOCK & COMA) Dr Mubarak Abdelrahman Assistant Professor Jazan University SHOCK Definition: Shock is a syndrome = inability to provide sufficient oxygenated blood to tissues. Oxygen

More information

Shock. Shao Mian Emergency Department,Zhongshan Hospital

Shock. Shao Mian Emergency Department,Zhongshan Hospital Shock Shao Mian Emergency Department,Zhongshan Hospital What is shock THE BEGINNINGS OF UNDERSTANDING: THE LATE 19TH CENTURY THE AGE OF REASON: 1890 1925 THE MODERN ERA: BLALOCK S EPIPHANY POSTMODERNISM:

More information

FLUID RESUSCITATION AND MONITORING IN SEPSIS PROTOCOLIZED VS USUAL CARE DEEPA BANGALORE GOTUR MD, FCCP ASSISTANT PROFESSOR, WEILL CORNELL MEDICAL

FLUID RESUSCITATION AND MONITORING IN SEPSIS PROTOCOLIZED VS USUAL CARE DEEPA BANGALORE GOTUR MD, FCCP ASSISTANT PROFESSOR, WEILL CORNELL MEDICAL FLUID RESUSCITATION AND MONITORING IN SEPSIS PROTOCOLIZED VS USUAL CARE DEEPA BANGALORE GOTUR MD, FCCP ASSISTANT PROFESSOR, WEILL CORNELL MEDICAL COLLEGE NOVEMBER 10 TH 2017 TEXAS SCCM SYMPOSIUM Disclosures

More information

FUNDAMENTALS OF HEMODYNAMICS, VASOACTIVE DRUGS AND IABP IN THE FAILING HEART

FUNDAMENTALS OF HEMODYNAMICS, VASOACTIVE DRUGS AND IABP IN THE FAILING HEART FUNDAMENTALS OF HEMODYNAMICS, VASOACTIVE DRUGS AND IABP IN THE FAILING HEART CINDY BITHER, MSN, ANP, ANP, AACC, CHFN CHIEF NP, ADV HF PROGRAM MEDSTAR WASHINGTON HOSPITAL CENTER CONFLICTS OF INTEREST NONE

More information

Assessing Preload Responsiveness Using Arterial Pressure Based Technologies. Patricia A. Meehan, RN, MS Education Consultant Edwards Lifesciences, LLC

Assessing Preload Responsiveness Using Arterial Pressure Based Technologies. Patricia A. Meehan, RN, MS Education Consultant Edwards Lifesciences, LLC Assessing Preload Responsiveness Using Arterial Pressure Based Technologies Patricia A. Meehan, RN, MS Education Consultant Edwards Lifesciences, LLC Content Description : Fluid administration is a first

More information

Didier Payen, MD, Ph D DAR Lariboisière Université Paris 7 Unité INSERM 1160

Didier Payen, MD, Ph D DAR Lariboisière Université Paris 7 Unité INSERM 1160 Assessing response to therapy: SvO 2, lactate, PCO 2 gap, others Didier Payen, MD, Ph D DAR Lariboisière Université Paris 7 Unité INSERM 1160 dpayen1234@orange.fr How can we see the question? Some useful

More information

Hell or High Lactate. Charles Bruen, MD. resusreview.com/regionsmar17

Hell or High Lactate. Charles Bruen, MD. resusreview.com/regionsmar17 Hell or High Lactate Charles Bruen, MD resusreview.com/regionsmar17 No Disclosures No Off-label Use 3 Positive troponin? Inpatient or Observation? Lactate elevated? Goals What causes lactate production?

More information

What is. InSpectra StO 2?

What is. InSpectra StO 2? What is InSpectra StO 2? www.htibiomeasurement.com What is InSpectra StO 2? Hemoglobin O 2 saturation is measured in three areas: 1) Arterial (SaO 2, SpO 2 ) Assesses how well oxygen is loading onto hemoglobin

More information

Cardiogenic shock -a major component of the the mortality associated with cardiovascular disease (the #1 cause of U.S. deaths)

Cardiogenic shock -a major component of the the mortality associated with cardiovascular disease (the #1 cause of U.S. deaths) Shock Pathophysiology, Classification, and Approach to Management Shock Cardiogenic shock -a major component of the the mortality associated with cardiovascular disease (the #1 cause of U.S. deaths) Hypovolemic

More information

Goal-directed resuscitation in sepsis; a case-based approach

Goal-directed resuscitation in sepsis; a case-based approach Goal-directed resuscitation in sepsis; a case-based approach Jorge A Guzman, MD, FCCM Head, Section Critical Care Medicine Respiratory Institute Cleveland Clinic Foundation The challenges to managing septic

More information

Sepsis Combine experience and Evidence. Eran Segal, MD Director General ICU, Sheba Medical Center, Israel

Sepsis Combine experience and Evidence. Eran Segal, MD Director General ICU, Sheba Medical Center, Israel Sepsis Combine experience and Evidence Eran Segal, MD Director General ICU, Sheba Medical Center, Israel The Science of Sepsis A complex and diverse clinical entity Outcome is affected by: Infecting organism

More information

SHOCK. Voravit Chittithavorn. Cardiovascular Thoracic Surgery Department of Surgery

SHOCK. Voravit Chittithavorn. Cardiovascular Thoracic Surgery Department of Surgery SHOCK Voravit Chittithavorn Cardiovascular Thoracic Surgery Department of Surgery Shock: Introduction Cellular Injury Multiorgans Dysfunction Irreversible Processing Unbalance Supply vs Demand Perfusion

More information

Utilizing Vasopressors:

Utilizing Vasopressors: Utilizing Vasopressors: Critical Care Advances in the Emergency Department José A. Rubero, MD, FACEP, FAAEM Associate Program Director University of Central Florida/HCA GME Consortium Emergency Medicine

More information

Shock, Monitoring Invasive Vs. Non Invasive

Shock, Monitoring Invasive Vs. Non Invasive Shock, Monitoring Invasive Vs. Non Invasive Paula Ferrada MD Assistant Professor Trauma, Critical Care and Emergency Surgery Virginia Commonwealth University Shock Fluid Pressors Ionotrope Intervention

More information

SHOCK and the Trauma Victim. JP Pretorius Department of Surgery & SICU Steve Biko Academic Hospital.

SHOCK and the Trauma Victim. JP Pretorius Department of Surgery & SICU Steve Biko Academic Hospital. SHOCK and the Trauma Victim JP Pretorius Department of Surgery & SICU Steve Biko Academic Hospital. Classification of Shock Cardiogenic - Myopathic Arrythmic Mechanical Hypovolaemic - Haemorrhagic Non-haemorrhagic

More information

Cardiovascular Management of Septic Shock

Cardiovascular Management of Septic Shock Cardiovascular Management of Septic Shock R. Phillip Dellinger, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Critical Care Medicine and Med/Surg ICU Cooper University Hospital

More information

The Use of Dynamic Parameters in Perioperative Fluid Management

The Use of Dynamic Parameters in Perioperative Fluid Management The Use of Dynamic Parameters in Perioperative Fluid Management Gerard R. Manecke Jr., M.D. Chief, Cardiac Anesthesia UCSD Medical Center San Diego, CA, USA Thanks to Tom Higgins, M.D. 1 Goals of today

More information

Evidence-Based. Management of Severe Sepsis. What is the BP Target?

Evidence-Based. Management of Severe Sepsis. What is the BP Target? Evidence-Based Management of Severe Sepsis Michael A. Gropper, MD, PhD Professor and Vice Chair of Anesthesia Director, Critical Care Medicine Chair, Quality Improvment University of California San Francisco

More information

How to resuscitate the patient in early sepsis? A physiological approach. J.G. van der Hoeven, Nijmegen

How to resuscitate the patient in early sepsis? A physiological approach. J.G. van der Hoeven, Nijmegen How to resuscitate the patient in early sepsis? A physiological approach J.G. van der Hoeven, Nijmegen Disclosure interests speaker (potential) conflict of interest Potentially relevant relationships with

More information

What would be the response of the sympathetic system to this patient s decrease in arterial pressure?

What would be the response of the sympathetic system to this patient s decrease in arterial pressure? CASE 51 A 62-year-old man undergoes surgery to correct a herniated disc in his spine. The patient is thought to have an uncomplicated surgery until he complains of extreme abdominal distention and pain

More information

Management of Cardiogenic Shock. Dr Stephen Pettit, Consultant Cardiologist

Management of Cardiogenic Shock. Dr Stephen Pettit, Consultant Cardiologist Dr Stephen Pettit, Consultant Cardiologist Cardiogenic shock Management of Cardiogenic Shock Outline Definition, INTERMACS classification Medical management of cardiogenic shock PA catheters and haemodynamic

More information

UTILITY of ScvO 2 and LACTATE

UTILITY of ScvO 2 and LACTATE UTILITY of ScvO 2 and LACTATE Professor Jeffrey Lipman Department of Intensive Care Medicine Royal Brisbane Hospital University of Queensland THIS TRIP SPONSORED AND PAID FOR BY STRUCTURE Physiology -

More information

Physiological Response to Hypovolemic Shock Dr Khwaja Mohammed Amir MD Assistant Professor(Physiology) Objectives At the end of the session the

Physiological Response to Hypovolemic Shock Dr Khwaja Mohammed Amir MD Assistant Professor(Physiology) Objectives At the end of the session the Physiological Response to Hypovolemic Shock Dr Khwaja Mohammed Amir MD Assistant Professor(Physiology) Objectives At the end of the session the students should be able to: List causes of shock including

More information

Shock. Undifferentiated Shock: Beyond Blood Pressure. Shock. Epidemiology. Matthew Strehlow, MD Stanford University

Shock. Undifferentiated Shock: Beyond Blood Pressure. Shock. Epidemiology. Matthew Strehlow, MD Stanford University Shock Undifferentiated Shock: Beyond Blood Pressure Matthew Strehlow, MD Stanford University Shock Shock - The rude unhinging of the machinery of life -SD Gross 1872 Epidemiology Shock - inadequate tissue

More information

Disclosures. Objectives 10/11/17. Short Term Mechanical Circulatory Support for Advanced Cardiogenic Shock. I have no disclosures to report

Disclosures. Objectives 10/11/17. Short Term Mechanical Circulatory Support for Advanced Cardiogenic Shock. I have no disclosures to report Short Term Mechanical Circulatory Support for Advanced Cardiogenic Shock Christopher K. Gordon MSN, ACNP-BC Disclosures I have no disclosures to report 1. Pathophysiology 2. Epidemiology 3. Assessment

More information

Intraaortic Balloon Counterpulsation- Supportive Data for a Role in Cardiogenic Shock ( Be Still My Friend )

Intraaortic Balloon Counterpulsation- Supportive Data for a Role in Cardiogenic Shock ( Be Still My Friend ) Intraaortic Balloon Counterpulsation- Supportive Data for a Role in Cardiogenic Shock ( Be Still My Friend ) Stephen G. Ellis, MD Section Head, Interventional Cardiology Professor of Medicine Cleveland

More information

PERANAN LAKTAT PADA PASIEN KRITIS DI ICU. Prof. Dr. dr. Made Wiryana, SpAn.KIC.KAO

PERANAN LAKTAT PADA PASIEN KRITIS DI ICU. Prof. Dr. dr. Made Wiryana, SpAn.KIC.KAO PERANAN LAKTAT PADA PASIEN KRITIS DI ICU Prof. Dr. dr. Made Wiryana, SpAn.KIC.KAO History of Lactate Karl Scheele, 1780 found in sour milk Joseph Scherer the German physician-chemist after 70 years demonstrate

More information

Hemodynamic Monitoring Pressure or Volumes? Antonio Pesenti University of Milan Italy

Hemodynamic Monitoring Pressure or Volumes? Antonio Pesenti University of Milan Italy Hemodynamic Monitoring Pressure or Volumes? Antonio Pesenti University of Milan Italy antonio.pesenti@unimi.it CCCF 2017 Is it useful? YES: CVP It is an important diagnostic element! Your best guess CVP

More information

CrackCast Episode 6 Shock

CrackCast Episode 6 Shock CrackCast Episode 6 Shock Episode overview: 1) List, define and explain the 5 causes of shock 2) What is the utility of lactate and base deficit in the management of shock? 3) Define: SIRS, Sepsis, Severe

More information

Hemodynamic Monitoring and Circulatory Assist Devices

Hemodynamic Monitoring and Circulatory Assist Devices Hemodynamic Monitoring and Circulatory Assist Devices Speaker: Jana Ogden Learning Unit 2: Hemodynamic Monitoring and Circulatory Assist Devices Hemodynamic monitoring refers to the measurement of pressure,

More information

Introduction to Emergency Medical Care 1

Introduction to Emergency Medical Care 1 Introduction to Emergency Medical Care 1 OBJECTIVES 6.1 Define key terms introduced in this chapter. Slides 11, 15, 17, 26, 27, 31, 33, 37, 40 42, 44, 45, 51, 58 6.2 Describe the basic roles and structures

More information

Patient Safety Safe Table Webcast: Sepsis (Part III and IV) December 17, 2014

Patient Safety Safe Table Webcast: Sepsis (Part III and IV) December 17, 2014 Patient Safety Safe Table Webcast: Sepsis (Part III and IV) December 17, 2014 Presenters Mark Blaney, RN Regional Nurse Educator CHI Franciscan Health Karen Lautermilch Director, Quality & Performance

More information

Vasoactive Medications. Matthew J. Korobey Pharm.D., BCCCP Critical Care Clinical Specialist Mercy St. Louis

Vasoactive Medications. Matthew J. Korobey Pharm.D., BCCCP Critical Care Clinical Specialist Mercy St. Louis Vasoactive Medications Matthew J. Korobey Pharm.D., BCCCP Critical Care Clinical Specialist Mercy St. Louis Objectives List components of physiology involved in blood pressure Review terminology related

More information

PEDIATRIC SHOCK 10/9/2014. Objectives. What is shock? By the end of this presentation, the learner will be able to:

PEDIATRIC SHOCK 10/9/2014. Objectives. What is shock? By the end of this presentation, the learner will be able to: PEDIATRIC SHOCK Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CMS, CEN, CNRN, CPNP Education Specialist-LRM Consulting Nashville, TN Objectives By the end of this presentation, the learner will be able to:

More information

Definition. Emergency Treatment 11/13/13. Pathophysiology of circulatory shock. Characteristics of circulatory shock. Clinical features of shock

Definition. Emergency Treatment 11/13/13. Pathophysiology of circulatory shock. Characteristics of circulatory shock. Clinical features of shock Definition Pathophysiology of circulatory shock! Inadequate perfusion (oxygen supply) of tissues, resulting in:! Organ dysfunction! Cellular and organ damage And if not quickly corrected! Death Dr Badri

More information

Useful diagnostic measures: chest x ray to check pulmonary edema, ECG and ECHO to detect cardiac abnormalities (1).

Useful diagnostic measures: chest x ray to check pulmonary edema, ECG and ECHO to detect cardiac abnormalities (1). Cardiogenic shock Etiology The most common cause of cardiogenic shock is LV dysfunction and necrosis as a result of acute myocardial infarction (AMI) (1). Acute valvular insufficiency or stenosis prevents

More information

SPECIAL PATHOPHYSIOLOGY SHOCK

SPECIAL PATHOPHYSIOLOGY SHOCK SPECIAL PATHOPHYSIOLOGY SHOCK 1. How do we call blood pressure values below the reference range? 1.Hypovolemia. 2. Hypothermia. 3. Hypooncia. 4. Hypoosmia. 5. Hypotension. 2. What is acute circulatory

More information

Mechanical circulatory support in cardiogenic shock The Cardiologist s view ACCA Masterclass 2017

Mechanical circulatory support in cardiogenic shock The Cardiologist s view ACCA Masterclass 2017 Mechanical circulatory support in cardiogenic shock The Cardiologist s view ACCA Masterclass 2017 Pascal Vranckx MD, PhD. Medical director Cardiac Critical Care Services Hartcentrum Hasselt Belgium Disclosure

More information

Emergency Medical Training Services Emergency Medical Technician Paramedic Program Outlines Outline Topic: Shock Revised: 11/2013

Emergency Medical Training Services Emergency Medical Technician Paramedic Program Outlines Outline Topic: Shock Revised: 11/2013 Emergency Medical Training Services Emergency Medical Technician Paramedic Program Outlines Outline Topic: Shock Revised: 11/2013 (12 questions on trauma exam from this outline) DEFINITIONS Aerobic metabolism

More information

Impedance Cardiography (ICG) Method, Technology and Validity

Impedance Cardiography (ICG) Method, Technology and Validity Method, Technology and Validity Hemodynamic Basics Cardiovascular System Cardiac Output (CO) Mean arterial pressure (MAP) Variable resistance (SVR) Aortic valve Left ventricle Elastic arteries / Aorta

More information

Case Scenario 3: Shock and Sepsis

Case Scenario 3: Shock and Sepsis Name: Molly Boyle 1. Define the term shock (Lewis textbook): Shock is a syndrome characterized by decreased perfusion and impaired metabolism. Shock can have a number of causes that result in damage to

More information

IN THE NAME OF GOD SHOCK MANAGMENT OMID MORADI MOGHADDAM,MD,FCCM IUMS ASSISTANT PROFESSOR

IN THE NAME OF GOD SHOCK MANAGMENT OMID MORADI MOGHADDAM,MD,FCCM IUMS ASSISTANT PROFESSOR IN THE NAME OF GOD SHOCK MANAGMENT OMID MORADI MOGHADDAM,MD,FCCM IUMS ASSISTANT PROFESSOR The ability to evaluate and manage a critically ill patient is one of the most important skills any intensivist

More information

Hemodynamic Support of Sepsis

Hemodynamic Support of Sepsis Practice Parameters for Hemodynamic Support of Sepsis in Adult Patients Copyright by the SOCIETY OF CRITICAL CARE MEDICINE These guidelines can also be found in the March 1999 issue of Critical Care Medicine

More information

How Normal Body Processes Are Altered By Disease and Injury

How Normal Body Processes Are Altered By Disease and Injury 1 Chapter 4, GENERAL PRINCIPLES OF PATHOPHYSIOLOGY. Part 1 How Normal Body Processes Are Altered By Disease and Injury 2 How Cells Respond to Change and Injury 3 Pathology & Pathophysiology : the study

More information

How to maintain optimal perfusion during Cardiopulmonary By-pass. Herdono Poernomo, MD

How to maintain optimal perfusion during Cardiopulmonary By-pass. Herdono Poernomo, MD How to maintain optimal perfusion during Cardiopulmonary By-pass Herdono Poernomo, MD Cardiopulmonary By-pass Target Physiologic condition as a healthy person Everything is in Normal Limit How to maintain

More information

SHOCK PATHOPHYSIOLOGY

SHOCK PATHOPHYSIOLOGY SHOCK PATHOPHYSIOLOGY shock Shock is a condition in which the cardiovascular system fails to perfuse tissues adequately An impaired cardiac pump, circulatory system, and/or volume can lead to compromised

More information

Endpoints of Resuscitation for Circulatory Shock: When Enough is Enough?

Endpoints of Resuscitation for Circulatory Shock: When Enough is Enough? Endpoints of Resuscitation for Circulatory Shock: When Enough is Enough? Emanuel P. Rivers, MD, MPH, IOM Vice Chairman and Research Director Departments of Emergency Medicine and Surgery Henry Ford Hospital

More information

Nurse Driven Fluid Optimization Using Dynamic Assessments

Nurse Driven Fluid Optimization Using Dynamic Assessments Nurse Driven Fluid Optimization Using Dynamic Assessments 2016 1 WHAT WE BELIEVE We believe that clinicians make vital fluid and drug decisions every day with limited and inconclusive information Cheetah

More information

HYPOTENSION IS DANGEROUS C. R Y A N K E A Y, M D, F A C E P 1 6 M A R C H

HYPOTENSION IS DANGEROUS C. R Y A N K E A Y, M D, F A C E P 1 6 M A R C H HYPOTENSION IS DANGEROUS C. R Y A N K E A Y, M D, F A C E P 1 6 M A R C H 2 0 1 8 OBJECTIVES Case-based overview of pressors Debunking pressor myths Utilizing push-dose pressors CASE 1 82-year old male,

More information

Goal-directed vs Flow-guidedresponsive

Goal-directed vs Flow-guidedresponsive Goal-directed vs Flow-guidedresponsive therapy S Magder Department of Critical Care, McGill University Health Centre Flow-directed vs goal directed strategy for management of hemodynamics S Magder Curr

More information

Intra-operative Echocardiography: When to Go Back on Pump

Intra-operative Echocardiography: When to Go Back on Pump Intra-operative Echocardiography: When to Go Back on Pump GREGORIO G. ROGELIO, MD., F.P.C.C. OUTLINE A. Indications for Intraoperative Echocardiography B. Role of Intraoperative Echocardiography C. Criteria

More information

The Septic Patient. Dr Arunraj Navaratnarajah. Renal SpR Imperial College NHS Healthcare Trust

The Septic Patient. Dr Arunraj Navaratnarajah. Renal SpR Imperial College NHS Healthcare Trust The Septic Patient Dr Arunraj Navaratnarajah Renal SpR Imperial College NHS Healthcare Trust Objectives of this session Define SIRS / sepsis / severe sepsis / septic shock Early recognition of Sepsis The

More information

Patrick C. Cullinan, DO, NBPNS, FCCM, FACOEP, FACOI Associate Clinical Professor, UIWSOM, San Antonio, Texas Adjunct Assistant Professor, University

Patrick C. Cullinan, DO, NBPNS, FCCM, FACOEP, FACOI Associate Clinical Professor, UIWSOM, San Antonio, Texas Adjunct Assistant Professor, University Patrick C. Cullinan, DO, NBPNS, FCCM, FACOEP, FACOI Associate Clinical Professor, UIWSOM, San Antonio, Texas Adjunct Assistant Professor, University of Texas Health Science Center, Department of Emergency

More information

CARDIOGENIC SHOCK. Antonio Pesenti. Università degli Studi di Milano Bicocca Azienda Ospedaliera San Gerardo Monza (MI)

CARDIOGENIC SHOCK. Antonio Pesenti. Università degli Studi di Milano Bicocca Azienda Ospedaliera San Gerardo Monza (MI) CARDIOGENIC SHOCK Antonio Pesenti Università degli Studi di Milano Bicocca Azienda Ospedaliera San Gerardo Monza (MI) Primary myocardial dysfunction resulting in the inability of the heart to mantain an

More information

Maternal and Fetal Physiology

Maternal and Fetal Physiology Background Maternal and Fetal Physiology Anderson Lo, DO Fellow, Maternal-Fetal Medicine Wayne State University School of Medicine SEMCME Fetal Assessment Course July 20, 2018 Oxygen pathway Mother Placenta

More information

HYPEREMIA AND CONGESTION

HYPEREMIA AND CONGESTION HYPEREMIA AND CONGESTION Learning Objectives Define congestion and hyperemia Differentiate between the two with regard to: Mechanisms / underlying causes Appearance (gross and histologic) Effects Differentiate

More information

Topics to be Covered. Cardiac Measurements. Distribution of Blood Volume. Distribution of Pulmonary Ventilation & Blood Flow

Topics to be Covered. Cardiac Measurements. Distribution of Blood Volume. Distribution of Pulmonary Ventilation & Blood Flow Topics to be Covered MODULE F HEMODYNAMIC MONITORING Cardiac Output Determinants of Stroke Volume Hemodynamic Measurements Pulmonary Artery Catheterization Control of Blood Pressure Heart Failure Cardiac

More information

DESIGNER RESUSCITATION: TITRATING TO TISSUE NEEDS

DESIGNER RESUSCITATION: TITRATING TO TISSUE NEEDS DESIGNER RESUSCITATION: TITRATING TO TISSUE NEEDS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical School of Rowan University Chief of Medicine Cooper University Hospital

More information