1. SHOCK INSHOCK IN
CRITICAL ILLNESSCRITICAL ILLNESS
Vikas Kesarwani MD FCCPVikas Kesarwani MD FCCP
Consultant, Pulmonary & Critical Care,Consultant, Pulmonary & Critical Care,
Himalayan Institute of Medical Sciences,Himalayan Institute of Medical Sciences,
HIHT University,HIHT University,
Dehradun.Dehradun.
2626thth
Feb 2011Feb 2011

2. Dictionary definition of ShockDictionary definition of Shock
► 1. a sudden and violent1. a sudden and violent blow or impact; collision, disturbanceblow or impact; collision, disturbance oror
commotioncommotion of the mind, emotions, or sensibilitiesof the mind, emotions, or sensibilities
► 2. the physiological effect produced by the passage of an electric2. the physiological effect produced by the passage of an electric
current through the body.current through the body.
3. shocks, Informal3. shocks, Informal .. shock absorbersshock absorbers, especially in the suspension, especially in the suspension
of an automobile.of an automobile.
4.4. PathologyPathology . a collapse of circulatory function,. a collapse of circulatory function,
caused by severe injury, blood loss, or disease, andcaused by severe injury, blood loss, or disease, and
characterized by pallor, sweating, weak pulse, andcharacterized by pallor, sweating, weak pulse, and
very low blood pressure.very low blood pressure.
––verb (used with object) 8. to strike or jar with intense surprise, horror,verb (used with object) 8. to strike or jar with intense surprise, horror,
disgust, etc.: He enjoyed shocking people.disgust, etc.: He enjoyed shocking people.
► 9. to strike against violently.9. to strike against violently.
► 10. to give an10. to give an electric shockelectric shock to.to.
Origin: 1555–65; French choc armed encounter, noun derivative of
choquer to clash (in battle). Germanic; compare Dutch schokken to shake,
jolt, jerk

3. DefinitionDefinition
►Kumar and Parrillo (1995)Kumar and Parrillo (1995)
- “The state in which- “The state in which profoundprofound andand
widespreadwidespread reduction of effective tissuereduction of effective tissue
perfusionperfusion leadsleads first to reversiblefirst to reversible, and, and
thenthen if prolonged, to irreversible cellularif prolonged, to irreversible cellular
injuryinjury.”.”
►Clinically manifested byClinically manifested by
 Hemodynamic disturbances.Hemodynamic disturbances.
 Tissue Hypoxia.Tissue Hypoxia.
 Organ dysfunctionOrgan dysfunction..

4. Case ScenarioCase Scenario
► 45 yr old male. Teetotaller45 yr old male. Teetotaller
► BG: T2DM, HTN for 10 yrs. On OHA andBG: T2DM, HTN for 10 yrs. On OHA and
antihypertensive medication.antihypertensive medication.
► H/oH/o
Cough, Expectoration, Fever - 5 days.Cough, Expectoration, Fever - 5 days.
Delirious & Not passed urine since last 24 hours.Delirious & Not passed urine since last 24 hours.
► HR 121/min, BP 90/50,HR 121/min, BP 90/50,
RR 28/min, SpO2 85% on RA.RR 28/min, SpO2 85% on RA.

5. Case ScenarioCase Scenario
► 45 yr old male.45 yr old male.
► BG: T2DM, HTN for 10 yrs. On OHA and antihypertensive medication.BG: T2DM, HTN for 10 yrs. On OHA and antihypertensive medication.
► H/oH/o
Cough,Expectoration, Fever 5 days.Cough,Expectoration, Fever 5 days.
Dilirious, Not passed urine since last 24 hours.Dilirious, Not passed urine since last 24 hours.
►Hemodynamic disturbance:Hemodynamic disturbance: HR 121/min, BPHR 121/min, BP
90/50,90/50,
Tissue Hypoxia:Tissue Hypoxia: SpO2 85% on RA. Dilirious.SpO2 85% on RA. Dilirious.
Organ Dysfunction:Organ Dysfunction: Anuric, dilirious.Anuric, dilirious.

6. DefinitionDefinition
►Kumar and Parrillo (1995)Kumar and Parrillo (1995)
- “The state in which profound and- “The state in which profound and
widespreadwidespread reduction of effectivereduction of effective
tissue perfusiontissue perfusion leads first to reversible,leads first to reversible,
and then if prolonged, to irreversibleand then if prolonged, to irreversible
cellular injury.”cellular injury.”
►Clinically manifested byClinically manifested by
 Hemodynamic disturbances.Hemodynamic disturbances.
 Tissue Hypoxia.Tissue Hypoxia.
 Organ dysfunction.Organ dysfunction.

7. Tissue PerfusionTissue Perfusion
3 components3 components
PumpPump
ContainerContainer
FluidFluid

8. ► Cardiogenic shock –Cardiogenic shock –
due todue to cardiac pump failurecardiac pump failure ;loss of myocardial contractility;loss of myocardial contractility
/ functional myocardium or structural/mechanical/ functional myocardium or structural/mechanical
failure of the cardiac anatomy and characterized byfailure of the cardiac anatomy and characterized by
elevations of diastolic filling pressures and volumeselevations of diastolic filling pressures and volumes
► Hypovolemic shockHypovolemic shock ––
↓↓ circulating blood volumecirculating blood volume in relation to the totalin relation to the total
vascular capacity and characterized byvascular capacity and characterized by aa
reduction of diastolic filling pressures.reduction of diastolic filling pressures.
► Distributive shock –Distributive shock –
caused bycaused by loss of vasomotor controlloss of vasomotor control resulting inresulting in
arteriolar/venular dilatationarteriolar/venular dilatation and characterizedand characterized
(after fluid resuscitation) by(after fluid resuscitation) by increasedincreased
cardiac output andcardiac output and decreased SVR.decreased SVR.
Extra-cardiac obstructive shock –Extra-cardiac obstructive shock –
due todue to obstruction to flow in the cardiovascular circuitobstruction to flow in the cardiovascular circuit andand
characterized by eithercharacterized by either impairment of diastolic filling or excessiveimpairment of diastolic filling or excessive
afterloadafterload
ClassificationClassification

9. Distributive ShockDistributive Shock
►Results from a severe decrease in SVRResults from a severe decrease in SVR
 Vasodilation reduces both preload & afterloadVasodilation reduces both preload & afterload
 May be associated with increased COMay be associated with increased CO
►Etiologic categoriesEtiologic categories
-Septicemia-Septicemia
 Neurogenic / spinalNeurogenic / spinal
 Systemic inflammation(SIRS)Systemic inflammation(SIRS)
– pancreatitis, burns.– pancreatitis, burns.
 Anaphylaxis and anaphylactoid reactionsAnaphylaxis and anaphylactoid reactions
Toxin reactions – drugs, transfusion.Toxin reactions – drugs, transfusion.

10. The Sepsis ContinuumThe Sepsis Continuum
SIRS = systemic inflammatory
response syndrome
Severe
SepsisSIRS
Septic
Shock
Refractory
Septic Shock
SEPSI
S
ACCP: American college of chest physician.
SCCM: Society of critical care medicine

11. What is SIRS?What is SIRS?
Systemic level ofSystemic level of acute inflammationacute inflammation,,
that may or may not be due to infection.that may or may not be due to infection.
Requires 2 of the following 4 features to be present:Requires 2 of the following 4 features to be present:
►Temp >38.3° or <36.0° CTemp >38.3° or <36.0° C
►Tachypnea (RR>20 or PaCO2 <32 mmHg)Tachypnea (RR>20 or PaCO2 <32 mmHg)
►Tachycardia (HR>100,Tachycardia (HR>100, in the absence of intrinsic heart disease)in the absence of intrinsic heart disease)
►WBC > 10,000/mmWBC > 10,000/mm33
or <4,000/mmor <4,000/mm33
oror
>10% band forms on differential>10% band forms on differential

12. DefinitionsDefinitions (ACCP/SCCM)(ACCP/SCCM)
SepsisSepsis
• >>22 SIRSSIRS Criteria.Criteria.
• Either a culture-Either a culture- provenproven infectioninfection or anor an
infection identified by visual inspectioninfection identified by visual inspection
ACCP: American college of chest physician.
SCCM: Society of critical care medicine

13. Sepsis: Grade ISepsis: Grade I
•Severe Sepsis:Severe Sepsis:
SSepsisepsis ++ at least one of the following signsat least one of the following signs
ofof organ hypoperfusion or dysfunctionorgan hypoperfusion or dysfunction..
•• Mottled skin, Capillary refillingMottled skin, Capillary refilling>>3sec.3sec.
•• Urine output <0.5 mL/kg/Hr. or requiring Dialysis.Urine output <0.5 mL/kg/Hr. or requiring Dialysis.
•• Lactate >2 mmol/L.Lactate >2 mmol/L.
•• Altered sensorium.Altered sensorium.
•• Platelet count <100,000/mLPlatelet count <100,000/mL
•• Disseminated intravascular coagulation(DIC)Disseminated intravascular coagulation(DIC)
•• Acute lung injury or acute respiratory distressAcute lung injury or acute respiratory distress
syndrome (ARDS)syndrome (ARDS)
•• Cardiac dysfunction.Cardiac dysfunction.
Send the patient to higher
centre or to a friend Doctor
who can manage any further
deterioration.

14. • Septic ShockSeptic Shock:: severe sepsissevere sepsis ++ one orone or
both of the following:both of the following:
1. Mean1. Mean BP<60mmHgBP<60mmHg.. (<80 in Hypertensive pt.)(<80 in Hypertensive pt.) afterafter
Adequate fluid resuscitation.Adequate fluid resuscitation.
2. Requires2. Requires dopamine dopamine >5 mcg/kg/min, or>5 mcg/kg/min, or
norepinephrinenorepinephrine <0.25 mcg/kg/min, or <0.25 mcg/kg/min, or
epinephrineepinephrine <0.25 mcg/kg/min <0.25 mcg/kg/min despitedespite
adequate fluid resuscitation.adequate fluid resuscitation.
Sepsis: grade IISepsis: grade II
Adequate fluid resuscitation : infusion of 20 to 30 mL/kg of starch,
infusion of 40 to 60 mL/kg of saline solution, or
a measured pulmonary capillary wedge pressure (PCWP) of 12 to 20 mmHg.

15. • Refractory Septic ShockRefractory Septic Shock ::
To maintainTo maintain MMean BP >60ean BP >60 mmHgmmHg (or >80 mmHg(or >80 mmHg
if the patient has baseline hypertension)if the patient has baseline hypertension) requiresrequires
dopamine >15dopamine >15 mcg/kg/min,mcg/kg/min,
norepinephrine >0.25norepinephrine >0.25 mcg/kg/min, ormcg/kg/min, or
epinephrine >0.25epinephrine >0.25 mcg/kg/minmcg/kg/min
despite adequate fluid resuscitation.despite adequate fluid resuscitation.
Sepsis: grade IIISepsis: grade III
Adequate fluid resuscitation : infusion of 20 to 30 mL/kg of starch,
infusion of 40 to 60 mL/kg of saline solution, or
a measured pulmonary capillary wedge pressure (PCWP) of 12 to 20 mmHg.

16. The Sepsis ContinuumThe Sepsis Continuum
SIRS = systemic inflammatory
response syndrome
Severe
Sepsis
SIRS
Septic
Shock
Refractory
Septic Shock
SEPSI
S
ACCP: American college of chest physician.
SCCM: Society of critical care medicine
 A clinical responseA clinical response
arising from aarising from a
nonspecific insult, withnonspecific insult, with
≥≥2 of the following:2 of the following:
 T >38T >38oo
C or <36C or <36oo
CC
 HR >100 beats/minHR >100 beats/min
 RR >20/minRR >20/min
 WBC >12,000/mmWBC >12,000/mm33
or <4,000/mmor <4,000/mm33
oror
>10% bands>10% bands
Sepsis +
organ
hypo-perfusion
or dysfunction
SIRS +
confirmed
infection.
Septic
shock+
High
Inotropes.
Severe
Sepsis +
BP<60mmHg.
after fluid
resuscitation
or Low Inotrope

17. SEPSIS
Relationship Between Sepsis andRelationship Between Sepsis and
SIRSSIRS
TRAUMA
BURNS
PANCREATITIS
SIRSINFECTION
BACTEREMIA
Fungemia
Parasitemia
viremia

18. PrognosisPrognosis
Overall mortalityOverall mortality from SIRS/sepsis in the U.S.from SIRS/sepsis in the U.S.
isis approximately 20%.approximately 20%.
Mortality is roughly linearly related to theMortality is roughly linearly related to the
number of organ failures.number of organ failures.
Each additional organ failure raising theEach additional organ failure raising the
mortality rate by 15%.mortality rate by 15%.
HypothermiaHypothermia is one of the worstis one of the worst
prognostic signs.prognostic signs. Patients presenting with SIRSPatients presenting with SIRS
and hypothermia have an overalland hypothermia have an overall mortality of ~80%.mortality of ~80%.

19. Sepsis: PathophysiologySepsis: Pathophysiology

20. Pro-inflammatoryPro-inflammatory
MediatorsMediators
• Bacterial EndotoxinBacterial Endotoxin
• TNF-TNF-αα
• Interleukin-1Interleukin-1
• Interleukin-6Interleukin-6
• Interleukin-8Interleukin-8
• Platelet ActivatingPlatelet Activating
Factor (PAF)Factor (PAF)
• Interferon-GammaInterferon-Gamma
• ProstaglandinsProstaglandins
• LeukotrienesLeukotrienes
• Nitric OxideNitric Oxide
Mediators of SepticMediators of Septic
ResponseResponse
Anti-Anti-
inflammatoryinflammatory
MediatorsMediators
• Interleukin-10Interleukin-10
• PGE2PGE2
• Protein CProtein C
• Interleukin-6Interleukin-6
• Interleukin-4Interleukin-4
• Interleukin-12Interleukin-12
• LipoxinsLipoxins
• GM-CSFGM-CSF
• TGFTGF
• IL-1RAIL-1RA

21. Cohen, Nature: 2002 420:885

22. Management: Septic ShockManagement: Septic Shock

23. Starting from common ground…Starting from common ground…
►Appropriate supportive careAppropriate supportive care
 ABCsABCs (CAB if patient has arrested)(CAB if patient has arrested)
 FluidsFluids
 Vasopressors/inotropesVasopressors/inotropes
 Organ support (ventilation, dialysis, etc.)Organ support (ventilation, dialysis, etc.)
►Appropriate empiric and adjustedAppropriate empiric and adjusted
antibioticsantibiotics
►Source identification & control.Source identification & control.
►Steroids, Glycemic control, Nutrition,Steroids, Glycemic control, Nutrition,
Activated protein C.Activated protein C.

24. CVP:
central
venous
pressure
MAP:
mean
arterial
pressure
ScvO2:
central
venous
oxygen
saturation
Early Goal-DirectedEarly Goal-Directed
TherapyTherapy
NEJM 2001;345:1368-77.

25. What to do if you don’t have facilityWhat to do if you don’t have facility
for CVP measurement ?for CVP measurement ?
-20ml/Kg fluid bolus every 30--20ml/Kg fluid bolus every 30-
60minutes. (NS or Colloid)60minutes. (NS or Colloid)
Poor Man’s CVP assessment & GuidedPoor Man’s CVP assessment & Guided
fluid:fluid:
Passive leg raising (PLR)Passive leg raising (PLR) increasingincreasing
preload.preload.
Watch HR trendWatch HR trend
↓HR= Give more.↓HR= Give more.
↑HR= Stop giving.↑HR= Stop giving.
(other reasons for tachycardia/bradycardia ruled out)(other reasons for tachycardia/bradycardia ruled out)

26. What to do if you don’t have facilityWhat to do if you don’t have facility
for CVP measurement ?for CVP measurement ?
Poor Man’s CVP assessment & GuidedPoor Man’s CVP assessment & Guided
fluid:fluid:
Passive leg raising (PLR)Passive leg raising (PLR)
Poor Man’s Cardiac output:Poor Man’s Cardiac output:
U/OU/O>> 0.5ml/kg/hr.0.5ml/kg/hr.
►Spo2 ~95-97% (NOT 100%)Spo2 ~95-97% (NOT 100%)
►HRHR
►U/OU/O
►Neurological state.Neurological state.

27. Treatment:Treatment: (Vasopressors)(Vasopressors)
►Noradrenaline, Adrenaline, Vasopressin.Noradrenaline, Adrenaline, Vasopressin.
(after volume resuscitation).(after volume resuscitation).
►? Dopamine & Dobutamine.? Dopamine & Dobutamine.
► A goal MAP =60-65mmHg,A goal MAP =60-65mmHg,
► Urine output, mental status, and skin perfusionUrine output, mental status, and skin perfusion areare
better variables to use in monitoringbetter variables to use in monitoring adequateadequate
perfusion then BP aloneperfusion then BP alone..

28. TreatmentTreatment
AntibioticsAntibiotics
► ConsiderConsider possiblepossible organismsorganisms at suspected/confirmedat suspected/confirmed
sitesite of the infection.of the infection.
► Obtain cultures, give empirical antibioticsObtain cultures, give empirical antibiotics quicklyquickly and atand at
appropriate dose.appropriate dose.
► De-escalateDe-escalate ones organism identified.ones organism identified.
Mechanical VentilationMechanical Ventilation
► Do not delayDo not delay mechanical ventilation if indicated.mechanical ventilation if indicated.
Know your intubation criteria.Know your intubation criteria.
► Low tidal volume ventilation for ARDSLow tidal volume ventilation for ARDS
► Nearly all patientsNearly all patients with septic shock requirewith septic shock require oxygenoxygen, and, and
80%(80%(approx.) requireapprox.) require mechanical ventilation.mechanical ventilation.

29. Give your patientsGive your patients ONE FAST HUGONE FAST HUG
everyday in HDU & ICUeveryday in HDU & ICU
► OO: Oral care.: Oral care.
► NN: Nose care.: Nose care.
► EE: Ear care.: Ear care.
► FF: Feeding: Feeding (adequate calories.)(adequate calories.)
► AA: Analgesia: Analgesia (Check)(Check)
► SS: sedation: sedation (Check)(Check)
► TT: Thromboprophylaxis: Thromboprophylaxis
► HH: Head raised: Head raised 4545degreedegree
► UU: Ulcer prophylaxis.: Ulcer prophylaxis.
► GG: Glucose control.: Glucose control.
Crit Care Med 2005 Vol. 33, No. 6

30. Evidence-Based SepsisEvidence-Based Sepsis
GuidelinesGuidelines
Components:Components:
• Early Goal-Directed TherapyEarly Goal-Directed Therapy
• Steroid ReplacementSteroid Replacement
• Recombinant Activated Protein CRecombinant Activated Protein C
• Glycemic ControlGlycemic Control
• Nutritional SupportNutritional Support
• Adjuncts: Stress Ulcer Prophylaxis,Adjuncts: Stress Ulcer Prophylaxis,
DVT Prophylaxis, Transfusion,DVT Prophylaxis, Transfusion,
Sedation, Analgesia, OrganSedation, Analgesia, Organ
ReplacementReplacement

31. Evidence based Summary of SepsisEvidence based Summary of Sepsis
GuidelinesGuidelines
InitiativeInitiative GradeGrade
DVT prophylaxisDVT prophylaxis with low dose heparins orwith low dose heparins or
mechanical devicesmechanical devices
AA
Stress ulcer prophylaxisStress ulcer prophylaxis, preferably with H, preferably with H22
blockersblockers
AA
Do not use > 300 mg/day hydrocortisoneDo not use > 300 mg/day hydrocortisone AA
Weaning protocolWeaning protocol with spontaneouswith spontaneous
breathing trialsbreathing trials
AA
Do not increase cardiac index to supranormalDo not increase cardiac index to supranormal AA
Early initial resuscitation to goalsEarly initial resuscitation to goals BB
Red blood cell transfusion/dobutamineRed blood cell transfusion/dobutamine toto
goalsgoals
BB

32. InitiativeInitiative GradeGrade
Do not useDo not use low doselow dose dopaminedopamine for renalfor renal
protectionprotection
BB
rh Activated Protein Crh Activated Protein C [drotrecogin alfa[drotrecogin alfa
(activated)] in patients with high risk of death(activated)] in patients with high risk of death
BB
RBC transfusionRBC transfusion if hemoglobin <7 g/dLif hemoglobin <7 g/dL BB
Do not use erythropoietinDo not use erythropoietin for sepsisfor sepsis causedcaused
anemiaanemia
BB
Avoid high tidal volumesAvoid high tidal volumes and plateauand plateau
pressures in ALI/ARDSpressures in ALI/ARDS
BB
Continuous vs. intermittentContinuous vs. intermittent renal replacementrenal replacement
considered equivalentconsidered equivalent for acute renal failurefor acute renal failure
BB
Evidence based Summary of SepsisEvidence based Summary of Sepsis
GuidelinesGuidelines

33. InitiativeInitiative GradeGrade
Sedation protocolsSedation protocols with goal and assessmentwith goal and assessment
scalescale
BB
Daily interruptionDaily interruption if continuous i.v. sedationif continuous i.v. sedation BB
UseUse colloids or crystalloidscolloids or crystalloids CC
CorticosteroidsCorticosteroids for 7 daysfor 7 days in septic shockin septic shock
patients on vasopressorspatients on vasopressors
CC
Permissive hypercapniaPermissive hypercapnia to minimize plateauto minimize plateau
pressures and tidal volumespressures and tidal volumes
CC
Do not use bicarbonate if pH ≥7.15Do not use bicarbonate if pH ≥7.15 inin
hypoperfusion lactic acidemiahypoperfusion lactic acidemia
CC
Semirecumbent positioning to avoid VAPSemirecumbent positioning to avoid VAP (head of(head of
bed at 45-degrees)bed at 45-degrees)
CC
Evidence based Summary of SepsisEvidence based Summary of Sepsis
GuidelinesGuidelines

34. ►Fluid resuscitation, goal-directedFluid resuscitation, goal-directed
►Appropriate cultures prior to antibioticAppropriate cultures prior to antibiotic
administration (but do not delay) andadministration (but do not delay) and
source control ASAP.source control ASAP.
►Use of vasopressors/inotropes whenUse of vasopressors/inotropes when
fluid resuscitation optimized.fluid resuscitation optimized.
►Low tidal volumes (6cc/kg) forLow tidal volumes (6cc/kg) for
mechanical ventilation in ARDS.mechanical ventilation in ARDS.
Take home messageTake home message

35. ►Stress ulcer and DVT prophylaxisStress ulcer and DVT prophylaxis
►De-escalate antibiotic.De-escalate antibiotic.
►Prevent VAP: 45 degree elevationPrevent VAP: 45 degree elevation
►Facilitate early discontinuation ofFacilitate early discontinuation of
mechanical ventilation: sedationmechanical ventilation: sedation
interruption, early SBTinterruption, early SBT
Take home message (Cont’d)Take home message (Cont’d)
Prevent ComplicationPrevent Complication

36. "First Do No Harm"