SHOCK EN ACUUT LONGFALEN

SHOCK EN ACUUT LONGFALEN.

Carl Roosens Intensieve Zorg UZ Gent

Postgraduaat Heelkunde.

1.

SHOCK 1. 2.

2.

1

Indeling Behandeling

ACUUT PERIOPERATOIR LONGFALEN 1. 2.

Omschrijving Behandeling


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1.

SHOCK 1. 2.

2.





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1.1. Indeling.

Shock is een conditie van circulatoir falen gekarakteriseerd door inadequate weefselperfusie en oxygenatie, waardoor onvoldoende nutriënten naar en afvalproducten van de weefsels kunnen vervoerd worden, met als gevolg cellulaire dysfunctie, orgaanfalen en uiteindelijk dood.


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1.1. Indeling.


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1.1. Indeling.

1.

Hypovolemische shock Gedaald intravasculair volume tgv. exogeen of endogeen verlies van bloed, vocht of elektrolieten.

2.

Cardiogene shock Low cardiac output tgv. stoornis pompfunctie (AMI), ritmestoornis of klepdysfunctie

3.

Obstructieve shock Belemmerde vulling van rechter- en/of linkerhart (longembool, harttamponnade).

4.

Distributieve shock Abnormale verdeling van volumestatus door permeabiliteitsstoornis of verandering vaatweerstand (sepsis, anafylaxis,…)

WEIL EN SHUBIN 1972


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1.1. Indeling.

1. 2. 3. 4.

Hypovolemische shock Cardiogene shock Obstructieve shock Distributieve shock

•Low cardiac output •Hoge SVR

•Hoge cardiac output •Lage SVR CAVE. DE VERSCHILLENDE VORMEN KUNNEN VERMENGD OPTREDEN. Postgraduaat Heelkunde.

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Parker. Ann Int Med 1984; 100:483-490 Postgraduaat Heelkunde.

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1.1. Indeling. ARTERIAL PRESSURE

URINE OUTPUT

SKIN PERFUSION

MENTAL STATUS

CLINICAL ASSESSMENT

+ BLOOD LACTATE LEVELS

+ CARDIAC OUTPUT SvO2

SYSTEMIC AND REGIONAL HEMODYNAMIC AND OXYGENATION VARIABLES

TISSUE PO2

MICROCIRCULATION

OVERALL ASSESSMENT Postgraduaat Heelkunde.

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1.1. Indeling.

The individual response is determined by many factors as •Virulence of the organism •Size of inoculum •Patient’s condition eg.age) •Polymorphisms in gene for cytokines

Hotchkiss NEJM 2003; 348:138-150 Postgraduaat Heelkunde.

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1.1. Indeling.

SEPTISCHE SHOCK


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1.1. Indeling.

SHOCK EN ORGAANFALEN


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1.

SHOCK 1. 2.

2.





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1.2. Behandeling.

1.

CORRECTION OF THE CAUSE: Stop bleeding (traumatic, gastro-intestinal, ruptured aneurysm, ….) Treat myocardial infraction ( thrombolytic agents, PTCA, surgery, IABP, …) Drain pericardial fluid for tamponade, thrombolysis or even surgery fir pulmonat embolus. Administer antibiotics, remove source of infection.

2.

RESUSCITATION: VIP rule (Weil and Shubin 1969)

VENTILATE, INFUSE, PUMP Postgraduaat Heelkunde.

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1.2. Behandeling.

VENTILATE. Alle patiënten in circulatoire shock moeten O2 krijgen om hun O2-delivery te maximaliseren. Indien er enige twijfel bestaat, is het aangewezen over te gaan tot intubatie en kunstmatige ventilatie.

INFUSE. Vochttoediening is essentieel voor optimaliseren cardiac output en microcirculatie. Fluid challenge.


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1.2. Behandeling. Type of fluid

Remains matter of debate. No studies clearly demonstrate benefit one type over another. Personal decision.

Rate of fluid administration

E.g. 500-1000 mL crystalloids or 300-500 colloids over 30 min.

Target

Most commonly restoration of adequate mean arterial pressure. Restoration of urine output. Resolution of tachycardia.

Safety limits

Avoid excess fluid administration (pulmonary edema). Pulmonary artery occlusion pressure, central venous pressure, echocardiography.


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1.2. Behandeling.


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1.2. Behandeling.


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More catheter-related problems in PAC group ! Sandham. NEJM 2003; 348:5-14

ARDS Network. NEJM 2006; 354:2213-2224


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1.2. Behandeling.

PUMP.


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1.2. Behandeling.

De behandeling van een diepe distributieve shock zonder toediening van vasopressoren (α-agonisten), en dit soms in een forse dosis, is een utopie. Postgraduaat Heelkunde.

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Initial resuscitation. Immediately CVP 8-12 mm Hg; MAP > 65 mm Hg; SvO2 > 70

Diagnosis Cultures Imaging studies

Antibiotic therapy As early as posibble

Source identification and control Fluid therapy Vasopressors Inotropic therapy


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Steroids Consider hydrocortisone when hypotension poorly responds to adequate fluid resuscitation and vasopressors Hydrocortisone ≤ 300 mg / 24 h

Recombinant human activated protein C (Xigris®) Consider rhAPC in patients with organ dysfunction and clinical assessment of high risk of death (APACHE II > 25 or multiple organ failure), if there are no contraindications Cave bleeding

Blood product administration Give RBC when Hb decreases < 7.0 g/dl Do not use fresh frozen plasma

Mechanical ventilation


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Sedation, analgesia, neuromuscular blockade Glucose control Use IV insulin to control glycemia with the aim to keep glycemia < 150 mg/dl

Renal replacement Bicarbonate therapy Do not use HCO3 therapy when treating lactic acidemia pH ≥ 7.15

Deep vein thrombosis prophylaxis Stressulcer propylaxis Consider limitation of support


1.

SHOCK 1. 2.

2.

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2.1. Omschrijving.

Postoperative hypoxemia after abdominal surgery 30-50%. Respiratory failure with need for intubation 810%. Congestive heart failure 3-6% after intraabdominal operations. Highest incidence of respiratory failure develops at 1 – 3 days. Thompson. Arch Surg 2003; 138:596-603 Arozullah Ann Surg 2000; 232:242-253 Moller. Anesthesiology 1990; 72:890-895


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Postoperative pulmonary complications Atelectasis Respiratory depression Pneumonia Acute respiratory distress syndrome (ARDS) Acute cardiogenic pulmonary edema Acute COPD exacerbation Pulmonary embolus Pleural effusion … Postgraduaat Heelkunde.

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2.1. Omschrijving.


Roosens. Crit Care Med 2002; 30:2430-2437

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2.1. Omschrijving.

Roosens. Crit Care Med 2002; 30:2430-2437 Postgraduaat Heelkunde.

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2.1. Omschrijving.

Thompson. Arch Surg 2003; 138:596-603 Postgraduaat Heelkunde.

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2.1. Omschrijving.

•81.719 patients and 99.390 patients as validation. • PRF = mechanical ventilation > 48 h or reintubation and mechanical ventilation. •Female excluded ! •Noncardiac operations.

Arozullah. Ann Surg 2000; 232:242-253 Postgraduaat Heelkunde.

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2.1. Omschrijving.


Arozullah. Ann Surg 2000; 232:242-253

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2.1. Omschrijving.


Arozullah. Ann Surg 2000; 232:242-253

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2.1. Omschrijving.

Postoperative Pneumonia Risk Index. •160.805 patients and 155.266 patients as validation. •Non-cardiac operations. •Mortality wtih pneumonia 21% vs. 2% if no pneumonia !


Arozullah. Ann Int Med 2001; 135:847-857

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2.1. Omschrijving.

ARDS Acute onset Bilateral infiltrates PCWP < 18 mm Hg PaO2/FiO2 < 200 ALI = PaO2/FiO2 < 300 Mortality 70% -> 30-40% Decreased quality of life.


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ARDS

is an inflammatory response in the lung to both direct and indirect insults, characterised by severe hypoxemia, reduced lung-compliance and diffuse radiographic infiltrates. DIRECT Pneumonia Pulmonary contusion Aspiration Near-drowning Reperfusion

INDIRECT Sepsis Pancreatitis Trauma Blood transfusion Postoperatively Intoxication CPR …..


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2.1. Omschrijving.


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2.1. Omschrijving.


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Cardiogenic edema

Non-Cardiogenic edema


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Cardiogenic edema

Non-Cardiogenic edema


1.

SHOCK 1. 2.

2.

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2.2. Behandeling.

ARDS MECHANICAL VENTILATION Avoid cyclic opening and collaps of alveoli Reduction in tidal volume (6-8 mL/kg) PPLATEAU < 30 cm H2O High PEEP levels Permissive hypercapnia Keep FiO2 as low as possible


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2.2. Behandeling.

ARDS High Frequency Oscillatory Ventilation (HFOV) Prone positioning. Extracorporeal life support. Inhaled nitric oxide. Corticosteroids. Surfactant. Fluid management.


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2.2. Behandeling.

Non Invasive Ventilation ?. Meduri. Chest 1996; 109:179-193 Rocker. Chest 1999; 115:173-177 Wysocki. Chest 1995; 107:791-768 Antonelli. NEJM 1998; 339:429-435 Patrick. AJRCCM 1996; 153:1005-1011 Martin. AJRCCM 2000; 161:807-813 Hilbert. CCM 2000; 28:3185-3190 Antonelli. CCM 2002; 30:602-608 Antonelli. ICM 2001; 27:1718-1728 Ferrer. AJRCCM 2003; 168: 1438-1444 Jaber. Chest 2005; 128:2688-2695 Postgraduaat Heelkunde.

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2.2. Behandeling.

Non Invasive Ventilation ?. L’Her. AJRCCM 2005; 172:1112-1118 Principi. ICM 2004; 30:147-150 Antonelli. CCM 2007; 35:18-25 Kindgen-Milles. Chest 2000; 117:1106-1111 …

The possibility of a clear benefit exists. The safety of the use has been confirmed. Effect on mortality remains unclear. Postgraduaat Heelkunde.

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2.2. Behandeling.

209 patients after major abdominal surgery randomized After extubation 1 hour screening test Inclusion if PaO2/FiO2 ratio ≤ 300 Cardiac patients excluded. Patients in shock or with severe respiratory insufficiency excluded. Protocol: 6 hours O2 by Venturi mask or 6 hours O2 + CPAP 7.5 cm H2O (helmet)


Squadrone. JAMA 2005; 293:589-595

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2.2. Behandeling.

Primary outcome Intubation rate


Squadrone. JAMA 2005; 293:589-595

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2.2. Behandeling.


Squadrone. JAMA 2005; 293:589-595

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2.2. Behandeling. Prospective observational study. 72 patients with ARF after abdominal surgery. NIV with Servo 300 or Evita 4 ventilator with PS and PEEP. NIV applied intermittently (8-12 h/day). Intubation avoided in 67%


Jaber. Chest 2005; 128:2688-2695

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2.2. Behandeling.

Kindgen-Milles. Chest 2000; 117:1106-1111 Postgraduaat Heelkunde.

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2.2. Behandeling.


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2.2. Behandeling.


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2.2. Behandeling.


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2.2. Behandeling.

NIV after lung resection. No NIPPV (n=24)

NIPPV (n=24)

P-value

ETMV

12 (50%)

5 (20.8%)

0.035

Deaths (%)

9 (37.5%)

3 (12.5%)

0.045

ICU stay

14 ± 11.1

16.65 ± 23.6

0.52

Hospital stay

22.8 ± 10.7

27.1 ± 19.5

0.61

120d deaths (%)

9 (37.5)

3 (12.5%)

0.045

Auriant. AJRCCM 2001; 164:1231-1235 Postgraduaat Heelkunde.

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SHOCK EN ACUUT LONGFALEN

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