Shock Definiciones y Manejo

8/12/2019 Shock Definiciones y Manejo

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SHOCKCIRCUL TORIO

MR. A. Hctor Ramos Bravo

UCI-H.N.E.R.M.


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DEFINICIN

Insuficiencia circulatoria que origina hipoperfusin

e hipoxia tisular; con compromiso de la actividadmetablica celular y funcin orgnica

Shock is the clinical expression of circulatory failurethat results in inadequate cellular oxygen utilization

Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors N

Engl J Med 2013


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GENERALIDADES

Shock affecting about onethird of patients in theintensive care

unit (ICU).

Diagnosis of shock is based

on clinical, hemodynamic,and biochemical signs

Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors NEngl J Med 2013


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DISTRIBUCION DE VOLUMENES


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PRESION ONCOTICA


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CaO2 = (Hb X 1.34 X SaO2) + (0.003 X PaO2) n: 16-20 ml de O2 por cada 100 ml de sangreDO2 = CaO2 X Q


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Jean-Louis Vincent1*, Andrew Rhodes2, Azriel Perel3, Greg S Martin4, Giorgio Della Rocca5, Benoit

Vallet6 Clinical review: Update on hemodynamic monitoring - a consensus of 16 Critical Care 2011, 15:229


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5

120/0

120/80

PAM

100

10 20 30

2

25/0

PAPM15

12 8

CIRCULACION SISTEMICA Y PULMONAR

4

8

r

nlR

PAM = PD + (PS - PD)

3

FCmx=220-edad


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SHOCK

CONTENIDOCONTINENTE BOMBA

HIPOVOLEMICO CARDIOGENICO OBSTRUCTIVODISTRIBUTIVO


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TIPOS DE SHOCK:

Shock hipovolmico Obstructivo Cardiognico Distributivo

Hemorragia

deplecinfluidos

Taponamiento Masa miocrdicaDisfuncin

miocrdica

Resistencias

Vasc-sistem.

PrecargaLlenado

Disfuncin

diastlica

Contractilidad 90 %

10 %

GASTO CARDIACO

TRANSPORTE DE OXIGENO


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Hipovolmico Obstructivo Cardiognico Distributivo

GASTO CARDIACO

TRANSPORTE DE OXIGENOGasto normal/alto

DO2

TENSION ARTERIAL

Mala distribucin de

flujo (microcirculacin)SHOCK DISMINUCION PERFUSION

FALLA ORGANICA

MUERTE

TIPOS DE SHOCK:


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FASE

COMPENSACION

VOLUM RECEPAURICULASEST SIMP


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RESULTADOSDao tisular

DolorHipovolemia Infeccin

Hipoglicemia Hipoxemia

Vias

Espino-talmicas

Hipotermia Acidosis

Estrs Activacin del eje hipotalamo- Hipercapnia

Hipfisis-suprarenal

Liberacin de cortisol y

Catecolaminas


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VARIABLES DE GASTO CARDIACO


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PERFORMANCE CARDACA

FRECUENCIACARDIACA

FC: aumentadaAfecta VM

FC: disminuida

Deficit contracionVolumen minuto

Volumen eyeccion

Vm = FCXVE

FE (VE/VFD)x100]

LEY DE FRANK STARLING

longitud del msculo cardaco y la fuerza

de contraccin.

En diastole > estiramiento o >volumen

Ventriculo > energia para la prxima

contraccin en sstole


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PERFORMANCE CARDACA

FRECUENCIACARDIACA

PRECARGA

CONTRACTILIDAD

POST CARGA

Volumen minutoVolumen eyeccion

tensin parietal al final de la distole ovolumen en Ventriculo VFDV oindirecta PVFDVdependiente

COMPLIANCE MUSCULAR

Vm = FCXVE

FE = (VE/VFD)

x 100]


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PERFORMANCE CARDACA

FRECUENCIACARDIACA

PRECARGA

CONTRACTILIDAD

POST CARGA

Volumen minutoVolumen eyeccion

tensin parietal al final de la distole ovolumen en Ventriculo VFDV oindirecta PVFDVdependiente

COMPLIANCE MUSCULAR

Vm = FCXVE

FE = (VE/VFD)

x 100]

tensin parietal necesaria para

eyectar VS contra una

resistencia (sstole), calculado

como RVS y RVP

propiedad intrnseca de lasfibras miocrdicas de generar

una tensin sin alterar la

precarga

THE HEMODYNAMIC OXYGEN TRANSPORT AND


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THE HEMODYNAMIC, OXYGEN TRANSPORT ANDUTILIZATION COMPONENTS OF TISSUEPERFUSION

Fluid therapy in septic shock Emanuel P. Riversa,b, Anja Kathrin Jaehnea, Laura Eichhorn-Wharryb,Samantha Browna and David AmponsahCurr Opin Crit Care 16:000000 2010


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INITI L PPRO CHTO THE P TIENT IN SHOCK

MR. A. Hctor Ramos Bravo

UCI-H.N.E.R.M.


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Manejo

Adequatehemodynamic supportis crucial to prevent

organ failure.

Resuscitation shouldbe started even whileinvestigation of thecause is ongoing

Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors NEngl J Med 2013

CONTROL OF BLEEDING

PERCUTANEOUS CORONARYINTERVENTION

THROMBOLYSIS FOR MASSIVEPULMONARY EMBOLISM,

AND ADMINISTRATION OF

ANTIBIOTICS


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MANEJO VIP RULE

Ventilate (oxygen administration)

Infuse (fluid resuscitation)

Pump (administration of vasoactiveagents)

V

I

P

Weil MH, Shubin H. The VIP approach

to the bedside management ofshock. JAMA 1969;207:337-40


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VENTILATE (OXYGEN ADMINISTRATION)

Oxygen started, increase oxygen delivery and preventpulmonary hypertension

Pulse oximetry (peripheral vasoconstriction), and AGA

Mechanical ventilation Reducing the oxygen demand

Respiratory muscles and decreasing left ventricularafterload by increasing intrathoracic pressure.

Decrease in PA after the initiation of VM suggestshypovolemia and a decrease in venous return.

Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors N Engl J Med 2013


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INFUSE (FLUID RESUSCITATION) FLUID THERAPY TO IMPROVE MICROVASCULAR

BLOOD FLOW AND INCREASE CARDIAC OUTPUT

FLUID ADMINISTRATION SHOULD BE CLOSELYMONITORED

IN GENERAL, THE OBJECTIVE IS FOR CARDIACOUTPUT TO BECOME PRELOAD-INDEPENDENT

SIGNS OF FLUID RESPONSIVENESS MAY BEIDENTIFIED EITHER DIRECTLY FROM BEAT-BY-BEAT STROKE-VOLUME


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No Invasivo Sistema NICOM

Ultrasonografa

Doppler (sistema

USCOM)

Doppler esofgico

Eco Cardiografa

Espectroscopiacercana infrarroja

(NIRS)

Invasivo PVC

Lnea Arterial

Swan Ganz

Minimamente invasivo Sistema PiCCO

Sistema LiDCO

Sistema FloTrac/Vigileo

Sistema MostCare de

Vygon

Sistema Modelflow-Nexfin

El sistema NICO

SIGNS OF FLUID RESPONSIVENESS MAY BEIDENTIFIED EITHER DIRECTLY FROM BEAT-BY-BEASTROKE-VOLUME

Clinico Frecuencia arterial

Presion arterial Balance hidrico

Rayox Torax

Elevacion de piernas

Signos de perfusion

INFUSE (FLUID RESUSCITATION)


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Meta-anlisis previos concluyePVC no debe ser usada paratomar decisiones respuesta afluidos.

Conclusiones: No hay datos

que apoyen la utilizacin de laPVC para guiar la terapia defluidos. Debe ser abandonada.

( Crit Care Med 2013 ; 1:1774-1781 )

Monnet and Teboul Critical Care 2013 17:217


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DECISION-MAKING PROCESS OF FLUID

ADMINISTRATION

Monnet and Teboul Critical Care 2013, 17:217


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INFUSE (FLUID RESUSCITATION)

First, the type of fluid must be selected.

Crystalloid solutions , coloids or albumin

Second, Fluids should be infused rapidly an infusion of300 to 500 ml of fluid is administered during a period of

20 to 30 minutes. Third, the objective of the fluid challenge must be

defined

Finally, the safety limits must be defined. Pulmonaryedema is the most serious complication of fluid infusion


PUMP (ADMINISTRATION OF VASOACTIVE


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PUMP (ADMINISTRATION OF VASOACTIVEAGENTS) Hypotension is severe or if it persists

Adrenergic agonists are the first-line vasopressors becauserapid onset of action, high potency, and short half-life

Norepinephrinefirst choice;

-adrenergic, dose is 0.1 to 2.0 g/k/min

Dopaminehas predominantly-adrenergic lower do and -adrenergic higher doses


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Daniel De Backer, M.D., Ph.D., Patrick Biston Comparison of Dopamine and Norepinephrine

in the Treatment of Shock, N Engl J Med 2010;362:779-89.


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Forest Plot for Predef ined Subgroup AnalysisAccording to Type of Shock

Daniel De Backer, M.D., Ph.D., Patrick Biston Comparison of Dopamine and Norepinephrinein the Treatment of Shock, N Engl J Med 2010;362:779-89.


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EPINEFRINAAcciones dosis depenciente mcg / k / min

0.02- 0.08 : B 1 y B2

Aumenta gasto cardiaco

0.1-2 : B 1 Y ALFA 1

Aumenta resistencia vascular sistemca

Acumenta gasto cardiaco

>2 : ALFA 1 Aumenta resistencias vasculares disminuyendo el Gasto

cardiaco


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VASOPRESINAReceptores de Vasopresina y funciones


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DOSIS DE VASOPRESINA


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FOUR PHASES IN THE TREATMENT OF SHOCK


O O


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OVERVIEW OF PATIENTENROLLMENT ANDHEMODYNAMIC SUPPORT.

We randomly assignedpatients who arrived at anurban emergency department

Of the 263 enrolled patients

130 were randomlyassigned to early goal-directed therapy

133 to standard therapy

MANUEL RIVERS , M.D., M.P.H., BRYANT EARLY

GOAL-DIRECTED THERAPY IN THE TREATMENT OF

SEVERE SEPSIS AND SEPTIC SHOCK N Engl J Med,Vol. 345, No. 19 November 8, 2001

PROTOCOL FOR EARLY


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PROTOCOL FOR EARLYGOAL-DIRECTEDTHERAPY.

MANUEL RIVERS , M.D., M.P.H., BRYANT EARLY GOAL-DIRECTED

THERAPY IN THE TREATMENT OF SEVERE SEPSIS AND SEPTIC

SHOCK N Engl J Med, Vol. 345, No. 19 November 8, 2001


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KAPLANMEIER ESTIMATES OF MORTALITY ANDCAUSES OF IN-HOSPITAL DEATH

MANUEL RIVERS , M.D., M.P.H., BRYANT EARLY GOAL-DIRECTED THERAPY IN THE TREATMENT OF SEVERE SEPSIS AND SEPTIC SHOCK N

Engl J Med, Vol. 345, No. 19 November 8, 2001,


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Jean-Louis Vincent1*, Andrew Rhodes2, Azriel Perel3, Greg S Martin4, Giorgio Della Rocca5, Benoit

Vallet6 Clinical review: Update on hemodynamic monitoring - a consensus of 16 Critical Care 2011, 15:229


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GRACIAS


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Documents

Shock Definiciones y Manejo