Transcript VASOPRESSORS and INOTROPES

D. P. Laporta MD
SMBD-JGH
Dept of Adult Critical Care
SHOCK - OUTLINE
 DEFINITION
 CAUSES
 EFFECTS
OF INEFFECTIVE
TREATMENT
 ASSESSMENT
 CLINICAL APPROACH
CASE
CASE
CASE
CASE
CASE
CASE
SHOCK CASES
1. post Cardiac Surgery
- same day
- 1 week postop
2. in MVA victim
3. In young male with Crohn ’s
disease found febrile in shock
4. In drug addict, hospital worker
SHOCK  DEFINITION




CAUSES
EFFECTS OF INEFFECTIVE TREATMENT
ASSESSMENT
CLINICAL APPROACH
DEFINITION
A profound disturbance of the circulation
and metabolism, leading to
inadequate perfusion of vital organs,
necessary to maintain homeostasis
SHOCK 
DEFINITION
 CAUSES



EFFECTS OF INEFFECTIVE TREATMENT
ASSESSMENT
CLINICAL APPROACH
HYPOPERFUSED STATES
RV
Venous
PVR
LV
Arterial
(capacitance)
(resistance)
EF End-Diastolic Volume
SVR
BP 60/30
Hypovolemic
HR 140/min
CVP 0
Lactate 10
Cardiogenic
BP 70/50
HR 130/min
CVP 18
Lactate 12
Obstructive
BP 70/50
HR 140/min
CVP 15
Lactate 12
VTED
OAD
DLD
Distributive
BP 70/40
HR 140/min
CVP 5
Lactate 12
SHOCK 

DEFINITION
CAUSES
 EFFECTS
OF INEFFECTIVE
TREATMENT



ASSESSMENT
MEASUREMENT
CLINICAL APPROACH
EFFECTS OF INEFFECTIVE TREATMENT
MISERY !!!
MODS
• PO2/FiO2 ratio
• Serum creatinine
• Platelet count
• Glasgow coma score
• Serum bilirubin
• Pressure-adjusted heart rate
(hr x CVP/MAP)
INFECTION
SHOCK 


DEFINITION
CAUSES
EFFECTS OF INEFFECTIVE TREATMENT
 ASSESSMENT


MEASUREMENT
CLINICAL APPROACH
SHOCK: asssessment
 Class

1&2
vs 3&4
needs blood or crystalloid ?
Sublingual capnometry:
A new noninvasive measurement for diagnosis and
quantitation of severity of circulatory shock
Max Harry Weil MD, PhD, FCCM - CCM 1999
hypercarbia is a universal indicator of critically reduced
tissue perfusion.
Sublingual capnometry:
A new noninvasive measurement for diagnosis and
quantitation of severity of circulatory shock
Sublingual capnometry:
A new noninvasive measurement for diagnosis and
quantitation of severity of circulatory shock
Sublingual capnometry:
A new noninvasive measurement for diagnosis and
quantitation of severity of circulatory shock
P SL CO2
provides a prompt
indication of the
reversal of tissue
hypercarbia
when circulatory
shock is reversed
SHOCK 



DEFINITION
CAUSES
EFFECTS OF IEFFECTIVE TREATMENT
MEASUREMENT
 CLINICAL
APPROACH
SHOCK: an EMERGENCY !!!
GOAL:
RAPIDLY RESTORE TISSUE PERFUSION
• Recognize
it !!!
•Immediate stabilization: ABC
……. SHOTGUN approach
• ICU & Surgical consultation
•Treat the cause
Management priorities
in hypoperfused states
Priority # Physiology to Intervention
improve
1
Volume
Fluids
2
Pressure
Vasopressor
3
Flow
Inotrope
Parameter to target
CVP 10-15
PAC
targets
DO2
Low Sao2
See CXR
Low SV, DO2
High HR,
Resistances
DO2
Low BP, SV,
Resistances
SBP? 100 or within 20-25
torr
MBP ? 80 of patient's Nl
Signs of perfusion
Avoid
BP potency: Dopamine...NE…Vasopressin/Phenylephrine