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SHOCK CIRCULATORIO

MR. A. Hctor Ramos Bravo UCI-H.N.E.R.M.

DEFINICIN
Insuficiencia circulatoria que origina hipoperfusin e hipoxia tisular; con compromiso de la actividad metablica celular y funcin orgnica Shock is the clinical expression of circulatory failure that 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

GENERALIDADES
Shock affecting about one third of patients in the intensive 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 N Engl J Med 2013

DISTRIBUCION DE VOLUMENES

PRESION ONCOTICA

CaO2 = (Hb X 1.34 X SaO2) + (0.003 X PaO2) n: 16-20 ml de O2 por cada 100 ml de sangre DO2 = CaO2 X Q

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

CIRCULACION SISTEMICA Y PULMONAR


2 5

25/0

120/0

120/80

PAPM 15 PAM 100

8nl R 4 r
8

12

PAM = PD + (PS - PD) 3

10

20

30

FCmx=220-edad

SHOCK
CONTINENTE CONTENIDO BOMBA

DISTRIBUTIVO

HIPOVOLEMICO

CARDIOGENICO

OBSTRUCTIVO

TIPOS DE SHOCK:

Shock hipovolmico Hemorragia deplecin fluidos

Obstructivo Taponamiento

Cardiognico Masa miocrdica

Distributivo Disfuncin miocrdica Resistencias Vasc-sistem.

Precarga

Llenado Disfuncin diastlica

Contractilidad

90 %

10 %

GASTO CARDIACO TRANSPORTE DE OXIGENO

TIPOS DE SHOCK:
Hipovolmico Obstructivo Cardiognico Distributivo

GASTO CARDIACO TRANSPORTE DE OXIGENO DO2 TENSION ARTERIAL

Gasto normal/alto

SHOCK DISMINUCION PERFUSION

Mala distribucin de flujo (microcirculacin)

FALLA ORGANICA MUERTE

FASE COMPENSACION

VOLUM RECEP AURICULAS EST SIMP

FASE DESCOMPENSADA
Mecanismo desencadenante Prdida de volumen intravascular

Desequilibrio DO2/VO2 Metabolismo anaerbico


Shock refractario Muerte Dao intracelular por acidosis Metablica

Alteracin del gradiente electroltico


Parlisis vasomotora Edema celular Fuga capilar Edema tisular

Falla endotelial

RESULTADOS
Dao tisular

Dolor
Hipovolemia Hipoglicemia Vias Espino-talmicas
Hipotermia Estrs Activacin del eje hipotalamoHipfisis-suprarenal Liberacin de cortisol y Catecolaminas Acidosis Hipercapnia

Infeccin Hipoxemia

VARIABLES DE GASTO CARDIACO

PERFORMANCE CARDACA
FRECUENCIA CARDIACA

LEY DE FRANK STARLING

FC: aumentada Afecta VM FC: disminuida Deficit contracion

Volumen minuto Volumen eyeccion

Vm = FCXVE FE (VE/VFD)x100]

longitud del msculo cardaco y la fuerza de contraccin. En diastole > estiramiento o >volumen Ventriculo > energia para la prxima contraccin en sstole

PERFORMANCE CARDACA
FRECUENCIA CARDIACA PRECARGA tensin parietal al final de la distole o volumen en Ventriculo VFDV o indirecta PVFDV dependiente COMPLIANCE MUSCULAR

Volumen minuto Volumen eyeccion

CONTRACTILIDAD

Vm = FCXVE FE = (VE/VFD) x 100]

POST CARGA

PERFORMANCE CARDACA
FRECUENCIA CARDIACA PRECARGA tensin parietal al final de la distole o volumen en Ventriculo VFDV o indirecta PVFDV dependiente COMPLIANCE MUSCULAR

Volumen minuto Volumen eyeccion

CONTRACTILIDAD

propiedad intrnseca de las fibras miocrdicas de generar una tensin sin alterar la precarga

Vm = FCXVE FE = (VE/VFD) x 100]

POST CARGA

tensin parietal necesaria para eyectar VS contra una resistencia (sstole), calculado como RVS y RVP

THE HEMODYNAMIC, OXYGEN TRANSPORT AND UTILIZATION COMPONENTS OF TISSUE PERFUSION

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

INITIAL APPROACH TO THE PATIENT IN SHOCK

MR. A. Hctor Ramos Bravo UCI-H.N.E.R.M.

Manejo
Adequate hemodynamic support is crucial to prevent organ failure. Resuscitation should be started even while investigation of the cause is ongoing
CONTROL OF BLEEDING PERCUTANEOUS CORONARY INTERVENTION THROMBOLYSIS FOR MASSIVE PULMONARY EMBOLISM,

AND ADMINISTRATION OF ANTIBIOTICS

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

MANEJO VIP RULE


V
Ventilate (oxygen administration) Infuse (fluid resuscitation)
Pump (administration of vasoactive agents)
Weil MH, Shubin H. The VIP approach to the bedside management of shock. JAMA 1969;207:337-40

I P

VENTILATE (OXYGEN ADMINISTRATION)


Oxygen started, increase oxygen delivery and prevent pulmonary hypertension
Pulse oximetry (peripheral vasoconstriction), and AGA Mechanical ventilation
Reducing the oxygen demand Respiratory muscles and decreasing left ventricular afterload by increasing intrathoracic pressure. Decrease in PA after the initiation of VM suggests hypovolemia 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

INFUSE (FLUID RESUSCITATION)


FLUID THERAPY TO IMPROVE MICROVASCULAR BLOOD FLOW AND INCREASE CARDIAC OUTPUT FLUID ADMINISTRATION SHOULD BE CLOSELY MONITORED IN GENERAL, THE OBJECTIVE IS FOR CARDIAC OUTPUT TO BECOME PRELOAD-INDEPENDENT SIGNS OF FLUID RESPONSIVENESS MAY BE IDENTIFIED EITHER DIRECTLY FROM BEAT-BYBEAT STROKE-VOLUME

INFUSE (FLUID RESUSCITATION)

SIGNS OF FLUID RESPONSIVENESS MAY BE IDENTIFIED EITHER DIRECTLY FROM BEAT-BY-BEAT STROKE-VOLUME Invasivo

No Invasivo

Clinico

Frecuencia arterial Presion arterial Balance hidrico Rayox Torax Elevacion de piernas Signos de perfusion

Minimamente invasivo Sistema NICOM Sistema PiCCO Ultrasonografa Sistema LiDCO Doppler (sistema Sistema FloTrac/Vigileo USCOM) Sistema MostCare de Doppler esofgico Vygon Eco Cardiografa Sistema Modelflow-Nexfin El sistema NICO Espectroscopia

PVC

Lnea Arterial
Swan Ganz

cercana infrarroja (NIRS)

Meta-anlisis previos concluye PVC no debe ser usada para tomar decisiones respuesta a fluidos. Conclusiones : No hay datos que apoyen la utilizacin de la PVC para guiar la terapia de fluidos. Debe ser abandonada.

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

Monnet and Teboul Critical Care 2013, 17:217

DECISION-MAKING PROCESS OF FLUID ADMINISTRATION

INFUSE (FLUID RESUSCITATION)


First, the type of fluid must be selected. Crystalloid solutions , coloids or albumin
Second, Fluids should be infused rapidly an infusion of 300 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. Pulmonary edema is the most serious complication of fluid infusion
Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors N Engl J Med 2013

PUMP (ADMINISTRATION OF VASOACTIVE AGENTS)


Hypotension is severe or if it persists

Adrenergic agonists are the first-line vasopressors because rapid onset of action, high potency, and short half-life
Norepinephrine first choice; -adrenergic, dose is 0.1 to 2.0 g/k/min Dopamine has predominantly -adrenergic lower do and -adrenergic higher doses <3 g/k/min, not shown a protective effect on renal function, effects on the hypothalamic pituitary system, resulting in immunosuppression, a reduction in the release of prolactin.
Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors N Engl J Med 2013

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.

Forest Plot for Predef ined Subgroup Analysis According to Type of Shock

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.

EPINEFRINA
Acciones 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

VASOPRESINA
Receptores de Vasopresina y funciones

DOSIS DE VASOPRESINA

FOUR PHASES IN THE TREATMENT OF SHOCK

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

OVERVIEW OF PATIENT ENROLLMENT AND HEMODYNAMIC SUPPORT.


We randomly assigned patients who arrived at an urban emergency department
Of the 263 enrolled patients 130 were randomly assigned to early goaldirected 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 GOAL-DIRECTED 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

KAPLANMEIER ESTIMATES OF MORTALITY AND CAUSES 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 ,

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

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

GRACIAS