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

8nl
R 4
PAPM
15 r
PAM
100

12 8
PAM = PD + (PS - PD)
3

10 20 30

FCmx=220-edad
 SHOCK
CONTINENTE CONTENIDO BOMBA

DISTRIBUTIVO HIPOVOLEMICO CARDIOGENICO OBSTRUCTIVO

TIPOS DE SHOCK:

Shock hipovolmico Obstructivo Cardiognico Distributivo

Hemorragia Disfuncin Resistencias

Taponamiento Masa miocrdica
deplecin miocrdica Vasc-sistem.
fluidos

Llenado Contractilidad 90 %
Precarga
Disfuncin
diastlica
10 %

GASTO CARDIACO
TRANSPORTE DE OXIGENO
TIPOS DE SHOCK:

Hipovolmico Obstructivo Cardiognico Distributivo

GASTO CARDIACO
TRANSPORTE DE OXIGENO Gasto normal/alto
DO2

TENSION ARTERIAL

Mala distribucin de
SHOCK DISMINUCION PERFUSION 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 Dao intracelular por acidosis

Muerte Metablica

Alteracin del gradiente electroltico

Parlisis vasomotora
Edema celular
Fuga capilar
Edema tisular
Falla endotelial
RESULTADOS
Dao tisular

Dolor
Hipovolemia Infeccin

Hipoglicemia Hipoxemia
Vias
Espino-talmicas
Hipotermia Acidosis

Estrs Activacin del eje hipotalamo- Hipercapnia

Hipfisis-suprarenal
Liberacin de cortisol y
Catecolaminas
VARIABLES DE GASTO CARDIACO
PERFORMANCE CARDACA LEY DE FRANK STARLING

FRECUENCIA
CARDIACA
FC: aumentada
Afecta VM
FC: disminuida
Deficit contracion

Volumen minuto
Volumen eyeccion

Vm = FCXVE longitud del msculo cardaco y la fuerza

de contraccin.
FE (VE/VFD)x100] En diastole > estiramiento o >volumen
Ventriculo > energia para la prxima
contraccin en sstole
PERFORMANCE CARDACA
tensin parietal al final de la distole o
FRECUENCIA volumen en Ventriculo VFDV o
PRECARGA
CARDIACA indirecta PVFDV dependiente
COMPLIANCE MUSCULAR

Volumen minuto
CONTRACTILIDAD
Volumen eyeccion

Vm = FCXVE
POST CARGA

FE = (VE/VFD)
x 100]
PERFORMANCE CARDACA
tensin parietal al final de la distole o
FRECUENCIA volumen en Ventriculo VFDV o
PRECARGA
CARDIACA indirecta PVFDV dependiente
COMPLIANCE MUSCULAR

propiedad intrnseca de las

Volumen minuto fibras miocrdicas de generar
CONTRACTILIDAD
Volumen eyeccion una tensin sin alterar la
precarga

tensin parietal necesaria para

Vm = FCXVE
POST CARGA eyectar VS contra una
resistencia (sstole), calculado
FE = (VE/VFD) como RVS y RVP
x 100]
 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 CONTROL OF BLEEDING
hemodynamic support
PERCUTANEOUS CORONARY
is crucial to prevent INTERVENTION
organ failure.
THROMBOLYSIS FOR MASSIVE
PULMONARY EMBOLISM,
Resuscitation should
AND ADMINISTRATION OF
be started even while ANTIBIOTICS
investigation of the
cause is ongoing

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)

I Infuse (fluid resuscitation)

P Pump (administration of vasoactive

agents)
Weil MH, Shubin H. The VIP approach
to the bedside management of
shock. JAMA 1969;207:337-40
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-BY-
BEAT STROKE-VOLUME
INFUSE (FLUID RESUSCITATION)
SIGNS OF FLUID RESPONSIVENESS MAY BE
IDENTIFIED EITHER DIRECTLY FROM BEAT-BY-BEAT
STROKE-VOLUME Invasivo
No Invasivo Minimamente invasivo PVC
Clinico Sistema NICOM Sistema PiCCO
Lnea Arterial
Frecuencia arterial Ultrasonografa Sistema LiDCO
Doppler (sistema Sistema FloTrac/Vigileo Swan Ganz
Presion arterial
USCOM)
Balance hidrico Sistema MostCare de
Doppler esofgico Vygon
Rayox Torax
Elevacion de piernas
Eco Cardiografa Sistema Modelflow-Nexfin
Signos de perfusion Espectroscopia El sistema NICO
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 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
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