Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download VASOPRESSORS and INOTROPES
Document related concepts
Transcript
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
