Shock

Stephanie N. Sudikoff, MD
Pediatric Critical Care
Yale School of Medicine

Learning Objectives
Understand the pathophysiology of shock
Understand the principles of treatment of shock
Examine septic shock as one example

The reason you get up in the

morning is to deliver oxygen to
the cells.
Mark Mercurio, MD

Oxygen Consumption vs. Delivery

Oxygen consumption (DEMAND)
VO2 = CO x (CaO2-CvO2)
Oxygen delivery (SUPPLY)
DO2 = CO x CaO2

What are PRELOAD and

AFTERLOAD?

Preload
PreloadLV = (EDPLV)(EDrLV)/2tLV
where, LV = left ventricle
ED = end diastole
Represents all the factors that contribute to
passive ventricular wall stress at the end of
diastole

Venous return and CO

Factors affecting venous return

1. Decrease in intravascular volume
2. Increase in venous capacitance
3. Increase in right atrial pressure
4. Increase in venous resistance

Afterload
AfterloadLV = (SPLV)(SrLV)/2tLV
where, LV = left ventricle
S = systole
Represents all the factors that contribute to total
myocardial wall stress during systolic ejection

Myocardial contractility

Myocardial contractility

Positive
Negative
Inotropic Agents Inotropic Agents
1. Adrenergic
agonists
2. Cardiac
glycosides
3. High
extracellular
[Ca++]

1. Ca++-channel
blockers
2. Low
extracellular
[Ca++]

Heart rate
HR CO
At high HR, diastolic filling is impaired
Atrial contraction accounts for up to 30% of Stroke
Volume

SHOCK

Shock

Classification of Shock
Decreased preload (hypovolemic)

Hemorrhage
Dehydration
Cardiac tamponade
Pneumothorax

Decreased myocardial contractility

(cardiogenic)

Myocarditis
Cardiopulmonary bypass
Congestive heart failure
Myocardial infarction
Drug intoxication
Sepsis

Heart rate abnormalities (cardiogenic) Dysrhythmias

Increased afterload (obstructive)

Massive pulmonary embolus

Critical aortic and pulmonic stenosis

Decreased afterload (distributive)

Anaphylaxis
Neurogenic shock
Sepsis

Abnormalities in Hb affinity
(dissociative)

Methemoglobinemia
Carbon monoxide poisoning

Systemic response to low perfusion

Systemic response to low perfusion

Increase CO
Increase preload
Aldosterone
Na reabsorption
Interstitial fluid
reabsorption
ADH secretion
Venoconstriction

Systemic response to low perfusion

Increase CO
Increase contractility
Sympathetics

Increase afterload
Vasoconstriction

Increase HR
Sympathetics

Systemic response to low perfusion

Increase CO
Increase contractility
Sympathetics

Increase HR
Sympathetics

Increase SVR
Vasoconstriction
Increase blood
volume

Local response to low perfusion

Increase O2ER
Opening of
previously closed
capillaries
Increased surface
area for diffusion
Shortened diffusion
distance
Increased transit time

Physical Signs of low CO

Organ
System

Cardiac Output

Cardiac Output
(Compensated)

Cardiac Output
(Uncompensated)

CNS

Restless, apathetic

Agitated-confused,
stuporous

Respiration

Ventilation

Ventilation

Metabolism

Compensated
metabolic acidemia

Uncomensated
metabolic acidemia

Gut

Motility

Ileus

Kidney

Specific gravity,
volume

Oliguria

Oliguria-anuria

Skin

Delayed capillary
refill

Cool extremities

Mottled, cyanotic,
cold extremities

CVS

Heart rate

Heart rate,
peripheral pulses

Heart rate,
blood pressure,
central pulses only

Objective monitors
Systemic perfusion
base deficit
lactate

Objective monitors
Systemic perfusion
ABG
lactate

CO
PA catheter
Arterio-venous oxygen
difference

Preload

Myocardial contractility
Echo

Afterload
PA catheter
Invasive or noninvasive
BP

HR
EKG

CVP

CaO2

Echo

Hb
ABG

TREATMENT OF SHOCK

Goals of therapy

Treat underlying cause

Reduction of demands for CO

Treat hyperthermia aggressively

Reduction of demands for CO

Treat hyperthermia
Reduce work of breathing
As much as 20% of CO goes to respiratory
muscles

PPV and CO
Advantages
Decreases work of breathing
Improves acidosis
Decreases PVR
Decreases LV afterload
Improves oxygenation

Reduction of demands for CO

Treat hyperthermia
Reduce work of breathing
Sedation
Seizure control
Paralysis

Increase supply:
Restoration of perfusion
Preload
Fluid resuscitation
Colloids vs.
crystalloids

Increase supply:
Restoration of perfusion
Preload
Fluid resuscitation
Colloids vs.
crystalloids

Myocardial
contractility
Inotropic support
ECMO
Other mechanical
support

Increase supply:
Restoration of perfusion
Preload
Fluid resuscitation
Colloids vs. crystalloids

Myocardial contractility
Inotropic support
ECMO
Other mechanical
support

Afterload
Vasopressors
Vasodilators

Increase supply:
Restoration of perfusion
Preload

HR

Fluid resuscitation

Anti-arrhythmics

Colloids vs. crystalloids

Pacer

Myocardial contractility
Inotropic support
ECMO
Other mechanical
support

Afterload
Vasopressors
Vasodilators

Increase supply:
Restoration of perfusion
Preload

HR

Fluid resuscitation

Anti-arrhythmics

Colloids vs. crystalloids

Pacer

Myocardial contractility
Inotropic support
ECMO
Other mechanical
support

Afterload
Vasopressors
Vasodilators

Beta-blockers?

CaO2
Blood transfusion
Oxygen support

SEPTIC SHOCK

Types of septic shock

Cold shock
CO, SVR (60% pediatric)
Narrow pulse pressure, thready pulses, delayed
capillary refill

Phases of septic shock

Warm shock (early)
CO, SVR
CO, SVR
Wide pulse pressure, bounding pulses, brisk
capillary refill
Cold shock (late)
CO, SVR
Narrow pulse pressure, weak pulses, delayed
capillary refill

Early recognition!

Early recognition!

Increase preload
Aggressive fluid resuscitation

Increase preload
Aggressive fluid resuscitation
Usually requires 40-60 mL/kg but can be
as much as 200 mL/kg
20 mL/kg IV push titrated to clinical
monitors

Monitor improvement in CO
Cardiac output

Heart rate
Urine output
Capillary refill
Level of consciousness
Blood pressure NOT reliable endpoint

Increase preload
Aggressive fluid resuscitation with
crystalloids or colloids
Usually requires 40-60 mL/kg but can be
as much as 200 mL/kg
20 mL/kg IV push titrated to clinical
monitors
Maintain hemoglobin within normal for age
(10 g/dL)

Antibiotic therapy
IV antibiotics within 1 hr of recognition of severe
sepsis
Cultures before antibiotics
Cover appropriate pathogens
Penetrate presumed source of infection

Improve myocardial contractility and

titrate afterload

Cold Shock, Adequate BP:

Decrease afterload

Adequacy of resuscitation

Capillary refill < 2 sec

Adequate pulses
Warm limbs
Normal mental status
Urine output > 1 mL/kg/hr
Adequate blood pressure
Improved base deficit
Decreased lactate
ScvO2 > 70%

Early shock reversal improves

outcome

Carcillo JA et al. Pediatrics 2009;124:500-508

SUMMARY

Shock

Goals of therapy

Treat underlying cause

Special thanks to Vince Faustino, MD

for use of his slides