Objectives: Identify a patient in shock Learn the different types of shock and their acute management With a focus on septic shock, identify best practices Familiarize yourself with vasopressors and advanced medical therapies

MKSAP Question A 71 y/o female is brought to the ED from a SNF because of confusion, fever and flank pain. Her temperature is 38.5 C, BP 82/48, pulse 123, RR 27. Mucous membranes are dry, there is CVA tenderness, poor skin turgor and no edema. Hgb 10.5, WBC 15.6, UA with 50-100 wbc/hpf and many bacteria. There is an anion gap metabolic acidosis. A CVC is placed and antibiotic therapy is started. Which of the following interventions is most likely to improve survival for this patient? A) Aggressive fluid resuscitation B) Hemodynamics monitoring with a PA catheter C) Maintaining Hgb concentration above 12g/dL D) Maintaining Pco2 below 50 mmHg

INTRO to shock

Shock What is shock? Inadequate cellular oxygenation Hypotension? Vasopressor-o-penia? Inadequate cellular oxygenation Oxygen delivery equation DO2 = CaO2 x Q CaO2 = (1.34 x Hgb x SaO2) + (0.003 x PaO2) Q = HR x SV “The final common pathway before death” Josh Farkas, MD in IBCC

Multiple Organ System Failure

Shock Identifying the patient in shock Exam findings The “other” look Supreme Court Justice Potter Stewart Hemodynamics SBP MAP CVP SvO2 PCWP Lactate?

Shock Cardiogenic Hypovolemic Obstructive Distributive AMI, Cardiomyopathy, Valvular Disease, Myocarditis, Arrhythmia Hypovolemic Fluid loss, internal or external Obstructive Pneumothorax, Cardiac Tamponade, Acute PE Distributive Sepsis, Anaphylaxis

Shock MAP Cardiac Output CVP PCWP SVR Cardiogenic ↓/NL ↓ ↑ Hypovolemic Obstructive ↑/NL Distributive

Determining type of shock He’s been having diarrhea for the last week, today he was too weak to get out of bed. He said he was feeling dizzy earlier. History taking Physical exam Invasive testing Central line – CVP, ScvO2 PA catheter – PCWP, SvO2 Measures of cardiac output Bioimpedence Vigileo Lidco Esophageal doppler Echocardiogram/POCUS

Determining type of shock - POCUS https://twitter.com/emuss_uk/status/966353653815656448 https://twitter.com/EM_RESUS/status/606157034980032513 https://twitter.com/EM_RESUS/status/1102288034538668035] https://twitter.com/DrAndrewDixon/status/732314227340271616

Septic Shock: Management

Rivers, NEJM 2001 SIRS Criteria + SBP <90 mmHg or Lactate >4 mmol/L 130 patients in each group Standard vs EGDT EGDT = ScvO2 monitoring x 6 hours Fluid resus to CVP goal Vasopressors if <65 PRBC, Dobutamine Standard therapy had lower MAP, higher HR, lower SvO2 Higher mortality in standard therapy Rivers, NEJM 2001

Rivers, NEJM 2001 Rivers, NEJM 2001

ProCESS 2014 Multicenter Study Randomized 1:1:1 (450 in each) United States Academic Medical Centers Similar inclusion criteria Randomized 1:1:1 (450 in each) EGDT Protocol based (CVC not necessary, volume assessment) SI = HR/SBP Standard Therapy ProCESS investigators, NEJM 2014

ProCESS 2014 Less IV fluid use in usual care 2.8L vs 3.3L vs 2.3L @ 6hr 7.3L vs 8.2L vs 6.6L @ 72hr ProCESS investigators, NEJM 2014

ARISE 2014 Multicenter Randomized 1:1 (800 in each) Australia, New Zealand, Hong Kong, Ireland, Finland Tertiary and non-tertiary hospitals Similar inclusion criteria Randomized 1:1 (800 in each) EGDT Usual care (ScvO2 not permitted) Less fluid in usual care: 1.9L vs 1.7L CVC placed in 60.9% usual care ARISE Investigators NEJM 2014

ProMISe 2015 Multicenter study Randomized 1:1 (600 in each) English NHS hospitals Similar inclusion Randomized 1:1 (600 in each) EGDT Usual care EGDT group received more IV fluids 1.7L.vs 1.5L CVC placed in 50.9% usual care Mouncey NEJM 2015

ProMISe 2015 Mouncey NEJM 2015

Surviving Sepsis Initially conceived following the Rivers trial and before ProCESS. Quality improvement in the care of sepsis 1 hour bundle Measure lactate, obtain cultures, start antibiotics, fluid resuscitate (30cc/kg) and start vasopressors