1. How to approach the patient in shock Payam Parvinchiha, MD Internal Medicine Chief Resident July 2014

2. Case 1, Part 1 It’s your first day on wards. You get a page “patient’s BP is 80/40.” When are you going to see the patient? What questions do you want to ask? What are some orders to consider?

3. Learning Objectives 1. Approach to the patient with shock Physiology Pathophysiology Physical exam 2. Recognize Shock 3. Differentiate b/w SIRS, Sepsis, & Septic Shock 4. Lactate levels and mortality in sepsis 5. Implement Early Goal Directed Therapy

4. Blood Pressure Physiology Mean arterial blood pressure – MAP = CO x SVR – MAP = 1/3 SBP + 2/3 DBP – MAP goal is to maintain perfusion of the vital organs – MAP goal is dependent on patient’s individual physiology Cardiac Output – CO = HR x SV

5. Physiologic Approach: MAP= CO x SVR – Low CO, High SVR Cool extremities, slow capillary refill Cardiogenic, Tamponade, Pulmonary Embolus, Tension pneumothorax, and Hypovolemic shock Very late septic shock – High CO, Low SVR Wide pulse pressure, warm extremities, normal capillary refill Early septic shock, adrenal insufficiency, anaphylaxis, neurogenic, thyroid storm, AV fistulas

6. Hypotension vs. Shock Hypotension is an abnormal vital sign Shock is a physiologic state defined by vital organ hypoperfusion Not everyone with hypotension is in shock Not everyone in shock is hypotensive By evaluating and treating hypotension EARLY, you can prevent progression to shock

7. Etiologies of Shock CATEGORYPHYSIOLOGYETIOLOGIES HypovolemicDecreased venous returnBlood loss Fluid loss CardiogenicCardiac pump failure/Low COLeft/Right Ventricular failure Valvular dysfunction Arrhythmia DistributiveDecreased SVR (Vasodilated) Anaphylactic (FFP) Adrenal insufficiency Neurogenic ObstructiveExtra-cardiac obstruction to blood flow Tamponade Pulmonary Embolus Tension Pneumothorax SepticSepsis

8. Case 1: Part 1 It’s your first day on wards. You get a page “patient’s BP is 80/40.” When are you going to see the patient? What questions do you want to ask? What are some orders to consider?

9. When do you evaluate the hypotensive patient? Immediately I will be there in 1 minute

10. Questions to ask yourself Is patient symptomatic – delirium, dyspnea, chest pain, oliguria, bleeding, vomiting, diarrhea Why is patient in hospital Vitals: Temp, HR, RR, pulse ox, prior BP Meds: Antibiotics/Blood pressure Recent procedures – endoscopy, cardiac catheterization, IR procedures, surgery How much IVF has been given and did they respond

11. Orders to consider as you head over to see the patient CBC, CMP Lactate, troponin Urinalysis, Urine Culture, Blood Cultures ABG/EKG/CXR Cortisol level/ACTH stim test IVF/Blood Transfusion Grab the bedside ultrasound

12. Case 1, Part 2 Bedside, the patient is lethargic and unable to speak and there is no family at bedside What constellation of physical exam signs can help you narrow you differential diagnosis?

13. Helpful physical exam findings GEN: Delirium, confusion, lethargy, accessory muscle use HEENT: Dry mucous membranes CV: Jugular venous distension/flattening, murmurs, extra heart sounds, irregular tachycardia? Lungs: Asymmetric hemi-thorax, rales or other abnormalities Abdomen: Absent bowel sounds, distension, rebound – Palpate the back, groin, and thigh Extremities: edema Skin: Pallor, cyanosis, capillary refill, warm or cold

14. Case 1, Part 3 Patient admitted earlier today for confusion Vitals: 39 C, HR 130, RR 22, BP 80/40, 98% RA, Confused Dry mucous membranes Symmetric, CTAB S1 S2 regular tachycardia Cool extremities Abd Soft, mildly distended, nontender, few bowel sounds CVA tenderness on Right UA: 200 WBC and few bacteria Urine output 10cc/hr WBC 25,000

15. Definitions of SIRS/Sepsis Bacteremia: Positive Blood Cultures SIRS: 2 or more – T 38 – HR >90 – RR >20 – WBC 12000 or 10% bands SEPSIS: SIRS that has proven or suspected microbial etiology SEVERE SEPSIS: Sepsis induced tissue hypoperfusion with organ dysfunction SEPTIC SHOCK: Sepsis with hypotension despite adequate fluid resuscitation or vasopressors needed to maintain SBP >90 or MAP >65

16. What defines severe sepsis vs sepsis? Tissue hypoperfusion Elevated lactate Urine output <30cc/kg – foley Acute kidney injury Elevated troponins Transaminitis Altered mental status, chest pain Ischemic bowel gangrene

17. SIRS and SEPSIS

18. Lactate and Mortality in Sepsis Optimizing Oxygen delivery to the vital organs. O2 delivery = CO x 1.34 x Hb x %O2 saturation Serum Lactate: biochemical evidence of suboptimal tissue O2 delivery

19. © 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc. 2 Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock Critical Care Medicine. 37(5):1670-1677, May 2009. DOI: 10.1097/CCM.0b013e31819fcf68 Figure 3. Association between serum lactate level and 28-day mortality, stratified by the presence of shock. Serum lactate categorized as follows: low = 0-1.9 mmol/L, intermediate = 2-3.9 mmol/L high = 4 mmol/L.

20. Surviving Sepsis Campaign 1. Goal-oriented hemodynamic resuscitation 2. Cultures (Blood, Urine, CSF, etc) – Before antibiotics if does not delay antibiotic administration by more than 45 minutes 3. Antimicrobial antibiotics in the first 1 hour of recognizing severe sepsis or septic shock 4. Check lactate in first 3 hours 5. Source control of infection

21. Hemodynamic Resuscitation It’s all about optimizing Oxygen delivery to the tissue. MAP = CO x SVR CO = HR x SV O2 delivery = CO x 1.34 x Hb x %sat O2

22. Early Goal Directed Therapy Early hemodynamic resuscitation in the first 6 hours based on CVP, MAP, ScvO2 (%), Hct Randomized, controlled, single-center study Urban center ED 130 assigned to early goal directed therapy 133 assigned to standard therapy – Achieving these targets resulted in a 15.9% absolute reduction in 28 day mortality

23. Protocol for Early Goal-Directed Therapy. Rivers E et al. N Engl J Med 2001;345:1368-1377.

24. Early “Hemodynamic” Goal Directed Therapy: The first 6 hours Give first 2L IVF bolus over 10 minutes, then check CVP immediately (use pressure bags or rapid infuser) check measures of vital organ perfusion: – lactate, blood pH, urine output, MAP Repeat 1L bolus every 10 minutes until CVP 8-12 or vital organ perfusion is achieved

25. Case 1, Part 4 Patient receives 6L of IVF, CVP 12, and BP now 80/60, urine output 15cc/hr, lactate 5 Patient meets criteria for septic shock

26. Protocol for Early Goal-Directed Therapy. Rivers E et al. N Engl J Med 2001;345:1368-1377.

27. Vasopressors

28. First line: Norepinephrine (Levophed) Second line: Epinephrine Third line: Vasopressin (0.04 units/min fixed dose) Patient requires norepinephrine and epinephrine to maintain adequate vital organ perfusion

29. Protocol for Early Goal-Directed Therapy O2 delivery = CO x 1.34 x Hb x %saturation O2

30. Inotropes First line: Dobutamine (max dose 20mcg/kg/min) -myocardial dysfunction -ongoing hypoperfusion despite adequate intravascular volume and MAP

31. Corticosteroids in ICU Why? – Cytokine release TNF alpha, IL-1, IL-2 via an unknown mechanisms induces adrenal insufficiency When to start? – When adequate fluid hydration and vasopressors are not enough to restore hemodynamic stability – Cortisol level, ACTH stim test are not needed Hydrocortisone 50mg IV q6 – Glucocorticoid + Mineralocorticoid effect

32. Protocol for Early Goal-Directed Therapy. Rivers E et al. N Engl J Med 2001;345:1368-1377.

33. Protocol for Early Goal-Directed Therapy

34. UCI Severe Sepsis Order Set

36. Case 1 Review SIRS criteria 39 C, HR 130, RR 22, WBC 25K Source of infection identified UO 15cc/hr, lactate 5 2L IVF -> BP 80/60 How much IVF do you give and how? What do you do if MAP still inadequate for vital tissue perfusion? How do you assess adequate tissue perfusion? Which vasopressors? When do you transfuse PRBC? When do you start steroids and which one? What is the name of the order set if you don’t know what to do for sepsis?

37. Case 1 Finale Transferred out of ICU 2 days later Patient survived GOOD WORK!

38. The key to success as an intern in the ICU: Hypotension is a vital sign Shock is a physiologic state defined by vital organ hypoperfusion MAP goal is to maintain perfusion of the vital organs – MAP = CO x SVR – MAP = 1/3 SBP + 2/3 DBP 5 categories of shock: Hypovolemic, Distributive, Cardiogenic, Obstructive, Septic Identify shock early in patients on the wards and ICU Know goal directed therapy!

39. Etiologies of Shock CATEGORYPHYSIOLOGYETIOLOGIES HypovolemicDecreased venous returnBlood loss Fluid loss CardiogenicCardiac pump failure/Low COLeft/Right Ventricular failure Valvular dysfunction Arrhythmia DistributiveDecreased SVR (Vasodilated) Anaphylactic (FFP) Adrenal insufficiency Neurogenic ObstructiveExtra-cardiac obstruction to blood flow Tamponade Pulmonary Embolus Tension Pneumothorax SepticSepsis

40. References Early Goal Directed Therapy in the Treatment of Severe Sepsis and Septic Shock NEJM 345, 19. Nov 8, 2001 Principles of Critical Care, 3 rd edition. Chapter 21: Shock Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Critical Care Medicine. 37(5):1670-1677, May 2009. Surviving Sepsis Campaign Corticus trial: Corticosteroids in sepsis Transfusion Requirements in Crticial Care evaluated mortality and Hb 7-9

41. Date of download: 7/20/2013 Copyright © 2012 American Medical Association. All rights reserved. From: Medical Management of Advanced Heart Failure JAMA. 2002;287(5):628-640. doi:10.1001/jama.287.5.628