1. Slideset adapted from:
Shock and Sepsis
William Graham, MD
Chief Resident
July 13-14th, 2015
This will be interactive!
Slideset adapted from:
Payam Parvinchiha, MD

2. When are you going to see the patient?
Case 1, Part 1
It’s your first day on wards and you receive the following page:
“Hi doc, new transfer in T3Bd23, need diet order. FYI: HR 120, BP 80/40, pt asleep. ”
When are you going to see the patient?
What questions do you want to ask?
What are some orders to consider?

3. Objectives
Develop a systematic approach to the patient with hypotension
Recognize the difference between hypotension and shock
Identify the causes of shock
Define the stages of the SIRS scale
Use of lactate levels and mortality in sepsis
Initial management of the septic patient

4. Objectives
Develop a systematic approach to the patient with hypotension
Recognize the difference between hypotension and shock
Identify the causes of shock
Define the stages of the SIRS scale
Use of lactate levels and mortality in sepsis
Initial management of the septic patient

5. Hemodynamics of 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
If you only take one thing away from this lecture, its that I want you to develop a pavlovian response with equation. Every time you are paged about a patient with hypotension, I want you to immediately think of this equation. Sear it into your minds.
The mean arterial pressurse is the product of the cardiac output and the systemic vascular resistance
It is also the sum of 1/3 the SBP plus 2/3 the DBP

6. Systematic Approach to the Hypotensive Patient
MAP = CO x SVR
↓ Cardiac Output = Heart Rate x Stroke Volume 1) Is the Heart Rate the cause? - bradycardia - non-sinus tachycardia (shortened diastole-> ↓LVEDV)
We can break down the components of this equation to guide our approach to the hypotensive patient.
There are 5 basic questions to ask yourself:
Tx: electrical
Morchi, R. Diagnosis Deconstructed: Solving Hypotension in 30 Seconds. Emergency Medicine News, March 2015 Vol Issue 3: p 17

7. Systematic Approach to the Hypotensive Patient
MAP = CO x SVR
↓ Cardiac Output = Heart Rate x Stroke Volume 2) Is the venous volume adequate? - Collapsable IVC means low volume upstream: ↓ IVC volume -> RA -> RV -> pulmonary circuit -> LA -> ↓ LVEDV - Capillary leak/venodilation? Hemorrhage?
SV = EDV - ESV

8. Systematic Approach to the Hypotensive Patient
MAP = CO x SVR
↓ Cardiac Output = Heart Rate x Stroke Volume
3) Is the thoracic circuit obstructed?
-Tension pneumothorax
Cardiac tamponade
Constrictive Pericarditis
RV infarction
Massive PE
Pulmonary HTN
Positive Pressure Ventilation
i.e. is IVC volume actually becoming LVEDV?

9. Systematic Approach to the Hypotensive Patient
MAP = CO x SVR
↓ Cardiac Output = Heart Rate x Stroke Volume
4) Is contractility compromised?
-Decompensated systolic heart failure
Severe/Acute valvular disease
Acute VSD

10. Systematic Approach to the Hypotensive Patient
MAP = CO x SVR
Causes of ↓ Systemic Vascular Resistance:
5) What is the tone of the arterioles?
- Poor tone may be due to sepsis, anaphylaxis, or loss of sympathetic neural tone (SCI)
Morchi, R. Diagnosis Deconstructed: Solving Hypotension in 30 Seconds. Emergency Medicine News, March 2015 Vol Issue 3: p 17

11. Case 1: Part 1
“Hi doc, new transfer arrived in T3Bd23, need diet order. FYI, pt HR 120, BP is 80/40, sleepy. ” When are you going to see the patient? What questions do you want to ask? What are some orders to consider?
Do not spend 20 minutes chart reviewing, unless you want the nurse to call a rapid response. The computer will not have the answer for why the patient is hypotensive.
Go assess the patient at bedside.
“I am on my way.”

12. Questions to ask yourself:
MAP = CO x SVR
Questions to ask yourself:
Is patient symptomatic? Delirium, dyspnea, chest pain, oliguria, bleeding, vomiting, diarrhea? Why is patient in hospital? Complete Vitals: Temp, HR, BP, RR, pulse ox, trend? Meds: Antibiotics? correlation between BP and new meds? Recent procedures? Endoscopy, cardiac catheterization, IR procedures, surgery How much IVF has been given and did they respond?

13. Orders to consider:
CBC Lactate, Troponin Cultures ABG/EKG/CXR Cortisol level/ACTH stim test IVF/Blood Transfusion Grab the ultrasound!

14. Case 1, Part 2
At Bedside: The patient is lethargic, minimally arousable, and mumbling incoherently. There is no family at bedside.

15. Case 1, Part 2
Well so much for getting some subjective information… Onto obtaining the objective data: What findings on exam signs can help you narrow your differential diagnosis?

16. Examining the Hypotensive patient:
MAP = CO x SVR
Examining the Hypotensive patient:
GEN:
think about the components of the equation to guide your exam!
Get audience participation

17. Examining the Hypotensive patient:
MAP = CO x SVR
Examining the Hypotensive patient:
GEN: Delirium, confusion, lethargy, accessory muscle use HEENT:

18. Examining the Hypotensive patient:
MAP = CO x SVR
Examining the Hypotensive patient:
GEN: Delirium, confusion, lethargy, accessory muscle use HEENT: Dry mucous membranes CV:

19. Examining the Hypotensive patient:
MAP = CO x SVR
Examining the Hypotensive patient:
GEN: Delirium, confusion, lethargy, accessory muscle use HEENT: Dry mucous membranes CV: Jugular venous distension/flattening, murmurs, extra heart sounds, irregular tachycardia Lungs:

20. Examining the Hypotensive patient:
MAP = CO x SVR
Examining the Hypotensive patient:
GEN: Delirium, confusion, lethargy, accessory muscle use HEENT: Dry mucous membranes CV: Jugular venous distension/flattening, murmurs, extra heart sounds, irregular tachycardia Lungs: Asymmetric hemithorax, rales or other abnormalities Abdomen:

21. Examining the Hypotensive patient:
MAP = CO x SVR
Examining the Hypotensive patient:
GEN: Delirium, confusion, lethargy, accessory muscle use
HEENT: Dry mucous membranes
CV: Jugular venous distension/flattening, murmurs, extra heart sounds, irregular tachycardia
Lungs: Asymmetric hemithorax, rales or other abnormalities
Abdomen: Absent bowel sounds, distension, rebound
Palpate the back, groin, and thigh
Extremities:

22. Examining the Hypotensive patient:
MAP = CO x SVR
Examining the Hypotensive patient:
GEN: Delirium, confusion, lethargy, accessory muscle use
HEENT: Dry mucous membranes
CV: Jugular venous distension/flattening, murmurs, extra heart sounds, irregular tachycardia
Lungs: Asymmetric hemithorax, rales or other abnormalities
Abdomen: Absent bowel sounds, distension, rebound
Palpate the back, groin, and thigh
Extremities: edema
Skin:

23. Examining the Hypotensive patient:
MAP = CO x SVR
Examining the Hypotensive patient:
GEN: Delirium, confusion, lethargy, accessory muscle use
HEENT: Dry mucous membranes
CV: Jugular venous distension/flattening, murmurs, extra heart sounds, irregular tachycardia
Lungs: Asymmetric hemithorax, 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

24. Case 1, Part 3
Patient transferred earlier today for confusion Vitals: 39⁰C, HR 130, RR 22, BP 80/40, 98% RA, Confused Dry mucous membranes Symmetric, CTAB S1/S2 regular, tachycardic 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
Seniors: Is this hypotension or shock?
Seniors: What kind of shock is this?
Seniors: What level of care is best for this patient?

25. ∴ Not everyone with hypotension is in shock
Hypotension vs. Shock
Hypotension is an abnormal vital sign.
Shock is a physiologic state, characterized by end organ hypoperfusion.
∴ Not everyone with hypotension is in shock
By evaluating and treating hypotension early, you can prevent progression to shock
What is a “normal” BP? It’s relative. Hypotension is simply a vital sign. It is something the nurse measures and pages you about.
Shock, on the other hand, is a physiological state. It is an assessment of the consequences of sustained hypotension due to some underlying pathology.
Some patients have low BP but have adequate vital organ perfusion (ex. 80/50 in a cirrhotic or high cervical cord disease). This is not shock.

26. Types of Shock: MAP = CO x SVR
CATEGORY
PHYSIOLOGY
ETIOLOGIES
Hypovolemic
↓ venous return -> ↓ CO
Blood loss (internal/external)
Fluid losses
Cardiogenic
↓ CO
LV/RV failure (MI, cardiac arrest)
Valvular dysfunction
Arrhythmia
Distributive
↓ SVR (Vasodilated)
Anaphylaxis
Adrenal insufficiency
Neurogenic
Septic
Obstructive
Extra-cardiac obstruction to blood flow -> ↓ CO
Tamponade
Pulmonary Embolus
Tension Pneumothorax

27. Develop a systematic approach to the patient with hypotension
Learning Objectives
Develop a systematic approach to the patient with hypotension
Understand and recognize the difference between hypotension and shock
Identify the different causes of shock
Define the stages of the SIRS scale
Use of lactate levels and mortality in sepsis
Initial management of the septic patient

28. SIRS Scale
SIRS ≥ 2:
Temperature: <36⁰C or >38⁰C (<96.8⁰F or >100.4⁰F)
Heart Rate > 90
Respiratory Rate > 20
WBC < 4000, > 12000, or >10% bands
SEPSIS:

29. SIRS Scale
SIRS ≥ 2:
Temperature: <36⁰C or >38⁰C (<96.8⁰F or >100.4⁰F)
Heart Rate > 90
Respiratory Rate > 20
WBC < 4000, > 12000, or >10% bands
SEPSIS: SIRS + proven or suspected microbial etiology
SEVERE SEPSIS:

30. SIRS Scale
SIRS ≥ 2:
Temperature: <36⁰C or >38⁰C (<96.8⁰F or >100.4⁰F)
Heart Rate > 90
Respiratory Rate > 20
WBC < 4000, > 12000, or >10% bands
SEPSIS: SIRS + proven or suspected microbial etiology
SEVERE SEPSIS: Sepsis + evidence of sepsis-induced tissue hypoperfusion or organ dysfunction
SEPTIC SHOCK:

31. SIRS Scale
SIRS ≥ 2:
Temperature: <36⁰C or >38⁰C (<96.8⁰F or >100.4⁰F)
Heart Rate > 90
Respiratory Rate > 20
WBC < 4000, > 12000, or >10% bands
SEPSIS: SIRS + proven or suspected microbial etiology
SEVERE SEPSIS: Sepsis + evidence of sepsis-induced tissue hypoperfusion or organ dysfunction
SEPTIC SHOCK: Sepsis with hypotension refractory to adequate fluid resuscitation, or vasopressors needed to maintain SBP >90 or MAP >65
RC Bone, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. Chest, 1992; 101(6):

32. Q: Does SIRS always mean infection?

33. Q: Does SIRS always mean infection?

34. Q: What distinguishes severe sepsis vs sepsis?

35. Q: What distinguishes severe sepsis vs sepsis?
Answer: Tissue Hypoperfusion
Sepsis-Induced hypotension
Urine output < 0.5 cc/kg/hr for > 2 hrs
Cr > 2.0 mg/dL
Bilirubin > 2.0 mg/dL
Platelet count < 100,000
INR > 1.5
Altered mental status
Ischemic bowel
Gangrene
Elevated lactate
Levy MM, Fink MP, Marshall JC, et al: 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31: 1250–1256.

36. Surviving Sepsis Campaign 2002-2012
Within 3 Hours of Identifying Sepsis:
Measure lactic acid
Obtain blood cultures before antibiotics
Start broad-spectrum antibiotics
Administer 30cc/kg crystalloid for low BP or lactate > 4
Within 6 Hours of Identifying Sepsis:
Vasopressors for hypotension refractory to initial resuscitation for goal MAP ≥ 65
For persistent hypotension despite resuscitation (septic shock!) or lactate > 4, check:
- CVP (goal ≥ 8)*
- ScvO2 (goal ≥ 70%)*
7. Repeat lactate if initially elevated
How do we manage sepsis?
SSC international guidelines, first in 2002, updated twice since, most recently 2012
Lets look at the different components of this bundle, starting with the lactate.
Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign:  International guidelines for management of severe sepsis and septic shock: Crit Care Med. 2013;41(2): Intensive Care Med. 2013;39(2):

37. Lactate and Mortality in Sepsis
What is it? Lactic acid is generated by anaerobic metabolism. Elevated lactic acid is evidence of suboptimal tissue O2 delivery to the end- organs.
Why do we measure it?

38. Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock
Figure 3. Association between serum lactate level and 28-day mortality, stratified by the presence of shock. Serum lactate categorized as follows:
low = mmol/L
intermediate = 2-3.9
high = 4
So:
if poor O2 delivery causes elevated lactate…
and elevated lactate is associated with worsening mortality…
lets improve O2 delivery!
Critical Care Medicine (5):

39. Hemodynamic Resuscitation
It’s all about optimizing oxygen delivery to the tissue. The delivery of oxygen to the tissues per minute (DO2) is calculated by: DO2 = [1.39 x Hb x SaO2 + (0.003 x PaO2)] x CO Remember!!!
MAP = CO x SVR
In sepsis low vascular tone, vasodilated.
Therefore to optimize MAP and perfusion of vital organs, you have to optimize CO and
Increase vascular tone with vasopressors

40. Early Goal Directed Therapy
Early hemodynamic resuscitation in the first 6 hours based on specific goals for 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
EGDT is how we resuscitate patients with severe sepsis and septic shock.
Rivers E, et al. Early Goal Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. The New England Journal of Medicine (19):

41. Goals of EGDT: The first 6 hours:
Minimum resuscitation = 30cc/kg
CVP 8-12, achieved with IVF boluses
MAP > 65, achieved with vasopressors
Mixed venous oxygen saturation >70%, achieved with PRBC transfusions or dobutamine
Urine output > 0.5cc/kg/hr

42. Case 1, Part 4
Patient receives 6L of IVF, CVP 12, and BP now 80/60, urine output 15cc/hr, lactate 5 How would you classify this patient?
Think about it…

43. Case 1, Part 4
Patient receives 6L of IVF, CVP 12, and BP now 80/60, urine output 15cc/hr, lactate 5 How would you classify this patient? SEPTIC SHOCK

44. EGDT Algorithm: The First 6 Hours:
DO2 = [1.39 x Hb x SaO2 + (0.003 x PaO2)] x CO

45. Vasopressors
Alpha 1
Norepinephrine
Epinephrine
vasopressin

46. Vasopressors
First line: Norepinephrine (Levophed) Second line: Epinephrine Third line: Vasopressin (0.04 units/min fixed dose)

47. Protocol for Early Goal-Directed Therapy
DO2 = [1.39 x Hb x SaO2 + (0.003 x PaO2)] x CO

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

49. Is EGDT all it’s cracked up to be?
Controversy:
TRICC trial (1999) showed mortality reduction using a restrictive transfusion strategy for septic shock patients
accuracy of CVP as surrogate for intravascular volume determination has been controversial
Landmark follow-up studies since River’s EGDT:
ProCESS trial- NEJM US
ARISE trial- NEJM Australia
ProMISe trial- NEJM UK

50. Is EGDT all it’s cracked up to be?
Controversy:
TRICC trial (1999) showed mortality reduction using a restrictive transfusion strategy for septic shock patients
accuracy of CVP as surrogate for intravascular volume determination has been controversial
Landmark follow-up studies since River’s EGDT:
ProCESS trial- NEJM US
ARISE trial- NEJM Australia
ProMISe trial- NEJM UK
* Achieving specific goals did not improve mortality
* Fewer transfusions in non-EGDT groups
* Shorter LOS in ICU in non-EGDT groups
No difference in 60/90 day mortality between patients randomized to receive EGDT from standard care

51. Surviving Sepsis Campaign 2015 Update
“With publication of 3 trials that do not demonstrate superiority of required use of a CVC to monitor CVP and SCVO2 in all patients with septic shock who have received timely antibiotics and fluid resuscitation compared with controls or in all patients with lactate > 4, the SSC Executive committee has revised the improvement bundles.” - SSC Executive Committee Statement, April 2015

52. Surviving Sepsis Campaign 2015 Update
Within 3 Hours of Identifying Sepsis:
Measure lactic acid
Obtain blood cultures before antibiotics
Start broad-spectrum antibiotics
Administer 30cc/kg crystalloid for low BP or lactate > 4
Within 6 Hours of Identifying Sepsis:
Vasopressors for hypotension refractory to initial resuscitation for goal MAP ≥ 65
For persistent hypotension despite resuscitation (septic shock!) or lactate > 4, check:
- CVP (goal ≥ 8)*
- ScvO2 (goal ≥ 70%)*
Reassess volume status and tissue perfusion clinically (vitals, capillary refill, pulse, skin), OR by CVP, ScvO2 or CV ultrasound
7. Repeat lactate if initially elevated

53. UCI Severe Sepsis Order Set

55. In Summary
Use a systematic approach to the hypotensive patient, based on: MAP = CO x SVR
Hypotension is a vital sign, shock is a physiologic state
Shock can be Hypovolemic, Cardiogenic, Distributive, and/or Obstructive
Lactate levels correlate with mortality in septic shock
Key to managing patients with septic shock is to treat early with fluids, antibiotics, and pressors if needed
Specific hemodynamic goals are less important than ensuring starting treatment ASAP.

56. Case Scenario
A 77-year-old woman was evaluated in the ED for a UTI and hypotension. Antibiotics were administered in the ED, and she was admitted to the floor. Eight hours after admission, she is confused and lethargic. Temp 37.8C (100.0F), BP 88/50 mm Hg, HR 112/min, and RR 28/min. Other than tachycardia, the cardiopulmonary examination is normal. Her extremities are cool and mottled appearing. She has had no urine output since admission to the hospital. Hb 10.5 WBC 16,700 Plts 110,000 Cr: Normal Electrolytes: normal ECG: sinus tachycardia

57. What is the next best step?
Hydrocortisone 50mg IV q6H
IV fluid bolus
Norepinephrine
Two units RBCs

58. What is the next best step?
Hydrocortisone 50mg IV q6H
IV fluid bolus
Norepinephrine
Two units RBCs