1. 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

2. 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 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

3. INTRO to shock

4. 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

5. Multiple Organ System Failure

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

7. 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

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

9. 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

10. Determining type of shock - POCUS

12. Septic Shock: Management

13. 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

14. Rivers, NEJM 2001
Rivers, NEJM 2001

15. 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

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

17. 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

18. 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

19. ProMISe 2015
Mouncey NEJM 2015

20. 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